Israel Journal of Psychiatry and Related Sciences by MEDIC

israel journal of

psychiatry

Vol. 50 - Number 3 2013

ISSN: 0333-7308

148

PTSD Symptoms and Disorder of Extreme Stress (NOS) Symptoms Following War Captivity Gadi Zerach and Zahava Solomon

157

Impact of Exposure to Terror Attacks on Israeli Mothers and Children Mally Shechory-Bitton

165

Post-traumatic Reaction of Israeli Jewish and Arab Children Exposed to Rocket Attacks Leo Wolmer et al.

174

Predictors of Professional Quality of Life among Physicians in a Conflict Setting Yeela Haber et al.

182

Psychiatric Symptoms among Nurses Exposed to War Stressors Menachem Ben-Ezra et al.

188

Food Insecurity Among Psychiatric Patients and Welfare Clients in Israel Roni Kaufman et al.

194

Health-related Quality of Life Changes and Weight Reduction After Bariatric Surgery vs. a Weight-loss Program Laura Canetti et al.

202

Israeli Psychiatrists Report on Their Ability to Care for Individuals with Intellectual Disability and Psychiatric Disorders Shirli Werner et al.

210

The Effects of the Survival Characteristics of Parent Holocaust Survivors on Offspringsâ&#x20AC;&#x2122; Anxiety and Depression Symptoms

Psychiatry and Conflict: Part 2

Yael Aviad-Wilchek et al.

israel journal of

psychiatry

The Official Publication of the Israel Psychiatric Association Vol. 50 - Number 3 2013

and related sciences EDitor

David Greenberg

Psychiatry and Conflict: Part 2

DEPUTY EDITORS

Doron Gothelf Yoav Kohn Ivonne Mansbach Ora Nakash Shaul Lev-Ran David Roe Rael Strous

148 > The Relations Between

Posttraumatic Stress Disorder Symptoms and Disorder of Extreme Stress (Not Otherwise Specified) Symptoms Following War Captivity

Book reviews editor

Gadi Zerach and Zahava Solomon

PAst Editor

157 > The Impact of Repetitive

Yoram Barak

Eli L. Edelstein

188 > Food Insecurity Among Psychiatric Patients and Welfare Clients in Israel Roni Kaufman, Julia Mirsky, Eliezer Witztum and Nimrod Grisaru

194 > Health-related Quality of

Life Changes and Weight Reduction After Bariatric Surgery vs. a Weight-loss Program

Laura Canetti, Yoel Elizur, Yair Karni and Elliot M. Berry

Founding Editor

and Chronic Exposure to Terror Attacks on Israeli Mothers’ and Children’s Functioning

Editorial Board

Mally Shechory-Bitton

202 > Israeli Psychiatrists Report on Their Ability to Care for Individuals with Intellectual Disability and Psychiatric Disorders

165 > Post-traumatic Reaction of

Shirli Werner, Itzhak Levav, Mike Stawski and Yakov Polakiewicz

Heinz Z. Winnik

Alean Al-Krenawi Alan Apter Omer Bonne Elliot Gershon Talma Hendler Ehud Klein Ilana Kremer ltzhak Levav Yuval Melamed Shlomo Mendlovic Ronnen Segman Eliezer Witztum Gil Zalsman Zvi Zemishlany International Advisory Board

Paul Appelbaum Yoram Bilu Boris Birmaher Aaron Bodenheimer Stephen Deutsch Carl Eisdorfer Michael First Helen Herrman Julian Leff Ellen Liebenluft John Mann Phyllis Palgi Soumitra Pathare Daniel Pine Bruce Pollock Dan Stein Robert Wallerstein Myrna Weissman Associate editor

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Israeli Jewish and Arab Children Exposed to Rocket Attacks Before and After Teacher-Delivered Intervention Leo Wolmer, Daniel Hamiel, Michelle Slone, Maya Faians, Mayrav Picker, Tal Adiv and Nathaniel Laor

174 > Predictors of Professional Quality of Life among Physicians in a Conflict Setting: The Role of Risk and Protective Factors Yeela Haber, Yuval Palgi, Yaira Hamama-Raz, Amit Shrira and Menachem Ben-Ezra

210 > The Effects of the Survival

Characteristics of Parent Holocaust Survivors on Offsprings’ Anxiety and Depression Symptoms

Yael Aviad-Wilchek, Diana Cohenca-Shiby and Yehuda Sasson

217 > Book reviews

Yoram Barak, Shelly Tadger, Hava Ben Shalom

182 > Somatization and Psychiatric Symptoms among Hospital Nurses Exposed to War Stressors

Menachem Ben-Ezra, Yuval Palgi Amit Shrira andYaira Hamama-Raz

Hebrew Section

222

> Abstracts

Jaswant Guzder Jewish General Hospital, Montreal, Canada, transcultural and child psychiatrist, psychoanalyst, artist and a mother This painting is from a series of portraits on migrating women who have to integrate vastly different worlds and identities. The portraits in this series were shown in mumbai and were meant to depict how we are marked by emotions as we move through experience and time.

Isr J Psychiatry Relat Sci - Vol. 50 - No 2 (2013)

The Relations Between Posttraumatic Stress Disorder Symptoms and Disorder of Extreme Stress (Not Otherwise Specified) Symptoms Following War Captivity Gadi Zerach, PhD,1 and Zahava Solomon, PhD2 1

Department of Behavioral Sciences, Ariel University Israel School of Social Work, Tel Aviv University, Ramat Aviv, Israel

Abstract Objective: War captivity is a recognized pathogenic agent for both posttraumatic stress disorder (PTSD) symptoms and disorder of extreme stress not otherwise specified (DESNOS) symptoms, also known as Complex PTSD. However, the relationship between the two disorders remains unclear. While some scholars assume that the two diagnoses are overlapping and share the same predictors, others believe that the two diagnoses are relatively independent and differ in phenomenology and functional impairment. This study aims to assess both PTSD and DESNOS symptoms and their inter-relations among ex-prisoners of war (ex-POWs) and matched controls, 35 years after the end of the war. Method: The sample included two groups of male Israeli veterans from the 1973 Yom Kippur War: ex-POWs (n = 176) and comparable veterans who had not been held captive (n = 118). PTSD and DESNOS symptoms, battlefield and captivity stressors, and ways of coping in captivity were assessed using self-report questionnaires in 2008. Results: Ex-POWs reported a higher number of PTSD symptoms and higher rates of PTSD symptoms that fill criteria for the diagnosis of PTSD than controls. Furthermore, ex-POWs reported a higher number of DESNOS symptom clusters and higher rates of DESNOS symptoms that fill criteria for the diagnosis of DESNOS. Moreover, we found positive relationships between PTSD symptom clusters and DESNOS symptom clusters.

Address for Correspondence: â&#x20AC;&#x2020; gadize@ariel.ac.il

148

Finally, weight loss and mental suffering in captivity, loss of emotional control and total number of DESNOS symptoms predicted total number of PTSD symptoms. However, only the total number of PTSD symptoms predicted the total number of DESNOS symptoms. Conclusions: This study demonstrated the heavy and extensive toll of war captivity, three decades after the ex-POWsâ&#x20AC;&#x2122; release from captivity. Importantly, approaching the publication of DSM-5, this study depicts both the high number of DESNOS symptom clusters alongside PTSD symptoms and highlights the complex relationship between the two diagnostic entities. Thus, DESNOS characteristics might be viewed as associated features of PTSD but also that the symptoms of PTSD are the core foundations of DESNOS.

Introduction Participation in war entails highly traumatogenic experiences (1). Combatants often face exposure to physical injury and potential loss of life. As compared to combat veterans who were not taken captive, former prisoners of war (ex-POWs) endure both the trauma of combat and the extreme nature of captivity trauma. Specifically, captivity trauma occurs in circumstances under which a victim cannot escape and is deliberately traumatized and controlled by his or her captors (2). Moreover, the

Gadi Zerach, PhD, Department of Behavioral Sciences, Ariel University , Ariel 40700, Israel.

Gadi Zerach and Zahava Solomon

use of psychological tactics aimed at breaking and altering the prisoner’s psyche is common (3). Gradually a deep relationship between the captive and the captor is formed in which the captive is highly dependent on the captor for both survival and human communication. This pathological relationship sometimes results in a transformation of the perception of the captor from the threatening enemy into a benevolent-malevolent powerful source (4). Research on adaptation following war captivity has found ex-POW’s to be a high risk group for elevated psychological distress, including Posttraumatic Stress Disorder (PTSD). High rates of PTSD, ranging from 16% to 88%, were observed in ex-POWs samples (5, 6). Among Israeli veterans of the 1973 Yom-Kippur War, 23.2% of ex-POWs and only 4.3% of the matched group (i.e., veterans who participated in the same war and were not held captive) met PTSD criteria assessed as far as 30 years after the war (7). Despite the significant utility of the PTSD diagnosis, since its formulation it has been consistently argued that it is not an exhaustive diagnosis and only partially covers the range of posttraumatic psychopathology (e.g., 8). Several prominent clinicians have argued that the current diagnosis does not address the complicated and enduring symptomatology associated with exposure to prolonged and repeated traumas such as child sexual abuse and war captivity (e.g., 9, 10). In the same vein, several empirical studies confirmed that exposure to severe inter-personal trauma was implicated in symptoms far more varied than those acknowledged by the current DSM diagnosis of PTSD (e.g., 11, 12). To fill this gap, a new diagnosis termed “disorders of extreme stress not otherwise specified” (DESNOS) or “complex PTSD” (CPTSD) was suggested (13). While the exposure of “simple” or type I trauma is mostly a single event which is limited in time, the complex trauma occurs repeatedly and cumulatively, usually over a period of time. Furthermore, simple trauma usually develops following exposure to either a nature disaster (e.g., tsunami) or human-made aggression (e.g., rape), while DESNOS often results from more severe inter-personal trauma in a dose-respondent manner (14, 15). With regard to the clinical presentation, individuals with DESNOS suffer from characterological changes, beyond the PTSD symptoms (16). According to the DSM-IV field trial (13, 17) DESNOS consists of chronic alterations in seven aspects of selfregulation and psycho-social functioning: (a) regulation

of affect and impulses, (b) physical self-regulation (i.e., somatization), (c) attention or consciousness, (d) perception of perpetrator or perpetrators, (e) sense of self and identity, (f) relationships with others, and (g) systems of meaning or sustaining beliefs (i.e., hopelessness). Only a few empirical studies have examined and validated DESNOS concept. Studies have shown that DESNOS is prevalent in severely traumatized samples such as borderline personality disorder patients (e.g., 18), but only a few studies examined DESNOS among combat veterans (e.g., 19). For example, in 84 non-acute residential inpatient male combat veterans, 58% met diagnostic criteria for life-time DESNOS (8). To the best of our knowledge there are no other studies that examined DESNOS symptoms among ex-POWs. The association between DESNOS and PTSD diagnoses is somewhat unclear. One formulation suggests that DESNOS is an associated feature of PTSD. This formulation gained support from the DSM-IV field trial study that found a considerable overlap between DESNOS and PTSD (17). One prediction of this formulation is that the predictors of PTSD are also the predictors of DESNOS. Other studies, however, reported that the two diagnoses are relatively independent and differ in phenomenology and functional impairment (8). From this perspective one can argue that the predictors of PTSD would be different from the predictors of DESNOS. This study aims to clarify relations between PTSD symptoms and DESNOS symptoms with examination of the war-related risk factors of these two phenomena. With the publication of the DSM-5, understanding the relations between the two diagnoses can contribute to the formulation of a more comprehensive and clinically sensitive stress-related diagnosis (20). Moreover, understanding the differences and similarities between the two diagnoses might lead to the development of different treatment strategies (21). The empirical literature identified several risk factors for post-captivity psychopathology. Among these factors are socio-demographic and military factors, such as lower level of education, younger age, and lower military rank (e.g., 22). Furthermore, the socio-political conditions of the war and the timing of captivity (23), captivity location and duration (e.g., 24), pre-captivity personality factors (25), and social support during and after captivity (26), were identified as significant factors impacting on postcaptivity psychopathology. It has been suggested that the strongest predictors of PTSD are the severity of captivity in the form of perception of torture experiences (27), and weight loss during 149

ptsd Symptoms and Disorder of Extreme Stress Symptoms Following War Captivity

imprisonment (28). It is worth noting that it was suggested that the cumulative effect of captivity stressors is not simply additive but multiplicative. Thus, in conditions in which the ex-POWs experienced subjective lack of control, the captivity stressors of torture, humiliation and deprivation are greatly magnified (3). In some cases, the experience of lack of control might continue to accompany the ex-POW’s posttraumatic reactions, even years after the release from captivity (2). Far fewer studies examined risk factors for DESNOS. For example, a number of studies found a high incidence of DESNOS in women reporting childhood sexual abuse before the age of 13 (18). This relationship was found in both male and female participants, with various psychiatric disorders. Other studies found that along with early childhood trauma, the perceived psychological impact of exposure to the conflict in Northern Ireland and reduced inter-personal connectedness were significant risk factors for DESNOS (29). Ford (8) also found that participating in war-time atrocities was a significant risk factor for DESNOS. In spite of the proposed relational-based traumatic experience of captivity in DESNOS etiology, most of the studies were performed on children who were victims of repeated trauma, so captivity stressors were not examined as possible predictors of DESNOS symptoms. The present study aims to assess PTSD and DESNOS symptoms and their inter-relationship among ex-POWs of the 1973 Yom-Kippur War and comparative veterans who fought in the same war but were not held in captivity. More specifically, we aim to assess group differences in (1) rates of PTSD and DESNOS symptoms that fill criteria for the diagnosis of PTSD and DESNOS, (2) total number of PTSD and DESNOS symptoms, (3) relationships between PTSD symptom clusters and DESNOS symptom clusters and captivity-related variables, and (4) predictors of both PTSD and DESNOS symptoms. Method Participants and Procedure

This study is part of a longitudinal study that examines the psychological and psychosocial consequences of captivity among Israeli ex-POWs (for more details see 30). This study is part of the third wave of measurement that was carried out in 2008. According to records of the Israeli Ministry of Defense, 240 soldiers serving in the Israeli Army land forces were taken prisoner in the 1973 Yom Kippur War. Of the 240 ex-POWs, 11 could not be located, 20 had died, 11 live abroad and 6 could not 150

participate due to deterioration in their mental status. Of the remaining 192 ex-POWs, 176 participated in this study. In addition, 280 veterans were sampled from the Israel Defense Forces (IDF) computerized database. These individuals also participated in the Yom Kippur War, but were not taken captive and were matched to ex-POWs on military background and socio-demographic status. Of these, 185 participated at first assessment and 118 took part in this study (20 could not be located/refused and 5 had died). No significant differences were found between the exPOWs and control groups in the following background variables: age, education, father’s country of origin, military assignment during the war, and participation in war activity prior to the Yom Kippur War. The only significant difference was found in military rank, with a higher rate of soldiers (as opposed to officers or NCOs) among ex-POWs compared to controls (χ2 (2) = 8.55, P < 0.05). The two groups did not differ on socio-demographic variables such as age (M = 57.91, SD = 3.52, for ex-POWs and M = 57.89, SD = 3.57, for controls), length of marriage (M = 28.48, SD = 6.86, for ex-POWs, M = 26.44, SD = 6.41, for controls), divorce rate (5.5% of ex-POWs and 5% of controls had divorced), or number of children (M = 3.27, SD = 1.12, for ex-POWS, M = 3.24, SD = 1.33, for controls). Procedure

All of the participants had taken part in a 2008 study by Solomon et al. (31). Approval for this study was given by both IDF and Tel Aviv University human subject committees. The names of ex-POWs were passed on by IDF authorities as part of the periodic examination of veterans after their military service. We contacted the participants by telephone and, after explaining the purpose of our study, asked them to take part in it. Questionnaires were administered in the participants’ homes or in other locations of their choice. Before filling out the questionnaires, the participants signed an informed consent agreement. Measures

The Posttraumatic Stress Disorder (PTSD) Inventory (32) taps the 17 PTSD symptoms listed in the DSM-IV (33). Participants were asked to rate how often they suffered from each symptom in the previous month on a scale ranging from 0 (not at all) to 4 (very often). The number of positively endorsed symptoms (participants

Gadi Zerach and Zahava Solomon

who choose only 3 (often) or 4 (very often)) was calculated and the symptom count was used to operationalize PTSD both as a continuous variable of number of posttraumatic symptoms and as a dichotomized DSM diagnosis. We operationalized the PTSD diagnosis, using DSM-IV symptom criteria; that is, at least one intrusion symptom, three avoidant symptoms and two hyperarousal symptoms. The inventory has proven psychometric properties in terms of high test-retest reliability (α=0.93), concurrent validity, and convergent validity compared with structured clinical interviews conducted by trained psychiatrists and mental health professionals (34). In this study, the inventory had high internal consistency (α Cronbach= 0.96 for total posttraumatic symptoms, 0.93 for intrusion, 0.90 for avoidance, 0.91 for hyper-arousal). DSM-IV-TR also specified the F criterion as clinically significant distress or impairment in the social area, occupational area, or other important areas of functioning. In order to follow DSM-IV-TR PTSD diagnosis F criteria we used one more index of work dysfunction. We defined work dysfunction as not working in the time of the study. Disorders of Extreme Stress-NOS questionnaire. In the absence of a widely used standardized self-report questionnaire that taps characteristics of DESNOS or complex PTSD, we constructed a self-report questionnaire for the purpose of the present study. The questionnaire is based on a translation and adaptation of the Revised Structured Interview for Disorders of Extreme Stress-NOS (SIDES-R) (13, 35). Participants were asked to note if they have undergone the mentioned experience the previous month (yes vs. no). The questionnaire consists of 38 items that form six theoretically-based categories: Alteration in the regulation of affect and impulses (15 items; Cronbach’s alpha, α = .80); Alterations in attention and consciousness (3 items; α = .52); Alterations in self-perception (5 items; α = .69); Alteration in relationships with others (5 items; α = .55); Somatization (3 items; α = .50); and Alterations in systems of meaning (4 items; α = .72). Cronbach’s alpha for the total scale in the current study was .88. Severity of captivity. This was assessed using two measures: first, participants were asked about injuries in combat and captivity (yes/no). Second, in the absence of medical records after release, participants were asked to report on the amount of weight lost in captivity, which has been documented to be a valid indicator of the physical severity of captivity (36). Subjective suffering during captivity. Participants

were asked to rate on a scale of 1-5, (a) the severity of physical abuse, (b) the severity of psychological abuse, and (c) the severity of humiliation to which they had been subjected. The score for each respondent was the average of these three. Psychological responses during captivity. In the absence of any valid and reliable standardized measure, we constructed a 23-item self-report questionnaire, based on both clinical interviews with ex-POWs and a literature review. Factor analysis with Varimax rotation revealed three main factors that explained 38.1% of the variance. Factor 1 explained 14.6% of the variance and consisted of nine items describing active coping (e.g., “I was busy learning new things”). Factor 2 explained 12.14% of the variance and consisted of six items describing a loss of emotional control (e.g., “I felt I was going crazy”). Factor 3 explained 11.4% of the variance and consisted of eight items describing detachment (e.g., “I closed myself off from the world”). Socio-demographic background. Items assessed included: age, father’s country of origin, family status, religiosity, education and income level. Results Rates of PTSD symptoms that fill criteria for the diagnosis of PTSD and number of PTSD symptoms Among the ex-POWs, 58 participants (34.7%) met the criteria for PTSD diagnosis by composition of PTSD symptoms compared to 3 participants (2.5%) among the controls (χ² (1) = 45.58, p<0.00). We also performed MANOVA analysis in order to assess group differences in the total number of PTSD symptoms and the number of symptoms in each of the PTSD clusters. As can be seen in Table 1, ex-POWs reported more PTSD symptoms and more symptoms on each of the PTSD symptom clusters (F (3,290) = 59.55, p<.00, η²ρ =.38). Rate of DESNOS total symptoms and DESNOS symptom clusters We used the SIDES-R recommendations for the determination of a “case” or “diagnosis” of DESNOS (for full details please see 19, 22). As can be seen in Table 2, among the ex-POWs, 23 participants (13.1%) met the full DESNOS criteria by composition of DESNOS symptoms compared to one participant (1%) among the controls (χ² (1) = 13.94, p<.00). Furthermore, we assessed the prevalence of DESNOS symptom clusters and subcategories among ex-POWs and controls. As can be seen 151

ptsd Symptoms and Disorder of Extreme Stress Symptoms Following War Captivity

Table 1. Means, Standard Deviations and F values for total number of PTSD symptoms, PTSD symptom clusters and total number of DESNOS symptom clusters by study group Ex-POWs (N=175)

Ex-POWs (N=175)

Controls (N=117)

F (1,291)

η²ρ

Total PTSD symptoms

9.54

5.15

2.27

3.52

178.41***

0.38

Intrusion

2.64

1.98

0.27

0.80

122.99***

0.44

Avoidance

3.60

2.22

0.77

1.44

149.16***

0.34

Hyper-arousal

3.29

1.1.69

1.08

1.59

125.72***

0.30

Total DESNOS Symptoms

3.63

1.56

1.52

1.41

136.29***

0.32

***p<.001

in Table 2, ex-POWs reported significantly higher rates in all DESNOS symptom clusters and specifically high rates of alterations in relations, alterations in system of meanings with others symptoms and alterations in attention or consciousness. In addition, a MANOVA analysis showed that ex-POWs reported general higher number of DESNOS symptoms compared to the controls (see Table 1). Relationships between PTSD and DESNOS symptom clusterss among ex-POWs In this section we examined the inter-relations between the study variables among ex-POWs. Specifically, we examined Pearson correlations between PTSD symptoms clusters and DESNOS symptoms clusters. As can be seen in Table 3, results revealed significant positive inter-relations between PTSD symptom clusters (r=0.61 to r=0.70). Significant positive inter-relations were also observed between DESNOS symptom clusters (r=0.17 to r=0.50). It is worth noting that significant relations were not found between altered affect regulation and somatization and between somatization and altered relationships. Furthermore, the altered beliefs cluster was found to relate only to altered relationships. Most importantly, we found a set of significant interrelations between posttraumatic symptom clusters and DESNOS symptom clusters apart from altered beliefs. The range of inter-relations was between r=0.15 to r=0.55 with stronger relations between intrusion, avoidance and hyper-arousal clusters and altered affect regulation, dissociation and altered self-perception clusters. In addition, as can be seen in Table 3, all the “subjective suffering in captivity” variables were positively associated with PTSD symptom clusters (r=0.33 to r=0.57) and the altered affect regulation, dissociation and altered 152

Table 2. Prevalence of DESNOS assessment and DESNOS clusters by study group Controls (N=117)

Yes (%)

χ² (1)

DESNOS total

13.1

0.9

13.94***

Alternations in regulation of affect and impulses Affect regulation Anger modulation Self destructiveness Suicidal preoccupation Sexual preoccupation

89 110 47 26 18 99

51.1 63.2 27 14.9 10.8 56.9

20 26 18 9 2 34

17.1 22.2 15.4 7.7 1.8 29.1

34.63*** 47.23*** 5.45* 3.47 8.34** 21.8***

Alternations in Attention or Consciousness Amnesia Dissociative episodes

66 62 66

67.9 37.3 37.9

15 12 15

12.8 10.4 12.8

23.07*** 26.41*** 21.96***

Alternations in self perceptions No control over life Permanently damaged Guilt Shame Different than others

94 118 42 41 15 73

54 70.7 25.1 24.8 8.9 44

15 18 5 11 2 23

12.8 16.1 4.3 9.6 1.7 20.4

50.69*** 80.94*** 22.39*** 11.69** 7.62* 17.70***

Alternations in relations with others Inability to trust Avoid people Conflicts with others Re-victimization Victimizing others

161 96 81 96 72 34

92.5 57.8 48.5 58.5 43.4 20.5

68 15 19 45 21 14

58.1 13.3 16.5 39.5 18.3 12.3

49.40*** 56.44*** 31.36*** 10.80** 20.38*** 4.54

Symptoms of somatization Somatic diseases Sought medical care No medical explanation

78 78 76 58

47 47 45.8 36.9

22 22 41 10

19.3 19.1 36 9.4

22.57*** 23.98*** 3.50 26.05***

Alterations in system of meanings Pessimistic about the future Pessimistic about relationships Satisfaction with work Loss of beliefs

144 96 113 103 108

82.8 57.8 69.8 64.4 67.1

39 14 13 17 20

33.3 12.4 11.8 15.2 17.9

73.22*** 58.85*** 88.90*** 65.26*** 66.48***

*=p<.05; **=p<.01; ***=p<.001

self-perception clusters (r=0.17 to r=0.37), but not with the other three DESNOS clusters. With regard to the psychological responses during captivity, we found positive interrelations between the factor named “loss of emotional control” and PTSD symptom clusters (r=0.41 to r=0.62) and DESNOS symptom clusters (r=0.18 to r=0.52) beside altered beliefs. Predicting total numbers of PTSD and DESNOS symptoms Three-step hierarchical regression analyses were conducted to examine the unique contribution of adaptation to captivity variables to the total number of PTSD and DESNOS symptoms among ex-POWs. In the first step of the regressions, we entered six variables that tap the

Gadi Zerach and Zahava Solomon

Table 3. Pearson correlation coefficients among PTSD and DESNOS symptom clusters and captivity experiences variables among ex-POWs 1 1. PTSD total symptoms

2. Intrusion

.88***

3. Avoidance

.87***

.62***

4. Hyper-arousal

.86***

.70***

.61***

5. DESNOS total symptoms

.59***

.53***

.47***

.54***

6. Affect regulation

.54***

.55***

.36***

.53***

.72***

7. Dissociation

.51***

.45***

.38***

60***

.50***

8. Altered selfperception

.43***

.34***

.41***

.37***

.63***

.34***

.41***

9. Altered relationships

.19**

.15*

.19**

.16*

.49***

.25***

.19**

.28***

10. Somatization

.22**

.17*

.20**

.31***

.10

.20**

.17*

.06

11. Altered beliefs

.09-

-.07

-.10

-.09

.19***

.01

-.05

.05

.41***

.01

12. Physical suffering in captivity

.48***

.33***

.48***

.28***

.33***

.17*

.24**

.05

.11

-.08

13. Mental suffering in captivity

.58**

.57***

.42***

.53***

.37***

.25**

.11

.15*

-.09

.78***

14. Humiliation in captivity

.45***

.41***

.37***

.41***

.33***

.36***

.22**

.21**

.07

.09

.03

.50***

.66***

15. Active coping

.01-

-.07

.02

.04

.05

-.14

-.11

.08

.15

-..02

.13

-.69

-.03

-.01

16. Loss of emotional control

.58***

.62***

.41***

.51***

.55***

.38***

.52***

.33***

.18*

.22**

.08

.22**

.25**

.30***

.00

17. Detachment

.13

.10

.14

.10

.08

.16*

-.04

.08

.15

-.10

.05

.22**

.25***

.30***

.00

Note: *p < .05, **p < .01, ***p < .001

captivity experiences: being wounded during capture and during captivity, weight loss (kg), physical and mental suffering, and humiliation during captivity. In the second step, we entered the three factors of coping in captivity: active coping, loss of emotional control and detachment coping. In the third step, we entered the total number of DESNOS symptoms (when predicting PTSD symptoms) or alternatively we entered the total number of PTSD symptoms (when predicting DESNOS symptoms). Table 4 presents regression coefficients for the total number of PTSD and DESNOS symptoms. The total set of variables explained 58.7% of the variance of the total number PTSD symptoms (F (10, 101) = 16.75, p<.00). As can be seen in Table 4, in the last model weight lost during captivity, mental suffering during captivity, loss of emotional control as a way of coping, and total number of DESNOS symptom clusters in the last month were associated with an increased probability to report more PTSD symptoms. With regards to DESNOS, the total set of variables explained 43.5% of the variance (F (10, 101) = 9.56, p<.00).

As can be seen in Table 4, only the total number of PTSD symptoms in the last month was associated with increased probability to report DESNOS symptoms. It is worth noting that in the model of the second step physical injury and humiliations, and loss of emotional control as way of coping, were all positively related to the total number of DESNOS symptoms. These results suggest that PTSD symptoms (entered in the third step) might mediate the relationship between captivity experience variables and DESNOS symptoms. Discussion The present study reveals that Israeli ex-POWs, 35 years after their release from captivity, display a higher number of PTSD and DESNOS symptoms, in comparison to veterans of the control group. Furthermore, significant relationships between captivity-related variables and PTSD symptom clusters and DESNOS symptom clusters were found. Most importantly, we found that weight loss, mental suffering and loss of emotional control in 153

ptsd Symptoms and Disorder of Extreme Stress Symptoms Following War Captivity

Table 4. Hierarchical regressions predicting total number of PTSD and DESNOS symptoms among ex-POWs Total number of PTSD symptoms Model 1

Model 2

Total number of DESNOS symptoms Model 3

Model 1

Model 2

Model 3

Variables

SE B

Wounding during capture (yes/no)

.07

.04

.07

.04

.05

.06

.05

.01

.09

.01

-.02

.08

-.02

-.04

.07

-.04

Wounding during captivity (yes/no)

.19

.08

.19*

.18

.07

.18*

.10

.07

.10

.24

.08

.24**

.23

.09

.23**

.13

.07

.13

Weight lost (Kg)

.14

.07

.14

.11

.07

.11

.14

.07

.14*

-.04

.09

-.04

-.06

.08

.03

-.12

.07

-.12

Physical suffering in captivity

-.07

.11

-.07

-.01

.10

-.05

-.01

.09

-.01

-.04

.12

.02

.03

.10

-.05

.03

.11

.03

Mental suffering in captivity

.49

.14

.45**

.27

.14

.25*

.25

.12

.27*

.25

.15

.24

.06

.15

.06

-.08

.14

-.07

Humiliation in captivity

.16

.11

.15

.13

.10

.12

.04

.09

.03

.12

.14

.26*

.25

.12

.23*

.18

.10

.17

Active coping

.01

.07

.01

.06

-.01

.03

.07

.03

.07

.03

Loss of emotional control

.37

.08

.35***

.23

.08

.22**

.34

.09

.33***

.15

.09

.15

Detachment

.07

.02

.08

.03

.01

.07

-.01

.50

.10

.51***

Total number of DESNOS symptoms

.06

.07

.38

.08

.37***

Total number of PTSD symptoms Adjusted R2 F change

40.7%

49.2%

58.7%

23.6%

30.7%

43.5%

F(6,105)=13.69***

F(3,102)=6.87***

F(1,101)=24.29***

F(6,105)=6.70***

F(3,100)=4.58**

F(1,101)=24.29***

Note: *p < .05, **p < .01, ***p < .001

captivity, and the total number of DESNOS symptoms significantly contribute to the total number of PTSD symptoms. However, the total number of PTSD symptoms concealed the contribution of captivity-related variables and left PTSD symptoms to be the exclusive predictor of DESNOS symptoms. These findings once again demonstrate the potent pathogenic effects of war captivity that often follow highly traumatic combat experiences (e.g., 37). This finding is in line with previous studies, showing that war captivity often results in long-term traumatic consequences ranging from specific posttraumatic symptoms (6) to general psychiatric symptomatology (27). As compared to combat veterans who were not taken captive, ex-POWs endure both the trauma of combat and the trauma of captivity. In addition to extending the duration of the traumatic experience, a factor that is known to affect the severity of one’s psychological reaction (38), the trauma of captivity draws on the possibly depleted coping resources (29). Therefore, the vulnerability of ex-POWs to PTSD symptoms lends support to the clinical observation that multiple, recurrent and long-lasting traumatic experi154

ences are associated with negative outcomes in the form of anxiety disorders (e.g., 6). One of the innovations of this study was the assessment of characterological changes in the form of DESNOS symptoms among ex-POWs. Although it was previously suggested that ex-POWs might suffered from DESNOS symptoms similar to childhood sexual abuse survivors (6), to the best of our knowledge this is the first empirical study that assessed and found higher numbers of DESNOS symptoms among ex-POWs than combat veterans. Specifically, we found that about half of the ex-POWs reported alterations in each of the DESNOS six symptom clusters with higher rates of alterations in inter-personal relations, system of meanings and in attention or consciousness. These findings lend support to clinical observations suggesting that repeated and prolonged trauma may lead to major personality changes, including significant changes in relationships and identity (9). These findings are also in line with previous empirical research showing that war captivity can lead to alterations in basic attachment orientation (31) and in social and marital functioning

Gadi Zerach and Zahava Solomon

and satisfaction (39). The trauma of captivity is deeply inter-personal, as it occurs within the relationship between captive and captor. Torture and humiliation are intentional efforts to “break” one’s spirit (40), inflicted by people one gets to know and on whom one is dependent for survival on a daily basis. According to Herman (4), this kind of ongoing and directed abuse may entail serious damage to one’s self, as well as to one’s inter-personal life. Consistent with our third hypothesis we found significant associations between PTSD and DESNOS symptom clusters and captivity-related variables. This study revealed moderate relations between the total number of PTSD symptoms and DESNOS symptoms and weak to moderate relations between PTSD symptom clusters and DESNOS symptom clusters (besides the alterations in the system of meanings). These findings were inconsistent with the DSM–IV field trial showing a 92% comorbidity rate between DESNOS and PTSD (17). Alternatively, several studies – mostly among abused women samples – suggested that despite a substantial overlap between PTSD and DESNOS, the two conditions were substantially different in terms of symptoms and functional impairment, with DESNOS relating to a more extensive impact (8). These findings, therefore, call into consideration the complex sequela of captivity that specifically affect inter-personal domains such as psychotherapy and social relations that are not fully captured by PTSD. This study also pointed to differential captivity-related predictors of PTSD and DESNOS symptoms. We found that weight loss, mental suffering and loss of emotional control in captivity, and the total number of DESNOS symptoms significantly contributed to the total number of PTSD symptoms. These results are consistent with other studies that revealed that the strongest predictors of PTSD are the severity of captivity in the form of captivity tortures (e.g., 27) and weight loss during imprisonment (e.g., 28). Our results point to identification of both “objective” risk factors (i.e., weight loss) and “subjective” risk factors such as the reports of mental suffering during captivity. With regard to the loss of emotional control in captivity, we found that it predicted both PTSD and DESNOS symptoms. This finding points to the importance of that experience in the negative ramifications of war captivity. Clinical observations reported that after a period of time POWs stop thinking about release from prison but rather focus on ways to survive in captivity. Two main coping modes are “emotional defeat” and development of “control strategies” (e.g., 41). The loss of emotional control – as manifested by a wish to die or by the feeling

that one is going insane – reflects the loss of emotional autonomy and the acceptance of defeat. A few studies documented the association between loss of emotional control and PTSD (3) and between catastrophic appraisals and PTSD (42). It is important to note that there is also a possibility that the ex-POW’s current psychological state of considerable distress colored his memory of having a lack of control in captivity. Importantly, in the final model for prediction of DESNOS symptoms the inclusion of the total number of PTSD symptoms concealed the contribution of captivity-related variables. First, PTSD symptoms are the sole predictor of DESNOS symptoms, but not vice versa. These differential patterns suggest that DESNOS characteristics might be viewed as associated features of PTSD but also that the symptoms of PTSD are the core foundations of DESNOS. Second, these results suggest that PTSD symptoms might mediate the relations between captivity-related variables and DESNOS. The current study suffers from several limitations. First, this study is cross-sectional, and therefore causal interpretations should be made with caution. Furthermore, shared method variance should also be suspected in the analyses. Second, we used self-report measures that, although commonly used in trauma studies, may suffer from report biases. When dealing with clinical diagnoses, it should be noted that there might be differences between the rates derived from clinical diagnosis and self-reports. Third, this is the first study to use the SIDES structural interview as a self-report measure in this format. Hence, the results should be taken as preliminary results until this measure would be validated. Fourth, this study lacks spouse reports concerning the significant inter-personal effects of captivity on ex-POWs’ lives. This is particularly relevant to the DESNOS symptoms of “alteration in relations with others.” Despite these limitations, the findings of the current study make an important contribution to the clinical knowledge regarding enduring changes in the personality of ex-POWs. This study demonstrates the heavy toll of war captivity decades after release. Importantly, with the publication of DSM-5, this study emphasizes the high rates of DESNOS symptom clusters which are comorbid with PTSD symptoms and the differential risk factors of the two phenomena. References 1. Vogt D, Smith B, Elwy R, Martin J, Schultz M, Drainoni M, Eisen S. Predeployment, deployment, and post deployment risk factors for posttraumatic stress symptomatology in female and male OEF/OIF veterans. J Abnorm Psychol 2011; 120: 819-831.

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ptsd Symptoms and Disorder of Extreme Stress Symptoms Following War Captivity

2. Başoğlu MA. Multivariate contextual analysis of torture and cruel, inhuman, and degrading treatments: Implications for an evidencebased definition of torture. Am J Orthopsychiatry 2009; 79: 135-145. 3. Punamaki RL, Qouta SR, El Sarraj E. Nature of torture, PTSD, and somatic symptoms among political ex-prisoners. J Trauma Stress 2010; 23: 532-536. 4. Herman JH. Trauma and recovery. New York, N.Y.: Basic Books, 1992. 5. Al-Turkait FA, Ohaeri JU. Prevalence and correlates of posttraumatic stress disorder among Kuwaiti military men according to level of involvement in the first Gulf War. Depress Anxiety 2008; 25: 932-941. 6. Rintamaki LS, Weaver FM, Elbaum PL, Klama EN, Miskevics SA. Persistence of traumatic memories in World War II prisoners of war. J Am Geriatr Soc 2009; 57: 2257-2262. 7. Neria Y, Solomon Z, Dekel R. An eighteen-year follow-up study of Israeli prisoners of war and combat veterans. J Nerv Ment Dis 1998; 186: 174-182. 8. Ford JD. Disorders of extreme stress following war-zone military trauma: Associated features of posttraumatic stress disorder or comorbid but distinct syndromes? J Consult Clin Psychol 1999; 67: 3-12. 9. Herman JL. Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. J Trauma Stress 1992; 5: 377-391. 10. Finkelhor D. The traumatic impact of child sexual abuse: A conceptualization. J Orthopsychiatry 1985; 55: 530–541. 11. Ford JD, Kidd P. Early childhood trauma and disorders of extreme stress as predictors of treatment outcome with chronic PTSD. J Trauma Stress 1998; 11: 743-761. 12. Van der Kolk BA, Courtois AC. Editorial comments: Complex developmental trauma. J Trauma Stress 2005; 18: 385-388. 13. Pelcovitz D, Van der Kolk BA, Roth S, Mandel FS, Kaplan S, Resick PA. Development of a criteria set and a structured interview for disorders of extreme stress (SIDES). J Trauma Stress 1997; 10: 3-17. 14. Courtois CA. Complex trauma, Complex reactions: Assessment and treatment. Psychol Trauma 2008; 1: 86-100. 15. Terr LC. Childhood traumas: An outline and overview. Am J Psychiatry 1991; 148: 10-20. 16. Taylor S, Asmundson GJG, Carelton RN. Simple versus complex PTSD: A cluster analytic investigation. Anxiety Disord 2006; 20: 459-472. 17. Roth S, Newman E, Pelcovitz D, Van der Kolk BA, Mandel FS. Complex PTSD in victims exposed to sexual and physical abuse: Results from DSM-IV field trial for posttraumatic stress disorder. J Trauma Stress 1997; 10: 539-555. 18. McLean LM, Gallop R. Implications of childhood sexual abuse for adult borderline personality and complex posttraumatic stress disorder. Am J Psychiatry 2003; 160: 369-371. 19. Newman E, Orsillo SM, Herman DS, Niles BL, Litz B. The clinical presentation of disorders of extreme stress in combat veterans. J Nerv Ment Dis 1995; 183: 664-668. 20. Friedman, MJ, Resick, PA, Bryant, RA, Brewin, CR. Considering PTSD for DSM. Depress Anxiety 2011, 28: 750-769. 21. Luterek, JA, Bittinger, JN, Simpson, TL. Posttraumatic sequelae associated with military sexual trauma in female veterans enrolled in VA outpatient mental health clinics. J Trauma Dissociation 2011; 12: 261-274. 22. Sutker PB, Vasterling JJ, Brailey K, Allain A. Memory, attention, and executive deficits in POW survivors: Contributing biological and psychological factors. Neuropsychology 1995; 9:118-125.

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23. Ursano RJ, Wheatley RD, Carlson EH, Rahe AL. The prisoner of war: Stress, illness and resiliency. Psychiatr Ann 1987; 17: 532-535. 24. Sutker PB, Allain AN. Assessment of PTSD and other mental disorders in World War II and Korean Conflict POW survivors and combat veterans. Psychol Assess 1996; 8:18-25. 25. Schnurr PP, Friedman MJ, Rosenberg SD. Preliminary MMPI scores as predictors of combat-related PTSD symptoms. Am J Psychiatry 1993; 150: 479-483. 26. Ursano RJ, Rundell JR, Fragala MR, Larson SG, Wain HJ, Brandt GT, Beach BL. The prisoner of war. In: Ursano RJ, Norwood AE, editors. Emotional aftermath of the Persian Gulf War. Washington: DC: American Psychiatric, 1996: pp. 443-476. 27. Beal AL. Post-traumatic stress disorder in prisoners of war and combat veterans of the Dieppe Raid: A 50-year follow-up. Can J Psychiatry 1995; 40; 177-184. 28. Speed N, Engdahl B, Schwartz J, Eberly R. Posttraumtic stress disorder as a consequence of POW experience. J Nerv Ment Dis 1989; 177: 147-153. 29. Dorahy MJ, Corry M, Shannon M, MacSherry A, Hamilton G, McRobert G, Elder R, Hanna D. Complex PTSD, interpersonal trauma and relational consequences: Findings from a treatment receiving northern irish sample. J Affect Disord 2009; 112: 71-80. 30. Solomon Z, Dekel R. PTSD among Israeli ex-Prisoners of war: 18 and 30 years after release. J Clin Psychiatry 2005; 66: 1031-1037. 31. Solomon Z, Dekel R, Mikulincer M. Complex trauma of war captivity a prospective study of attachment and PTSD. Psychol Med 2008; 38: 1427-1434. 32. Solomon Z, Benbenishty R, Neria Y, Abramowitz M, Ginzburg K, Ohry A. Assessment of PTSD: Validation of the revised PTSD inventory. Isr J Psychiatry Relat Sci 1993; 30:110-115. 33. American Psychiatric Association. Diagnostic and statistical manual of mental disorder (4th ed.).Washington DC: Author. 1994. 34. Solomon Z. Convergent validity of posttraumatic stress disorder (PTSD) diagnosis: Self-report and clinical assessment. Isr J Psychiatry Relat Sci 1988; 25:46-55. 35. Van der Kolk B, Pelcovitz D, Herman JL, Roth S, Kaplen S, Spitzer RL. The disorders of Extreme Stress Inventory. Unpublished Manuscript, 1992. 36. Myers M, Kimbrell TA, Booe LQ, Freeman TW. Weight loss and PTSD symptom severity in former POWs. J Nerv Ment Dis 2005; 193: 278-280. 37. Favaro A, Tenconi E, Colombo G, Santonastaso P. Full and partial post-traumatic stress disorder among World War II prisoners of war. Psychopathology 2006; 39: 187-191. 38. Hunter JA. A comparison of the psychosocial maladjustment of adult males and females sexually molested as children. J Interpers Violence 1991; 6: 205-217. 39. Cook JM, Thompson R, Riggs DS, Coyne JC, Sheikh JI. Posttraumatic stress disorder and current relationship functioning among World War II ex-prisoners of war. J Family Psychol 2004; 18: 36-45. 40. Molica RF, Wyshak G, Lavelle J, Truong T. Assessing symptom change in Southeast Asian refugee survivors of mass violence and torture. Am J Psychiatry 1990; 147: 83-88 41. Avneri A. Coping in prison. MA thesis unpublished. Hebrew University, Jerusalem. 1982. 42. Bryant R, Guthrie R. Maladaptive appraisals as a risk factor for posttraumatic stress: A study of trainee firefighters. Psychol Sci 2005; 16: 749-752.

Isr J Psychiatry Relat Sci - Vol. 50 - No 2 (2013)

Mally Shechory-Bitton

The Impact of Repetitive and Chronic Exposure to Terror Attacks on Israeli Mothers’ and Children’s Functioning Mally Shechory-Bitton, PhD Department of Criminology, Bar-Ilan University, Ramat Gan, Israel and Department of Criminology, Ariel University, Ariel, Israel

Abstract Studies point to the pathogenic impact of exposure to terror. However, most focus on specific traumatic events. The current study focused on the impact of continuous ongoing exposure to terror attacks. It examined the extent to which children’s PTSD and behavior problems are a function of mothers’ PTSD, child and mother exposure to terror events, and child and mother fear. A sample of 152 mother and children dyads, all living in communities on Israel’s southern border, were surveyed. Results indicate that children’s posttraumatic symptoms are significantly and positively predicted by their exposure to terror events, their fear, and their mothers’ posttraumatic symptoms. In addition, children’s current behavioral and social problems are positively predicted by mothers’ posttraumatic symptoms. Results are discussed in light of the importance of subjective interpretation. The findings suggest that further research should examine additional cognitive and social contextual factors.

Introduction Numerous studies indicate the pathogenic impact of exposure to traumatic events such as natural disaster (1), war, terror, and conflict events on adults as well as children and youth (2-4). However, most of the research focuses on specific traumatic events, while the impact of continuous ongoing exposure to terror attacks (e.g., suicide bombers, mortar attacks) on mental health has Address for Correspondence:

rarely been examined (5-7), particularly among children. The outbreak of the Second Intifada (al-Aqsa Intifada, October 2000) in Israel, as well as the spate of subsequent attacks on Israeli civilians and continued mortar attacks from Gaza on communities in the Western Negev (6), following the disengagement from Gaza (a unilateral decision made by the Israeli government in 2005 to evacuate all Jewish settlements and Israel Defense Forces troops from the Gaza Strip) (8, 9), afforded an opportunity to narrow this knowledge gap. Over the years, those living in the area of conflict have been exposed to attacks, both directly as well as indirectly through the injury or death of friends, family or neighbors, and ceaseless media coverage of the attacks. Thousands of missiles and mortars have been launched into this populated area, usually accompanied by the wailing of sirens, resulting in dozens of fatalities and hundreds of injuries (5). In the present study an attempt was made to examine factors associated with the coping ability of children and with the threat to their life as a result of repetitive exposure to these conflict events, while focusing on various demographic features, with particular attention to the coping processes of mothers. Exposure to terror attacks and violence, especially continued exposure, may have significant repercussions that may result in emotional stress, such as posttraumatic stress disorder, depression and risk behaviors (4, 10-14). Although exposure to violent events affects adults as well, children constitute a special risk group. A literature review reveals that this exposure has a negative effect on children’s behavior, emotions and cognitive perceptions (e.g., 15, 16). The discernable negative effects on children are higher distress levels, fear and anxiety, more symptoms of depression, and reduced concentration, memory and learning skills (15-20). Children living in war zones

Mally Shechory-Bitton, PhD, Department of Criminology, Ariel University, Ariel, Israel

mally@bezeqint.net

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Impact of Repetitive Exposure to Terror Attacks on Mothers’ and Children’s Functioning

perceive the social world as less secure and demonstrate more negative behaviors and disobedience (17, 18, 20). There is a general consensus that war situations cause children great suffering, impair their normal development, and leave them with long-term and irreversible damage (19, 21). Yet, how children cope with exposure to traumatic events is associated with several factors: The extent of (subjective and objective) exposure to danger, perception and understanding of the trauma, the child’s age, reactions by the child’s environment and family and how they cope, are all factors that influence children’s coping. For example, studies conducted in Israel during the 1991 Gulf War found that children who resided in closer proximity to the region targeted by missiles suffered from higher levels of emotional distress, compared to those of children residing further away (22), and that children with more social support were less susceptible to posttraumatic distress (23, 24). In fact, studies show that in stressful situations parents constitute their children’s main source of support. Studies consistently point to a close and direct connection between parental support and reduced emotional stress among children (25). Positive child-parent relationships were found to be associated with both reduced stress and promoting adjustment during stressful events (26-28). This relationship serves to regulate children’s reactions in traumatic situations and may be the most influential factor in reported sense of distress (29-31). The few studies that examined parental support in situations of attack found that family cohesion and parental support enhanced the resilience of children in face of military threat (24, 32). Nonetheless, it is notable that continued exposure to attack events may also influence parents’ ability to provide their children with support, as they too may experience high levels of pressure and distress and be unable to support their children (33). It appears that in situations of conflict and threat, parent–child relationships are characterized by reciprocal concern about each other’s well-being, conflict and vulnerability (24). The literature states the significance of mothers’ coping style for their children. Mothers’ emotional adaptation serves as a defense protecting children from the effects of war and has an important role in preventing evolvement of the child’s disorder as well as the severity of its symptoms and its trajectory over time (34). Studies on mothers and children exposed to war and terror situations found strong associations between their psychological distress (35, 36). For example, by evaluating whether conjoined 158

maternal posttraumatic stress disorder and depression are associated with increased behavioral problems among preschool children after the September 11 attacks, maternal depression and PTSD were found to be associated with substantially increased child problems (37). Yet the association between the effect of mothers’ distress level (PTSD) on that experienced by their children has rarely been addressed (24, 37). The purpose of the study was to examine the extent to which children’s posttraumatic symptoms and behavior problems are a function of mothers’ posttraumatic symptoms, child and mother exposure to terror events, and child and mother fear. Furthermore, children’s behavior problems were examined with the purpose of assessing to what extent they may be predicted by the research variables over and above past behavior problems, thus controlling for past behavior problems. The main hypotheses were that: (1) Children’s levels of distress resulting from conflict tensions will be moderated by their mothers’ levels of distress; (2) objective exposure and subjective exposure (exposure to incidents and level of fear) will be positively correlated; and (3) continued exposure to stressful situations will have a negative effect on children’s behavioral measures. As such, a difference will be found between mothers’ assessment of their children’s behavior prior to the onset of mass mortar assaults on their homes (2005) and at the time of the research (2009). Method Participants

Participants were 152 mothers and their children (a total of 304 participants). Mothers were 28-56 years old (M=42.17, SD=5.26). They had been living in the Western Negev for up to 55 years (M=20.20, SD=13.35): About a quarter had lived there 10 years or less, another quarter had lived there for 11 to 17 years, another quarter 18-28 years, and the final quarter had lived in the Western Negev for over 29 years. Eighty six percent of the sample had lived in the Western Negev for over five years. All participant families were permanent residents, and most had more than one child. Most mothers were Israeli born (N=119, 79.9%), while others were mainly of European-American origins (N=23, 15.4%). Most mothers were married (N=135, 91.2%), while others were divorced or separated (N=12, 8.8%). They had up to 12 children, (M=4.01, SD=1.79). Most mothers had either an academic education (N=77, 51.0%) or a high school education (N=60, 39.7%). Most were

Mally Shechory-Bitton

employed full time (N=115, 76.2%), while others were either employed part time (N=9, 6.0%) or not working (N=27, 17.9%). Most of those employed had jobs in the educational field (N=57, 47.5%), helping occupations (N=14, 15.0%), administration (N=18, 15.0%), technical occupations (N=24, 20.0%), or blue-collar non-professional jobs (N=7, 5.8%). The children in the study were 90 girls (59.2%) and 62 boys (40.8%), between the ages of 10-14 (M=11.53, SD=1.04). Measurements

Objective exposure to terror and conflict events Objective exposure to terror and conflict events was assessed by Solomon and Lavi’s exposure-to-war and terror questionnaire (38). The questionnaire was originally written in Hebrew. The modified version used in the present study comprises 17 items covering different types of trauma-related incidents. For example: “A relative of mine was wounded by a missile.” The objective level of exposure was scored as the total number of terror incidents to which the respondent had been exposed; scores ranged from 0-17, with higher scores indicating greater exposure. Subjective exposure For each terror and conflict incident respondents reported having experienced, they were asked to indicate the level of fear felt at the time of the incident on a 4-point scale (1= not scared; 4= very scared). Subjective level of exposure was defined as the mean of the subject’s responses on this scale (see also: 12, 39). PTSD Inventory To assess the degree of posttraumatic stress symptomatology, mothers completed the self-report version of the PTSD Inventory (40). It contains 17 items reflecting three symptom categories, based on DSM-IV-TR (41): intrusion, avoidance and hyperarousal. Respondents were asked to indicate whether or not they experienced the symptom, on a 4-point scale ranging from 1 (not at all) to 4 (very much). The inventory has both high test-retest reliability and concurrent validity compared with clinical diagnosis (40). In the current study, the mean number of PTSD symptoms, as well as the mean number of symptoms in each cluster (intrusion, avoidance and hyperarousal) was assessed. Respondents were identified as having PTSD if they endorsed at least one intrusive symptom, three avoidance symptoms, and two hyperarousal symptoms in the PTSD inventory. Internal

consistencies for total and subscale scores were high at all assessments (Cronbach’s alpha .81-.93). Posttraumatic Stress Disorder Reaction Index for Children To assess the degree of posttraumatic stress symptomatology, children completed the self-report version of the CPTS-RI (42), containing 20 items assessing PTSD symptoms by DSM criteria. Respondents were asked to indicate whether or not they experienced the symptom, on a 5-point scale ranging from 0 (not at all) to 4 (very much). A total RI score ranging from 0-80 is obtained by summing all items after adjusting for reverse scored items. A Global Symptom Score (GSS) ranging from 0-80 is obtained by summing all items after adjusting for reverse scored items. Internal consistency for this study (Cronbach’s alpha = .91) was similar to that reported by previous studies using the Hebrew version (e.g., α = 0.86) (43). Clinical categories for PTSD symptom severity were used to classify participants according to their total RI score as follows: doubtful (0–11), mild (12–24), moderate (25–39), severe (40–59), and very severe (60–80). Child Behavioral Checklist (CBCL) To assess levels of aggression, anxiety and social problems among the children, three CBCL subscales (44, 45, 46) were used: the Anxious/Depressed Scale (18 items); the Social Problems Scale (13 items); and the Aggressive Behavior Scale (25 items). Each item is rated on a 0-1-2 scale for how truly/ accurately it describes the child (0 = does not apply to this child; 1 = occasionally or to some degree; 2 = very true or often true). Thus, the higher the score of each child the more severe his/her level of disturbance. The CBCL was designed to obtain standardized data on children’s range of behavioral competencies and problems as reported by their parents, teachers, or other informants observing the children under different conditions. It has been used extensively in research on child psychopathology, including in Israel (47). In order to check whether any change had occurred in children’s behavior, mothers completed the questionnaires twice to assess their children’s state both before the onset of attacks on their home and when completing the questionnaires (2009). Internal consistencies for the subscales ranged from .77-.91, demonstrating good validity (48). Procedure

The study was approved by the National Insurance Institute of Israel and its Ethics Committee. After receiving the necessary authorizations and permits from the 159

Impact of Repetitive Exposure to Terror Attacks on Mothers’ and Children’s Functioning

National Insurance Institute, we used cluster sampling in which the level of exposure and place of residence were the sampling criteria, resulting in two areas in Israel: small communities (rural villages and kibbutzim of about 200-700 inhabitants) as well as a larger city (of about 21,000 inhabitants), all in areas that had been the target of missile attacks for years. Participants were located using the snowball method. Meetings and interviews took place at participants’ homes by prior appointment. With the mother’s consent, one of her children was chosen, aged 10 or older. Children aged 10 or older were chosen for this purpose as this age is an intermediate age between childhood and adolescence. Studies exploring exposure to traumatic events treat the age criterion as a discriminant criterion (e.g., 12). A decision was made to focus on this age in particular for practical reasons. These children form a population that has been exposed to missile attacks for years. We preferred to avoid including adolescents in order to reduce effects associated with unique features of adolescence. Before completing the questionnaires, participants were told that the questionnaires were anonymous and would be used solely for the purpose of the study. Each

mother signed an informed consent form confirming her own participation and that of her child, and then mothers and children were asked to answer the questionnaires separately, after which the purpose of the study was explained. When the questionnaires had been completed, each family received a token sum of $27 for their participation in the study. Questionnaires were distributed and administered during 2009 (June-November). Results Objective and subjective exposure to terror and conflict events

In general, mothers’ exposure to incidents was higher than that of their children (see Table 1). The score for mothers’ fear was M=2.72 (SD=1.09), while children’s was M=2.20 (SD=1.00). The difference was significant: t(151)=4.80 (p<.001), with a correlation of r=.79 for mothers and r=.68 for children (p<.001). PTSD Symptoms

Mothers’ mean scores on PTSD scales ranged from 1-4. Means were: intrusion M=1.91 (SD=0.82), avoidance

Table 1. Percents of exposure to terror events of mother and child Mother

Child

Due to the situation:

1. Forego an activity

134

88.2

106

69.7

4.14***

2. Didn’t get to work / school

100

65.8

134

88.2

4.45***

3. Left work / school

36.8

13.8

4.63***

4. Family left home

59.9

36.8

5.11***

5. Used other roads

104

68.4

46.7

4.37***

6. Stayed home to hide

110

72.4

106

69.7

0.45

7. House was hit

21.7

18.4

1.29

8. Work / school hit by missiles

33.6

31.6

0.56

9. Missile fell close by, No one was injured

42.1

32.2

2.10*

10. Missile fell close to an acquaintance, no one was injured

116

76.3

61.2

3.05**

11. Wounded by a missile

6.6

4.6

0.78

12. A relative was wounded by a missile

38.8

21.7

4.01***

13. An acquaintance was wounded by a missile

105

69.1

55.3

2.61**

14. A relative was killed by a missile

16.4

2.0

4.32***

15. An acquaintance was killed by a missile

48.0

26.3

4.37***

16. Saw a person killed

6.6

11.2

1.40

17. Other

23.0

23.7

1.51

Total exposure (1-17)

M=7.74

Sd=3.25

M=6.13

Sd=2.68

t(151)=7.41***

*p<.05, **p<.01, ***p<.001

160

Mally Shechory-Bitton

M=1.46 (SD=0.56), and hyperarousal M=1.96 (SD=0.84). The total mean score for PTSD was rather low at 1.74 (SD=0.65). Indeed, only 18 mothers (11.8%) were clinically defined as suffering from PTSD. Children’s total PTSD score ranged from 0-60 (M=13.66, SD=11.84). Classification by clinical categories revealed that 77 children (52.0%) were categorized as doubtful, 47 (31.7%) as mild, 18 (12.2%) as moderate, five (3.4%) as severe, and only one child (0.7%) as suffering from very severe PTSD (four children were not categorized). Child behavior problems

Differences between current and former (retrospectively assessed) child behavior symptoms were examined with a repeated measure MANOVA. Results show significant increases in mothers’ perceptions of all child behavior symptoms. Table 2. Means, standard deviations and F tests for former and current child behavior symptoms (N = 148) Former

Current

F(1, 147) (η2)

Aggressive behavior

4.52 (5.00)

7.74 (7.11)

54.93*** (.27)

Social problems

1.42 (2.10)

2.47 (2.87)

36.54*** (.20)

Anxious/Depressed

2.57 (3.19)

4.90 (4.39)

61.04*** (.29)

F(3, 145) = 23.20, p<.001, η2=.32

Predicting child posttrauma and behavior problems

Four multiple regressions were conducted to predict child posttrauma and behavior problems. Dependent variables were: current child posttraumatic symptoms, aggression, social problems and anxiety. The three latter variables were highly interrelated as retrospectively assessed (aggression: r=.67, social problems: r=.68, anxiety: r=.58, p<.001). The first step in the regression included control variables: child’s age, sex (defined as a dummy variable: 1-boys, 0-girls), and retrospective assessment of the respective behavior problem. Notably, other demographic variables, such as mother’s age, number of children in the family, religiosity and ethnic origin, were found to be unrelated to the dependent variables, and thus were not entered in the regression analysis. Current behavior problems were found to be predicted by mothers’ posttraumatic symptoms, and by child and mother objective exposure and fear of terror events, over and above the child’s past behavior problems. The second step of the

regressions included mothers’ variables: posttraumatic symptoms, extent of exposure, and fear of terror events, and the third step included the child’s extent of exposure and fear of terror events (see Table 3). All four regression models are significant. Mothers’ variables contribute 11% to 18% of the explained variance of the dependent variables, beyond the control variables, while children’s extent of exposure and fear of terror events contribute another 19% to the explained variance, beyond mothers’ variables, only regarding children’s posttraumatic symptoms. Children’s exposure and fear do not contribute significantly to explaining behavior problems, beyond mothers’ variables. More specifically, children’s posttraumatic symptoms are significantly and positively predicted by mothers’ posttraumatic symptoms, children’s exposure to terror events, and children’s fear. Notably, children’s posttraumatic symptoms are significantly predicted by children’s gender as well, such that girls show a higher extent of symptoms. However, exposure to incidents and level of fear are stronger predictors than gender, and turn gender into a insignificant variable. In addition, children’s current aggression, social problems, and anxiety/depression, are significantly and positively predicted by mothers’ posttraumatic symptoms, beyond children’s respective past behavior problems. Finally, when all variables are entered, children’s age is negatively related with anxiety/depression, so that older children show less anxiety/depression symptoms. Discussion The present study assessed the extent to which children’s posttraumatic symptoms and behavior problems are a function of their mother’s posttraumatic symptoms and long-term exposure to conflict tensions and terror events. As hypothesized, children’s levels of distress resulting from conflict tensions were found to be associated with their mothers’ levels of distress. This is compatible with theoretical approaches claiming that parents’ own emotion regulation moderates the relationship between parenting and children’s emotional and behavioral functioning as well as with empirical evidence obtained in previous studies (e.g., 24, 35-37). Regression analysis findings show that children’s posttraumatic symptoms may be predicted by their mother’s posttraumatic symptoms, i.e., the more mothers suffer from PTSD, the higher children’s reported levels of emotional distress. Interestingly, although mothers’ distress is a significant predictor of their children’s distress, it is not a primary 161

Impact of Repetitive Exposure to Terror Attacks on Mothers’ and Children’s Functioning

Table 3. Prediction of child’s PTSD symptoms and behavior problems (N=148) Step: 1

PTSD (β)

Anxious/Depressed (β)

-.25**

.07

-.01

.03

Child’s age

-.04

-.12

-.13*

-.18**

----

.67***

.59***

R2=.06, p<.05

R2=.47, p<.001

R2=.37, p<.001

Child’s sex

-.24**

.07

.01

.03

Child’s age

-.01

-.09

-.10

-.14*

Past behavior

----

.64***

.60***

.49***

Mother’s exposure

.09

.03

.09

.13

Mother’s fear

-.04

.02

.05

.06

Mother’s PTSD

.32**

.31***

.25***

.31***

∆R =.13, p<.001

∆R =.12, p<.001

∆R =.11, p<.001

∆R2=.18, p<.001

Child’s sex

-.13

.05

-.02

.02

Child’s age

-.03

-.10

-.12*

Past behavior

----

.64***

.61***

.49***

Mother’s exposure

-.15

.05

.13

.19*

Mother’s fear

.01

.02

.04

.06

Mother’s PTSD

.20*

.33***

.27***

.33***

Child’s exposure

.36***

-.01

-.09

-.12

Child’s fear

.28***

-.06

.01

-.01

∆R =.19, p<.001

∆R =.001, ns.

∆R =.01, ns.

∆R2=.01, ns.

R =.38, p<.001 F(7,140)=12.00

R =.59, p<.001 F(8,139)=24.81

R =.59, p<.001 F(8,139)=25.13

R2=.56, p<.001 F(8,139)=22.21

Social (β)

Child’s sex Past behavior

Aggression (β)

Model:

*p<.05, **p<.01, ***p<.001

influence, and children’s own exposure and fear are a stronger predictor. Most studies that found a strong connection between mothers’ and children’s levels of emotional distress examined a predefined war situation (12, 36). Perhaps the absence of such a strong connection in the present study may be linked to the fact that subjects completed the questionnaires while still in what may be defined as a war zone. During the period of data collection, missile attacks on respondents’ residential areas were an almost daily occurrence. Fear has been documented in numerous studies as playing a key role in posttraumatic symptoms. A subjective sense of fear was found to be even more strongly related to posttraumatic symptoms than the actual objective exposure (e.g., 12, 49, 50). However, the current study shows that the impact of objective exposure on children’s distress levels is highly significant, no less than that of fear aroused by exposure. Objective exposure and subjective sense of fear were found to be highly and positively correlated. This is in line with the claim by Lazarus and 162

Folkman (51) regarding the significance of subjective interpretation for understanding coping mechanisms. The significant impact of sense of fear and exposure levels also overshadows gender differences found in numerous other studies, in which girls were found to report more posttraumatic symptoms than boys (12, 52, 53). However, exposure to incidents and level of fear are stronger predictors than gender. An examination of mothers’ assessment of changes in behavior variables of their children indicates an increase in behavioral problems following the exposure to conflict events. These findings correlate with previous findings that found higher pathogenic levels among children living in border communities or in areas subjected to national conflict-related events (14, 17, 20, 54). Moreover, children’s current behavior problems are positively and significantly predicted by mothers’ posttraumatic symptoms, maybe since it was the mothers who assessed their children’s behavioral changes, while children’s exposure and levels of fear do not significantly

Mally Shechory-Bitton

contribute to explaining behavioral problems over and above mothers’ PTSD. The current findings add a new dimension to the few studies that examined prolonged exposure to war and terror (e.g., 15, 20) and support the connection between parents’ coping styles and those of their children (e.g., 28, 55). Overall, the results indicate that conflict events left their mark on mothers residing in areas exposed to hazardous conflict situations, as well as on their children. Findings also indicate the significant impact of exposure to events and of the interpretation attributed to them (fear), as well as the significant effect of mothers’ emotional state on children’s emotional state and behavior. However, the results leave us with some unanswered questions that arise from the research limitations. First, assessment of behavior problems may be impeded by focusing only on mothers as the source of information. Relying on mothers’ reports introduces a potential confusion, as maternal psychopathology may create systematic biases in the rating of children’s behavioral problems (e.g., 56, 57). This may also be the explanation for the finding that children’s exposure and fear do not contribute significantly to explaining behavior problems. Objective reports of behavior problems, such as assessment of children’s school performance, may yield clearer findings about the behavior of children. In addition, only children above the age of 10 (relatively older children) were studied. This may affect the impact of mothers on children. The negative correlation found in the current study, where older children show less anxiety/depression symptoms, confirms the effect of the age variable. Another study found that maternal posttraumatic stress disorder and depression were associated with increased behavioral problems among preschool children after the September 11 attacks (37). Nevertheless, the findings clearly indicate that the most significant factors were the extent of exposure and children’s feelings in light of the events they experienced. Overall, the regressions explained up to 19% of the PTSD variance. This clearly leaves room for other variables accounting for the unexplained variance. For example, Hobfoll (58) proposes two main variables that mediate the connection between exposure to terror and emotional distress: loss of resources and acquisition of other resources. This model was found to be compatible with explanations of how the adult population in Israel has managed to adapt to a situation of continued terror (59). It would also be worthwhile to examine its suitability among the younger population. Furthermore, there is need for future research to assess the

effects of cognitive variables (e.g., coping strategies) and social variables (e.g., social support) on fear and PTSD. As noted by Bensimon and colleagues (60), the objective exposure component may be of less importance than the subjective exposure component when exposure to terror is chronic and on a national scale. Obviously, this reality exists not only in Israel, but also in other parts of the world (e.g., Afghanistan and Iraq), and therefore such research has global implications. Acknowledgements This article supported by a grant from National Insurance Institute of Israel.

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Isr J Psychiatry Relat Sci - Vol. 50 - No 2 (2013)

Leo Wolmer at el.

Post-traumatic Reaction of Israeli Jewish and Arab Children Exposed to Rocket Attacks Before and After Teacher-Delivered Intervention Leo Wolmer, MA,1,2 Daniel Hamiel, PhD,1,2 Michelle Slone, PhD,3 Maya Faians, MA,1,2 Mayrav Picker, MA, 2 Tal Adiv, MD,1 and Nathaniel Laor, MD, PhD1,2,4,5 1

Brull Community Mental Health Center, Tel Aviv, Israel Donald J. Cohen & Irving B. Harris Resilience Center for Trauma and Disaster Intervention by the Association for Children at Risk, Tel Aviv, Israel 3 Department of Psychology, Tel Aviv University, Ramat Aviv, Israel 4 Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel 5 Child Study Center, Yale University, Connecticut, U.S.A. 2

Abstract Background: Belonging to ethnic minorities is a risk factor for traumatized children. This study investigated the influence of exposure to rocket attacks during the 2006 Lebanon War on Jewish and two groups of Arab Israeli students and the effect of implementing a teacher-delivered intervention focusing on resilience enhancement. Method: Children from both ethnic groups (N = 1,372) were assessed for stressful life events, symptoms and parental concern regarding adaptation before the 16week program (T1) and after its completion (T2). Results: Arab children reported more severe symptoms at T1. The three groups showed a significant decrease to the same level at T2. Both ethnic groups differed in the level of parental concern and in the way stressful life events affected children’s symptoms. Conclusions: The results suggest that school-based programs with teachers as clinical mediators could be a valuable, cost-effective cross-cultural model of intervention after mass trauma, moderating vulnerabilities of ethnic minorities.

This work was supported by grants from the Pritzker Family Foundation and the Irving Harris Foundation. Address for Correspondence:

Introduction During the Second Lebanon War (2006) Hezbollah fired around 4,000 missiles into Northern Israel, causing 44 Jewish and Arab civilian mortalities, over 1,400 wounded, significant property damage, and thousands displaced or required to live in shelters. According to Hobfoll, psychological distress occurs when one’s goals, resources or basic expectations are threatened (1). These goals include tangible objects, physical safety, a positive image of one’s self-worth, control and belonging to a social network. A stronger resource base diminishes the adverse psychological impact. The war disrupted children’s lives on multiple levels, including exposure to destruction, injury and terror and the effects to their surroundings. This disruption of the children’s ecology can threaten their basic expectations of safety and normalcy, leading to a clinical picture of grief, guilt, depression and posttraumatic stress disorder (PTSD) symptoms, as well as changes in behavior and personality (2). Children and adolescents often exhibit higher levels of psychological distress to disasters than adults despite seeming to perform normally on a superficial level (3, 4). While rates vary greatly depending on the type of trauma and the population exposed, levels of PTSD often reach or exceed 50% (5, 6). Certain factors protect children after traumatic exposure. Personal characteristics include optimism, high self-esteem, good temperament, strong self-efficacy and positive coping (7-10). A supportive family (11, 12) and strong social networks are key predictors of resilience (13, 14).

Leo Wolmer, MA, 18a Asherman St., Tel Aviv, Israel, 67199

tlv_cmhc@netvision.net.il

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Post-traumatic Reaction of Israeli Children Exposed to Rocket Attacks Before and After Intervention

In contrast, risk factors that intensify the perceived threat include intensity and duration of exposure, physical injury, death of a loved one, degree of terror experienced, younger age, female gender, prior disorders, poor social support, poor parental response, inadequate family cohesion, lower socioeconomic class, and stressful life events (2, 14-16). Minority as a risk factor for traumatized students

Minority ethnic groups share a common heritage and cultural values which differ from the mainstream population. Identification as a member of an ethnic minority affects the individual’s interaction with the social network in multiple ways. This leads to low actual and perceived social support which can lead to different traumatic exposure rates and differential degrees of vulnerability (17). The increased vulnerability of minorities to develop PTSD may function by altering the level of risk and protective factors (18). Discriminated minority groups often have disparities in access to economic and social resources (e.g., healthcare, education, income), leading to increased risk of psychological distress when further resources are threatened. The perceptions of discrimination may prevent the individual from seeking support and using available social resources. Furthermore, discrimination can lead to feelings of decreased self-worth (19). Moreover, degree of integration and acculturation affects PTSD development. In a study of the Taiwanese aboriginal population it was found that those with a lower degree of acculturation were twice as likely to develop PTSD as their higher acculturated counterparts (20). Individuals with low acculturation tend to be less integrated and have less support from social networks. Ethnicity also directly impacts the individual and the proximal ecology through culturally specific attitudes and beliefs that mediate coping with trauma. For example, a close family network can act as an invaluable resource when dealing with stress; however, it can increase the pressure and limit the individual’s willingness to obtain help from outside sources (17). In warfare, these viewpoints influence the extent to which individuals carry their commitment as citizens to their own country’s ideology, particularly when conflict arises with a nation they politically identify with (21). Strong support for the aims of one’s own side has been shown to be a protective factor. Servan-Schreiber, Le Lin and Birmaher found increased resilience in Tibetan refugee children with a strong sense of participating in their nation’s struggle against an oppressor (22). 166

Arab Israeli citizens (Muslims, Christians, Druze and Bedouins) comprise 20.3% of the Israeli population (23), speak a different language and have a distinct religious, cultural, historical and national identity from the mainstream Jewish society. While Jews and Arabs officially have equal rights, Arab citizens have lower socio-economic status, income and level of schooling, and schools have lower budgets and fewer available resources (24). School-based interventions for treating PTSD

Mental health interventions are known to increase resilience in child survivors of disaster. However, during disaster situations the traditional mental health resources are overwhelmed (2). Therefore, a public health ecological approach should be adopted and schools should be used for screening and implementation of post-disaster programs (25, 26). School-based interventions are effective when delivered to individuals or small groups, but group treatment is associated with better completion rates (25). In a randomized controlled trial of a 10-session small-group intervention delivered by school clinicians, students reported fewer symptoms, and parents reported less psychosocial dysfunction among their children in comparison to a waitlist group (27). Several reasons explain the effectiveness of schoolbased interventions, mainly the human resources available to strengthen the child’s social network and self efficacy, and the ability to integrate a developmentally appropriate program within a familiar framework, increasing compliance while erasing possible stigma (28, 29). In disaster situations, the limited number of professionals is insufficient to reach all the children in need. Therefore, Wolmer et al. proposed to empower “teachers” as “educators” serving as clinical mediators (29). Teachers occupy a central role in the child’s life and are trusted by both youth and their parents. Empowering teachers to assist the children with their psychological distress promoted school revitalization and decreased symptoms following a severe natural disaster and resulted in improved adaptive functioning three years later compared to a control group (29, 30). A similar pattern was found following a teacher-delivered intervention in Sri Lanka (31). The first aim of this study was to examine the effect of ethnic group affiliation on the development of PTSD symptoms in students following missile attacks and its interaction with gender and life stressors. We hypothesized that children living in Arab cities would display the most severe outcome, with the Jewish sample hav-

Leo Wolmer at el.

ing the least adverse reactions. The second aim was to assess whether ethnicity impacted on the effectiveness of a teacher-delivered intervention focusing on coping enhancement. The intervention was adapted for the Arab population and run by local Arab professionals. Therefore, we predicted it would be equally effective among Jewish and Arab schools. Method Participants

Participants were a convenience sample of Jewish and Arab Israeli children studying in 4th and 5th grade in schools located in northern Israel. All children had been exposed to rocket attacks during the war. There were 985 Jewish children from two Jewish cities and one mixed city (50.6% boys, 91% 4th grade), 61 Arab children from the mixed city (50.8 % boys, 100% 5th grade), and 326 Arab children from an Arab city (50.9% boys, 100% 4th grade). All students participated in the intervention but only those whose parents signed an informed consent form were assessed. The baseline measurement (T1: 5 months after the war) was completed by 1,372 students, 727 (53%) of the students in the classrooms available four months later (T2) completed the post-intervention measurement (Figure 1).

Instruments

We used two questionnaires at T1 and T2 to collect data from the students and their parents. The children’s questionnaire included: (a) Demographic information; (b) eight questions concerning stress and mood (e.g., “Are you scared that something would happen to you or your family?”) and (c) five questions derived from the CPTSD Reaction Index (32) that were found to be highly associated with the total scale in a pilot study (e.g., “Do you have thoughts about the events even when you don’t want to?”) (r = .90, p < .001, n = 253) (33). Scores in all items ranged from 1 (very little) to 5 (a lot) and the internal consistency of both scales was satisfactory (Cronbach’s α = .72). The parents’ questionnaire included: (a) 14 questions regarding stressful life events (SLE) experienced by the child or the family in the two-year period prior to the war (e.g., severe illness in the family, divorce, exposure to terrorist attacks, witnessing injured or dead people, physical injuries). The sum of the stressful events assembled the child’s SLE Index. (b) Questions concerning the perceived functioning of the child in six areas: school performance, social functioning, interpersonal relationships in the family, stress/anxiety, health and personal mood. The answers ranged from “not concerned at all” (1) to “very concerned” (4). The internal consistency for this scale was satisfactory (Cronbach’s α = .86).

Figure 1. Student flow through the teacher-delivered intervention

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Post-traumatic Reaction of Israeli Children Exposed to Rocket Attacks Before and After Intervention

Procedure

The program was approved by the IRB of the Ministry of Education. Parents also signed a consent form allowing their children to participate in the program and complete the questionnaires. The students completed the questionnaire with the help of the school counselor and the teacher. Parents returned their completed questionnaire to the school counselor, who assigned a code for each child to ensure anonymity. The questionnaires were delivered in Hebrew or Arabic, depending on the school. The intervention

The manualized intervention (29, 30, 33) consisted of 14 sessions. It focused on strengthening adaptive coping mechanisms and socio-emotional competences. Topics included processing positive and negative experiences, managing stress, dealing with emotions, correcting negative

cognitions and implementing adaptive coping mechanisms such as humor (see Table 1 for a description of each meeting). Teachers completed a 20 hour training program and were supervised weekly by school counselors. The contents were presented to the students using letters from an imaginary character, Adam, in which he describes his experiences, labeling complex emotions and enabling the children to do likewise, as well as proposes activities to learn, process and internalize the skills covered. Skills were practiced with daily stressful experiences (e.g., exams) to integrate the emerging coping skills into routine life. Data analysis

The internal consistency of the scales was computed with the Cronbach’s alpha procedure. Principal components factor analysis (Varimax rotation) explored the factorial design of the children’s scale. Three-way MANOVA fol-

Table 1. Description of the sessions of the teacher-delivered protocol Session 1: Introduction and processing positive experiences: Adam’s letter: Introduction, verbalization, legitimization. Processing a positive experience: Demonstration by teacher. Processing a positive experience in pairs. Sharing. A worksheet for personal positive processing. Writing in personal diary. Session 2: Slow breathing using soap bubbles: Adam’s letter: Psychoeducation. Breathing exercise to manage stress and regain control. Writing in personal diary. Session 3: Breathing and processing unpleasant experiences: Rehearsing slow breathing. Processing an unpleasant experience. Adam’s letter: Unpleasant experiences. Assessing one’s stress with emotions balloons. A worksheet for personal unpleasant processing. Writing in personal diary. Session 4: Adaptive and maladaptive tension: Breathing exercise. Adam’s letter: Adaptive and maladaptive tension. The arm test: Demonstrating maladaptive tension. The “fight or flight” reaction: Experiencing and processing. Writing in personal diary. Session 5: Correcting negative thoughts: Breathing exercise. Adam’s letter: Identifying negative thoughts. The Three Steps Model: A technique to identify and correct negative thoughts. Writing in personal diary Session 6: A safe place: Enlisting the “dwarf-friend”: Short breathing exercise and rehearsing thought correction. Adam’s letter: The dwarffriend. Guided imagery: Creating our “dwarf-friend.” Writing in personal diary Session 7: Progressive muscle relaxation: Measuring stress with thermometer and balloon “stressometer.” Adam’s letter: Integration, introduction of “Simon says.” Slow breathing exercise and reassessment using both methods. Progressive muscle relaxation exercise and “Simon says” game. Reassessment using both methods. Writing in personal diary. Session 8: “Uncle Harry’s positive experience bag”: Rehearsing “Simon says.” Adam’s letter: The “positive experience bag.” Collecting positive thoughts. A guided imagery exercise using the “positive experience bag.” Writing in personal diary. Session 9: The power of communication: Active listening and cooperation: Breathing exercise and imagery. Adam’s letter: Listening. Group puzzle. Discussion: the power of cooperation. Session 10: Perspective taking, distancing, and humor: Breathing exercise and imagery. The “Zoom” exercise: Taking perspective and distancing. Adam’s letter: Humor. Creating humor: Cartoons on the wall and children’s humoristic reactions. Laugh meditation/yoga. Writing in personal diary. Session 11: Rehearsing and integrating coping techniques: Slow breathing, correcting negative thoughts, positive thoughts bag, progressive muscle relaxation, active listening, zoom and humor. Measuring with thermometers and “stressometers” before and after a distraction exercise. Writing in personal diary. Session 12: Violence: Connecting between stress, tension, and aggression: Adam’s letter: Stress, anger, and aggression. Visual signs indicating ineffective reactions to anger situations. Identifying our reaction in a state of anger. Suggesting alternative ways to deal with anger situations. Discussion. Writing in personal diary. Session 13: An integrated balance exercise and SMBIA: An integrated balance exercise. Adam’s letter: The five-step method to effective reaction. SMBIA: Stop–muscle–breath–image–action. Writing in personal diary. Session 14: Conclusion: The power of the group: Adam’s letter: Summary, goodbye. Positive changes that derive from a crisis. Summary exercise: Measuring temperature biofeedback with the whole class. Festive releasing of balloons.

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lowed by Duncan post-hoc tests explored how ethnicity, SLE and gender (independent variable) affected child’s and parents’ reports (dependent variables). Multivariate analysis of variance with repeated measures assessed the symptomatic changes following the program according to ethnicity, SLE and gender. Significance level was set at p < .05. For repeated measures analyses only participants present at both assessments were included.

924) = 2.33, p < .05, η2 = 0.02]. Gender interacted with ethnicity [F (2, 1061) = 3.71, p < .05, η2 = 0.01]: parents from an Arab city reported more concern for boys than for girls (M = 1.54, Sd = 0.66 and M = 1.38, Sd = 0.66). Arabs from an Arab city had significantly more PTSD symptoms (M = 1.68, Sd = 0.97) than Arabs from a mixed city (M = 1.30, Sd = 0.90) and Jewish children [M = 1.46, Sd = 1.01; F(2, 1199) = 5.81, p < .01, η2 = 0.002]. In addition, a marginal effect for ethnicity appeared in regard to mood/stress symptoms [F(2, 1232) = 2.90, p = .06]. Duncan post-hoc analysis showed that Arabs from a mixed city reported higher symptom levels (M = 3.60, Sd = 0.74) than Jewish children (M = 3.80, Sd = 0.77).

Results Factor analysis distinguished between the stress/mood and the trauma factors in the child’s questionnaire that explained 22.6% and 19% of the variance, respectively (Eigenvalues = 3.86 and 1.54). Table 2. Pre-intervention children’s symptoms and parent’s concern with

child’s functioning by Stressful Life Events (means and standard deviations)

Ethnicity’s, SLE index and Gender effect on PTSD, functioning and mood at T1

SLE had a significant effect on mood/stress [F (5, 978) = 3.84, p < .01, η2 = 0.02]. Duncan post-hoc determined that the difference was between those with 0 through 4 SLE and those with more than 5 (Table 2). SLE also significantly affected PTSD symptoms [F(5, 978) = 5.17, p < .01, η2 = 0.03]. Children with 0 SLE had significantly less PTSD symptoms than those with 5 or more SLE. Moreover, SLE had a significant effect on the parent’s concern for the child’s functioning [F (5, 978) = 12.12, p < .01, η2 = 0.06]. Children with 0 SLE displayed better functioning than those with 4 or more SLE (Table 2). Boys had lower mood/stress levels than girls [M = 3.89, Sd = 0.69 and M = 3.62, Sd = 0.81; F(1, 924) = 4.76, p < .05, η2 = 0.01] and also less PTSD symptoms [M = 1.22, Sd = 0.93 and M = 1.79, Sd = 1.00; F (1, 924) = 12.22, p < .05, η2 = 0.01]. Ethnicity had a significant effect on parental concern [F (2, 924) = 4.53, p < .05, η2 = 0.01]. The highest parental concern was found for Jewish children, followed by Arabs from an Arab city and then for Arabs from a mixed city (M = 1.55, Sd = 0.66, M = 1.46, Sd = 0.65 and M = 1.39, Sd = 0.49, respectively). Ethnicity and SLE interacted with mood/ stress symptoms: in children with more than 5 SLE, Arabs from a mixed city had higher symptoms than Arabs from an Arab city [M = 2.38, Sd = 0.73 and M = 3.81, Sd = 0.76; F(2,

Stressful Life Events

Ethnicity

Mean

Jews

367

1.36

1.02

3.86

0.76

1.42

0.63

Total

PTSD

Mood/ Stress

Adaptation

Arabs - Arab city

139

1.56

0.97

3.71

0.75

1.27

0.51

Arabs - mixed city

0.92

0.66

3.76

0.61

1.21

0.34

Total

532

1.38

1.00

3.82

0.75

1.38

0.60

Jews

220

1.47

0.98

3.83

0.77

1.50

0.65

Arabs - Arab city

1.82

0.94

3.75

0.76

1.42

0.58

Arabs - mixed city

1.40

0.93

3.63

0.45

1.35

0.39

Total

315

1.54

0.98

3.80

0.76

1.48

0.63

Jews

166

1.47

1.02

3.73

0.74

1.63

0.62

Arabs - Arab city

1.95

0.78

3.71

0.72

1.41

0.60

Arabs - mixed city

1.87

0.99

3.52

0.88

1.31

0.52

Total

205

1.54

1.00

3.72

0.74

1.59

0.62

Jews

1.79

1.00

3.72

0.77

1.65

0.67

Arabs - Arab city

1.62

1.12

3.71

0.61

1.48

0.64

Arabs - mixed city

1.50

0.85

3.50

0.73

1.69

0.76

Total

101

1.74

1.00

3.70

0.73

1.62

0.67

Jews

1.56

1.03

3.59

0.97

1.86

0.65

Arabs - Arab city

1.17

0.84

3.40

0.89

1.96

0.67

Arabs - mixed city

1.00

0.87

4.46

0.51

1.94

0.35

Total

1.39

0.97

3.59

0.93

1.90

0.63

Jews

1.71

1.02

3.23

0.77

2.28

0.83

Arabs - Arab city

2.16

1.14

3.81

0.76

1.96

0.98

Arabs - mixed city

2.20

1.12

2.38

0.73

1.67

0.49

Total

1.94

1.06

3.40

0.88

2.05

0.89

Jews

866

1.46

1.01

3.80

0.77

1.55

0.66

Arabs - Arab city

309

1.68

0.97

3.71

0.75

1.46

0.65

Arabs - mixed city

1.30

0.90

3.60

0.74

1.39

0.49

Total

1235

1.49

1.00

3.77

0.76

1.52

0.65

169

Post-traumatic Reaction of Israeli Children Exposed to Rocket Attacks Before and After Intervention

Changes in symptoms and functioning following the intervention

Multivariate Analysis of Variance with Repeated Measures showed a significant decrease in stress/mood (due to the direction of the scales in the Stress/Mood scale, a decrease in the symptoms is marked by a higher mean score in the second measurement) [M = 3.73. Sd = 0.77 and M = 3.83, Sd = 0.75; F(1, 712) = 7.62, p < .01,η2 = 0.02] and PTSD symptoms [M = 1.47, Sd = 1.00 and M = 0.81, Sd = 0.77; F(1, 661) = 155.56, p < .001,η2 = 0.33]. No significant change appeared in regard to children’s functioning [M = 1.48, Sd = 0.60 and M = 1.44, Sd = 0.60; F(1, 311) = 0.36, p > .05]. A significant gender X PTSD change interaction [F (1, 661) = 10.00, p < .01, η2 = 0.02] revealed that boys had lower levels of PTSD symptoms than girls at both T1 and T2, but the difference was larger at T1 [M = 1.23, Sd = 0.92 and M = 1.80, Sd = 1.00 respectively; t(1180) = -10.19, p < .05, d = -0.59] than at T2 (M = 0.68, Sd = 0.72 and M = 0.95, Sd = 0.80 respectively; t(695) = -4.59, p < .05, d = -0.35]. There was a significant interaction between the cumulative number of lifetime stressors and PTSD symptom decrease [F(5, 650) = 1.47, p < .01, η2 = 0.01]: At T1, children who had no SLE had lower levels of PTSD than children with 5 or more SLE (M = 1.38, Sd = 1.01 and M = 1.89, Sd = 1.04 respectively). This difference was smaller at T2 (M = 0.75, Sd = 0.75 and M = 1.13, Sd = 1.08 respectively). Mood/stress change did not interact with SLE [F(5, 701) = 1.61, p > .05]. Additionally, ethnicity and PTSD decrease interacted significantly [F(2, 661) = 3.26, p < .05, η2 = 0.01]. Posthoc analysis showed that at T1, students from the Arab city had more PTSD symptoms than Jewish and Arab students from the mixed city [M = 1.68, Sd = 0.97, M = 1.45, Sd = 1.02 and M = 1.30, Sd = 0.90 respectively; F(2, 1199) = 5.81, p < .05]. However, these differences disappeared after the intervention (M = 0.84, Sd = 0.68, M = 0.79, Sd = 0.81 and M = 0.82, Sd = 0.73, respectively). Discussion The central aim of this paper was to establish the effectiveness of a teacher-delivered intervention on reducing students’ adverse reactions after the Second Lebanon War and to investigate differential effects of the intervention across ethnic group. Although Arab students from an Arab city had the highest levels of initial PTSD, the intervention eliminated any group difference. In line with 170

previous research, girls at T1 reported higher PTSD and mood/stress symptoms and higher SLE was associated with increased symptoms and more parental concern with children’s functioning (14, 16, 34, 35). However, the decrease in PTSD at T2 reduced the differences related to gender and stressful life events. Our first hypothesis stated that PTSD symptoms, mood/stress and parental concern would be most severe among the Arab students from the Arab city. These students did report the highest levels of PTSD. In addition, a less than expected marginal difference in stress/ mood symptoms showed that Arabs from the mixed city reported higher symptoms than Jewish children. However, contrary to our expectations, parents of Jewish children reported the highest concern for their children’s functioning and the least concern was reported by Arab parents from the mixed city. This may support Wolmer, Laor and Yazgan’s finding that after the 1999 earthquakes, Turkish children were expected to renounce their expression of grief in order to protect their caretakers (29). As a group, Arab students, especially girls, may have found it culturally difficult to express painful experiences at home, explaining why parents from an Arab city reported more concern for boys than for girls. The extent to which the different level of concern of parents affects the children’s initial reaction and that following the intervention remains an open question. In addition to the demonstrated parental tendency to under-appreciate the child’s reaction to trauma, this may explain why Arab parents could not accurately estimate their children’s functioning (36). Arab students report of worse mental health in comparison to the Jewish majority is consistent with previous research (24, 37-40). Perhaps, as a discriminated minority, Arab children come from homes with lower levels of education and income, under-funded schools, and poorer access to healthcare and education resources. Fewer resources represent a reduced capability to buffer further losses (1). Furthermore, the nationalistic atmosphere which may have supported the Jewish citizens, could have led to feelings of further isolation for Arabs with a dual Arab and Israeli identity, exposed to Arab suffering and traumatization on the other side. This could have been magnified in the mixed city, explaining why Arab students from the mixed city with multiple SLE reported more mood/stress symptoms than students from the Arab city. The shared ethnic identity with the “enemy,” the concern for relatives who lived in Lebanon and the

Leo Wolmer at el.

unexpectability of targeting Arab cities in Israel, may have led to further emotional turmoil. As expected, students from an Arab city had the highest PTSD symptoms prior to the intervention. Several reasons may explain this finding. First, this group is the least integrated into mainstream Israeli society. This is consistent with Perilla et al.’s (17) study after hurricane Andrew in which the least acculturated group had the highest level of PTSD. Secondly, as a group they had the lowest socio-economic standing, and lower standards of education and housing. A third explanation focuses on their ethnic identity. Mossakowski found that a strong ethnic identity served a buffering function against the stress of perceived discrimination and was strongly associated with fewer depressive symptoms among Filipino Americans (41). Minority ethnic groups that live among a separate majority often have a strengthened sense of identification with their ethnicity, more ethnic pride, involvement in ethnic practices and cultural commitment to their ethnic group. This may act as a buffer at times of stress. Arab students from the mixed city may possess this heightened ethnic identity which would augment their social networks and the associated support, providing a sense of belonging which can be protective when confronting trauma. Lastly, citizens of Jewish and mixed cities have been targeted repeatedly in wars and periods of terrorism and may have generated coping mechanisms and a degree of resilience (39). Conversely, Arab cities have less previous experience with war and were less prepared, lacking shelters and secure areas, producing thereby a sense of lack of control and helplessness increasing their adverse outcomes. Consistent with our second hypothesis, the teacherdelivered intervention was associated with a symptom decrease for all the ethnic groups that eliminated any symptoms difference between the groups. This is in line with a study of adult war veterans that found no differences between treatment effectiveness for White, Black or Hispanic patients (42). After the intervention, we also measured a reduction in the difference in PTSD levels between gender groups and high and low SLE groups, supporting prior research indicating that schoolchildren with more severe symptoms profit the most from schoolbased interventions (31, 33). Additionally, the training for the intervention may have assisted Arab schools and teachers in developing resources and techniques with which the Jewish schools were already familiar. Tatar and Horenczyk’s study comparing Jewish and Palestinian counselors found that the latter focused on helping chil-

dren integrate their ethnic identity and legitimizing their minority identity, while the Jewish counselors had more experience implementing psychological assistance to reduce anxiety after terror attacks (43). This previous experience would have assisted the Jewish more than the Arab teachers to help their students after the war. The intervention, however, provided the necessary tools that may have been missing. Overall, the universal teacher-delivered intervention was associated with symptom decrease but not with better functioning. Improved coping strategies and a strengthened peer network may enable the child to process the traumatic experiences. Parents are known to underestimate traumatic reactions of children (36). Perhaps the very little concern of parents’ baseline reports regarding the children’s functioning may have clouded their ability to detect changes after the intervention (flooring effect). Limitations Our main limitation was the lack of a control group to compare the effect of the intervention. However, a previous study found that the teacher-delivered intervention was more effective than waiting-list control when implemented following the Second Lebanon War (33) and preventively before Operation Cast Lead (44). Also, all children from the Arab city study in 4th grade and all Arab children from the mixed city study in the 5th grade. Although we do not expect to find developmental differences between children in 4th and 5th grades, a better distributed sample would add to the validity of the results. Moreover, we had no information about the children’s functioning before the war, and no long-term follow-up assessment of the effect of the intervention. Including pre-exposure assessment during disaster is extremely difficult. However, similar interventions demonstrated long-term positive outcomes in terms of children’s adaptation (30, 33). Future research may include additional parameters such as socioeconomic status, religiosity, family cohesion, perceived discrimination, and questions concerning cultural and ethnic identity. Also, due to administrative difficulties, no parent survey was obtained at T2 in the Arab city which would have impacted on the results. Conclusion While minority ethnic status is associated with increased risk of symptom development, there has been relatively 171

Post-traumatic Reaction of Israeli Children Exposed to Rocket Attacks Before and After Intervention

little research focusing on children. This study demonstrated that a minority status plays a role in the development of adverse psychiatric outcomes in children exposed to disaster. Further research is needed to elucidate how a minority ethnic status affects children and to determine mediating factors. To the best of our knowledge, this is the first study comparing post-disaster school-based treatment efficacy between an ethnic minority and mainstream society. The encouraging results demonstrate the effectiveness of public health measures after disasters, particularly the role of empowered educators as clinical mediators. Moreover, the equalizing of posttraumatic symptoms associated with the program suggests that by improving children’s coping skills, one can significantly diminish the vulnerability associated with being a minority. Preventive school-based programs successfully diminished posttraumatic cases in populations exposed to armed conflict (44). This should be a central component in implementing urban resilience programs aimed at preparing minorities at risk to face mass disasters. References 1. Hobfoll SE. Conservation of resources. A new attempt at conceptualizing stress. Am Psychol 1989;44:513-524. 2. Laor N, Wolmer L. Children exposed to disaster: The role of the mental health professional. In: Lewis M, editor. Textbook of child and adolescent psychiatry. 4th ed. Baltimore: Williams and Wilkins; 2007. p. 727-741. 3. Maeda M, Kato H, Maruoka T. Adolescent vulnerability to PTSD and effects of community-based intervention: Longitudinal study among adolescent survivors of the Ehime Maru sea accident. Psychiatry Clin Neurosci 2009;63:747-753. 4. Norris FH, Friedman MJ, Watson PJ. 60,000 disaster victims speak: Part II. Summary and implications of the disaster mental health research. Psychiatry (Edgmont) 2002;65:240-260. 5. Attanayake V, McKay R, Joffres M, Singh S, Burkle FJr, Mills E. Prevalence of mental disorders among children exposed to war: A systematic review of 7,920 children. Med Confl Surviv 2009;25:4-19. 6. Yule W, Bolton D, Udwin O, Boyle S, O’Ryan D, Nurrish J. The longterm psychological effects of a disaster experienced in adolescence: I: The incidence and course of PTSD. J Child Psychology Psychiatry 2000;41:503-511. 7. Boscarino JA, Adams RE. PTSD onset and course following the World Trade Center disaster: findings and implications for future research. Soc Psychiatry Psychiatr Epidemiol 2009;44:887-898. 8. Benight CC, Bandura A. Social cognitive theory of posttraumatic recovery: the role of perceived self-efficacy. Behav Res Ther 2004;42:1129-1148. 9. Charles CB, Benight CC, Swift E, Sanger J, Smith A, Zeppelin D. Coping self-efficacy as a mediator of distress following a natural disaster. J Appl Soc Psychol 1999;29:2443-2464. 10. Wadsworth ME, Santiago CD, Einhorn L. Coping with displacement from Hurricane Katrina: Predictors of one-year post-traumatic stress and depression symptom trajectories. Anxiety Stress Coping 2009;22:413 -432. 11. Costa NM, Weems CF, Pina AA. Hurricane Katrina and youth anxiety: The role of perceived attachment beliefs and parenting behaviors. J Anxiety Dis 2009;23:935-941.

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12. Thabet AA, Ibraheem AN, Shivram R, Winter EA, Vostanis P. Parenting support and PTSD in children of a war zone. Int J Soc Psychiatry 2009;55:226-237. 13. Pina AA, Villalta IK, Ortiz CD, Gottschall AC, Costa NM, Weems CF. Social support, discrimination, and coping as predictors of posttraumatic stress reactions in youth survivors of Hurricane Katrina. J Clin Child Adolesc Psychology 2008;37:564-574. 14. Moore KW, Varela RE. Correlates of long-term posttraumatic stress symptoms in children following Hurricane Katrina. Child Psychiatry Hum Dev 2010;41:239-250. 15. Hobfoll SE, Palmieri PA, Johnson RJ, Canetti-Nisim D, Hall BJ, Galea S. Trajectories of resilience, resistance, and distress during ongoing terrorism: The case of Jews and Arabs in Israel. J Consult Clin Psychol 2009;77:138-148. 16. Pfefferbaum B, North CS, Doughty DE, Gurwitch RH, Fullerton CS, Kyula J. Posttraumatic stress and functional impairment in Kenyan children following the 1998 American Embassy bombing. Am J Orthopsychiatry 2003;73:133-140. 17. Perilla JL, Norris FH, Lavizzo EA. Ethnicity, culture, and disaster response: Identifying and explaining ethnic differences in PTSD six months after Hurricane Andrew. J Soc Clin Psychol 2002;21:20-45. 18. Ladd GW, Cairns E. Children: Ethnic and political violence. Child Dev 996;6:14-18. 19. Weems CF, Overstreet S. Child and adolescent mental health research in the context of Hurricane Katrina: An ecological needs-based perspective and introduction to the special section. J Clin Child Adolesc Psychology 2008;37:487-494. 20. Lee CS, Chang JC, Liu CY, Chang CJ, Chen THH, Chen CH, et al. Acculturation, psychiatric comorbidity and posttraumatic stress disorder in a Taiwanese aboriginal population. Soc Psychiatry Psychiatr Epidemiol 2009;44:55-62. 21. Ehntholt KA, Yule W. Practitioner review: Assessment and treatment of refugee children and adolescents who have experienced war-related trauma. J Child Psychology Psychiatry 2006;47:1197-1210. 22. Servan-Schreiber D, Le Lin B, Birmaher B. Prevalence of posttraumatic stress disorder and major depressive disorder in Tibetan refugee children. J Am Acad Child Adolesc Psychiatry 1998;37:874-879. 23. Central Bureau of Statistics [homepage on the Internet]. Jerusalem, Israel: Central Bureau of Statistics [updated 2010 October 24; Cited 2011 January 26]. Available from: http://www1.cbs.gov.il/reader/cw_ usr_view_Folder?ID=141 24. Hobfoll SE, Canetti-Nisim D, Johnson RJ, Palmieri PA, Varley JD, Galea S. The association of exposure, risk, and resiliency factors with PTSD among Jews and Arabs exposed to repeated acts of terrorism in Israel. J Trauma Stress 2008;21:9-21. 25. Chemtob CM, Nakashima JP, Hamada RS. Psychosocial intervention for postdisaster trauma symptoms in elementary school children: A controlled community field study. Arch Pediatr Adolesc Med 2002;156:211-216. 26. Laor N, Wolmer L, Spirman S, Wiener Z. Facing war, terrorism, and disaster: Toward a child-oriented comprehensive emergency care system. Child Adolesc Psychiatr Clin North Am 2003;12:343-361. 27. Stein BD, Jaycox LH, Kataoka SH, Wong M, Tu W, Elliott MN, et al. A mental health intervention for schoolchildren exposed to violence: A randomized controlled trial. JAMA 2003;290:603-611. 28. Doll B, Lyon MA. Risk and resilience: Implications for the delivery of education and mental health services in schools. School Psych Rev 1998;27:348-363. 29. Wolmer L, Laor N, Yazgan Y. School reactivation programs after disaster: Could teachers serve as clinical mediators? Child Adolesc Psychiatr Clin N Am 2003;12:363-381. 30. Wolmer L, Laor N, Dedeoglu C, Siev J, Yazgan Y. Teacher-mediated intervention after disaster: A controlled three-year follow-up of children’s functioning. J Child Psychology Psychiatry 2005;46:1161-11.

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31. Berger R, Gelkopf M. School-based intervention for the treatment of tsunami-related distress in children: A quasi-randomized controlled trial. Psychother Psychosom 2009;78:364-371. 32. Pynoos RS, Frederick C, Nader K, Arroyo W, Steinberg A, Eth S, et al. Life threat and posttraumatic stress in school-age children. Arch Gen Psychiatry 1987;44:1057-1063. 33. Wolmer L, Hamiel D, Barchas JD, Slone M, Laor N. Teacher-delivered resilience-focused intervention in schools with traumatized children following the second Lebanon war. J Trauma Stress. 2011;24:309-316. 34. Birmes P, Raynaud JP, Daubisse L, Brunet A, Arbus C, Klein R, et al. Children’s enduring PTSD symptoms are related to their family’s adaptability and cohesion. Community Ment Health J 2009;45:290-299. 35. Weems C, Taylor LK, Cannon MF, Marino RC, Romano DM, Scott BG, et al. Post traumatic stress, context, and the lingering effects of the Hurricane Katrina disaster among ethnic minority youth. J Abnorm Child Psychol 2009;38:49-56. 36. Stover CS, Hahn H, Im JJY, Berkowitz S. Agreement of parent and child reports of trauma exposure and symptoms in the early aftermath of a traumatic event. Psychol Trauma 2010;2:159-168. 37. Baron-Epel O, Kaplan G. Can subjective and objective socioeconomic status explain minority health disparities in Israel? Soc Sci Med

2009;69:1460-1467. 38. Laor N, Wolmer L, Alon M, Siev J, Samuel E, Toren P. Risk and protective factors mediating psychological symptoms and ideological commitment of adolescents facing continuous terrorism. J Nerv Ment Dis 2006;194:279-86. 39. Yahav R, Cohen M. Symptoms of acute stress in Jewish and Arab Israeli citizens during the Second Lebanon War. Soc Psychiatry Psychiatr Epidemiol 2007;42:830-836. 40. Somer E, Maguen S, Or-Chen K, Litz BT. Managing terror: Differences between Jews and Arabs in Israel. Int J Psychol 2009;44:138-146. 41. Mossakowski KN. Coping with perceived discrimination: Does ethnic identity protect mental health? J Health Soc Behav 2003;44:318-331. 42. Rosenheck R, Fontana A. Black and Hispanic veterans in intensive VA treatment programs for Posttraumatic Stress Disorder. Med Care 2002;40:152-161. 43. Tatar M, Horenczyk G. Dilemmas and strategies in the counseling of Jewish and Palestinian children in Israeli schools. Br J Guid Counc 2003;31:375-391. 44. Wolmer L, Hamiel D, Laor N. Preventing children’s post-traumatic stress after disaster with teacher-based intervention: A controlled study. J Am Acad Child Adolesc Psychiatry 2011;50:340-348.

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Isr J Psychiatry Relat Sci - Vol. 50 - No 2 (2013)

Predictors of Professional Quality of Life among Physicians in a Conflict Setting: The Role of Risk and Protective Factors Yeela Haber, MA,1 Yuval Palgi, PhD,2 Yaira Hamama-Raz, PhD,3 Amit Shrira, PhD,4,5 and Menachem Ben-Ezra, PhD3 1

Clinical Psychology Section, The School of Behavioral Sciences, Tel Aviv-Yaffo Academic College, Tel Aviv, Israel Department of Gerontology, University of Haifa, Haifa, Israel 3 School of Social Work, Ariel University, Ariel, Israel 4 Department of Psychology, Tel Aviv University, Tel Aviv, Israel 5 Israel Gerontological Data Center, Paul Baerwald School of Social Work and Social Welfare, The Hebrew University of Jerusalem, Jerusalem, Israel 2

Abstract Background: Unlike other places in the western world, Israeli physicians are prone to be exposed to victims of terror and war (soldiers and civilians alike), while in some cases the patients are close friends or relatives. Moreover, in other armed conflict situations (stemming from war or terror), there is a direct threat to the physician’s life and his/her family. Among hospital personnel, there is little research concerning the factors associated with aspects of professional quality of life such as burnout, compassion fatigue, and compassion satisfaction. Aim: The current study compared a set of risk and protective factors associated with burnout, compassion fatigue, and compassion satisfaction. Methods: The sample consisted of 97 physicians who answered a wide battery of questionnaires tapping to the aforementioned factors that served as predictive variables (age, gender, marital status, PTSD symptoms, depressive symptoms, dissociative symptoms, life satisfaction, perceived self-efficacy, perceived family support) using multiple regressions. Results: The study results showed that higher levels of PTSD symptoms were associated with higher levels of compassion fatigue (β = .594; t = 4.419; p <.001). A higher level of life satisfaction was associated with lower burnout (β = -.436; t = -4.293; p <.001). The same results

Address for Correspondence: menbe@ariel.ac.il

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were found also in lower level of perceived family support (β = -.203; t = -2.533; p <.05), and higher level of perceived self-efficacy was associated with higher burnout (β = .298; t = 2.702; p <.01). Finally, a higher level of life satisfaction was associated with higher compassion satisfaction (β = .493; t = 4.419; p <.001). Conclusion: These results may suggest that life satisfaction is a predictor associated with burnout and compassion satisfaction. These results are viewed in light of the importance of life satisfaction as a barrier against burnout and its implication for physicians and hospital policy.

Introduction Over the past 20 years, the Israeli population has been exposed to many traumatic events, mainly due to war and terror (1). This exposure has led to a mental health toll that has affected Israeli society (2). One particular group that has been in constant exposure to the casualties of war and terror is hospital physicians (3). Israeli physicians have dealt with extreme terror waves during 1993-1995, 2002-2003 (2), and during the Second Lebanon War in 2006 (3, 4), in which they treated civilians and soldiers while under the stress of caring for their own family Authors’ note: This work was partially based on Ms. Haber’s thesis supervised by Prof. Ben-Ezra.

Menachem Ben-Ezra, PhD, School of Social Work, Ariel University Center of Samaria, Ariel 40700, Israel

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members, who were exposed to missile attacks. The situation was similar during the Gaza War in 2008-2009 (5). A recent review has found that job stress and burnout are positively associated with likelihood of committing errors in medical decisions and with suboptimal patient care (6). Moreover, job stress has been found to be related to a greater influence of non-medical factors in making medical decisions (7). While stress is common among hospital personnel due to their work, medical staff seem to deny the effect of stress and fatigue on performance (8). As the literature shows, hospital personnel have been found to be relatively resilient to potential trauma, both direct and indirect (9-13). However, they face heavy workloads, occupational stress, ethical dilemmas, and conflicting demands as part of their everyday life (14, 15). These may result in psychological stress, psychosomatic symptoms and psychiatric morbidity (3, 4, 9, 16). In the context of exposure, hospital personnel are constantly exposed to secondary traumatization as part of their daily work as well as during extreme conditions like wartime situations (1). Beyond the mentioned potential primary traumatization, the potential for secondary traumatization also exists. Within this context, the study of professional quality of life among physicians is quite scarce. The purpose of the present study was to investigate professional quality of life and its related concepts in a population of physicians. Looking from an Israeli perspective, the context in which physicians operate is much more stressful in comparison to their western counterparts. In sum, the Israeli context gives us a unique setting in which hospital personnel are exposed to ongoing stress as part of their job and extreme stress for particular periods in which their own lives are at stake. This distinctive situation makes the Israeli physicians population a highly selected and important study group within the field of traumatic stress. Compassion Fatigue

Compassion Fatigue (CF), also known as Secondary Trauma (ST) and related to Vicarious Trauma (VT), addresses work related secondary exposure to extremely stressful events (17). It is the stress resulting from helping or wanting to help a traumatized or suffering person (18). The different formulations developed to explain secondary traumatization tend to emphasize one of two major aspects. The first, more commonly referred to as Vicarious Traumatization, regards a latent alteration to cognitive schemes and basic beliefs that result from an empathic relationship with a trauma survivor (19-22). The second aspect refers to symptoms a person experi-

ences as a result of having been in contact (therapeutic or other) with a trauma survivor. These aspects partially overlap and may exist simultaneously (19, 23). In many cases, and especially among healthcare professionals, it is impossible to distinguish between direct and indirect traumatic effects. Empirically, CF was associated with the following factors: social support (24), previous trauma history (25, 26), perceived self-efficacy (27), depression (28), and life satisfaction (29). Burnout

Burnout is a condition that is present in many individuals under constant pressure. One of the most affected groups is physicians, as they are frequently overloaded with the demands of caring for sick patients within limited organizational resources (30, 31). Factors that were found associated with lower burnout are the existence of a supportive spouse, high social support, personal expectations, life satisfaction, and low level of depressive symptoms (30, 31). It was found that stressed, burned out, and dissatisfied physicians report a greater likelihood of making errors and more frequent instance of suboptimal patient care (6). In a study conducted among American surgeons (32), results showed that major medical errors reported by surgeons were strongly related to a surgeon’s degree of burnout and their quality of life (QOL). Compassion Satisfaction

Alongside the negative effects of working with trauma patients, being able to do your job well, whether it is helping others or any other form of contribution, provides a sense of satisfaction. Stamm (17) refers to this as Compassion Satisfaction (CS). A study by Rout, Cooper and Rout (33) found that the intensity of job demands related to patient-contacts, patients’ expectations, and interruptions by patients have a negative impact on general practitioners (GPs) job satisfaction and mental health. Professional Quality of Life

Professional quality of life is a general construct suggested by Stamm (17) in order to depict three previously described components that affect professional’s life from the field of caring (varies from social workers to physicians). These are viewed as negative and positive aspects of caring. Although the relationships between the three components – compassion fatigue, burnout and compassion satisfaction – is not yet fully understood (17), it seems that the trio can represent all major aspects of 175

Predictors of Professional Quality of Life among Physicians in a Conflict Setting

professional quality of life as it is affected by and affects professional well-being and performance. As addressed earlier, the separation of direct and indirect traumatic exposure among physicians is understudied. Understanding how risk and protective factors interact among hospital professionals is of great importance, as it can help in formulating customized medical policies and programs that would assist utilization of personnel resources and prevent the adverse effects of the negative components of professional quality of life (e.g., compassion fatigue and burnout).

two constructs. Life satisfaction is a global construct while compassion satisfaction is a very specific one. If the correlation between the two is moderate, it may be concluded that the two constructs share some variance but still represent separate entities (43). Third, perceived self-efficacy will be associated with lower levels of burnout and compassion fatigue, and higher levels of compassion satisfaction. Fourth, perceived family support will be associated with lower levels burnout and compassion fatigue, and higher levels of compassion satisfaction.

Risk Factors & Protective Factors Associated with Professional Quality of Life and its Components

Method

The literature has addressed several risk and protective factors that are associated with the components of professional quality of life (compassion fatigue, burnout, compassion satisfaction). Within this context, the first risk factor is posttraumatic stress disorder (PTSD) symptoms, as this is an important indication of primary trauma. Among medical personnel (ambulance workers and paramedics), there was a moderate correlation between CF and PTSD symptoms, indicating that they are distinctive constructs (34). The second risk factor was depressive symptoms that are known to be associated with burnout (35). This is important as burnout is most likely to be accompanied by depression (36). The third risk factor was dissociation that was found to be related to vicarious traumatization among therapists (37, 38). In terms of protective factors, life satisfaction is an important construct known to be associated with lower levels of burnout (26, 36, 39). It was also found to be a good indicator of global well-being and an indicator of positive mental health (40). Other important factors are perceived self-efficacy that was found to be associated with lower burnout (27, 41), and perceived family support that was also found to be negatively associated with burnout (42). The present study aimed to investigate whether certain risk and protective factors are associated with physician professional quality of life components. Based on previous literature, we devised four hypotheses. First, risk factors (PTSD symptoms, depressive symptoms, dissociative symptoms) will be associated with negative aspects of professional quality of life (compassion fatigue and burnout). Second, higher level of life satisfaction will be associated with lower levels of burnout and compassion fatigue, and higher levels of compassion satisfaction. At first glance, it may seem as a tautological hypothesis. However, there are differences between the 176

Design

The study design was a cross-sectional convenience sample of hospital physicians. Participants

The sample consisted of 97 physicians. The mean age in the sample was 35.07 (SD = 9.08; range = 25-65), 82 men (84.5%), 62 married (63.9%). The study was approved by the Helsinki Institutional Review Board in Sourasky Medical Center, Rabin Medical Center, and Sheba Medical Center. Instruments Demographics

Each participant was interviewed for background characteristics (age, gender, marital status, profession). The following demographic variables were coded as following: gender (1 = men; 2= women), marital status (1 = married; 2 = not married). For more demographic information and the study variables, see Table 1. Table 1. Descriptive Statistics for the study sample (n=97) Variables Demographics Age, years (SD) Gender, Men, N (%) Marital status, Married, N (%)

35.07 (9.08) 82 (84.5) 62 (63.9)

Risk Factors PTSD symptoms (IES-R), mean (SD) Depressive symptoms (CES-D), mean (SD) Dissociative symptoms (DES), mean (SD(

10.27 (12.03) 13.96 (6.82) 1.71 (1.54)

Protective Factors Life satisfaction (SAS), mean (SD) Perceived self-efficacy, mean (SD) Perceived family support, mean (SD)

7.30 (1.40) 3.53 (1.61) 2.71 (1.68)

Professional Quality of Life Compassion fatigue, mean (SD) Burnout, mean (SD) Compassion satisfaction, mean (SD)

8.55 (6.29) 17.16 (5.07) 33.16 (7.83)

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Independent Variables - Risk Factors

PTSD symptoms were assessed by the Impact of Event Scale – Revised (IES-R)(44). The IES-R is a 22-item selfreport measure that assesses subjective distress caused by traumatic events. The IES-R contains items related to the symptoms of PTSD. Items correspond directly to 14 of the 17 DSM-IV symptoms of PTSD. Respondents were asked to identify a specific stressful life event and then indicate how much they were distressed or bothered during the past seven days by each difficulty listed. Items are rated on a 5-point scale ranging from 0 (“not at all”) to 4 (“extremely”). The IES-R yields a total score (ranging from 0 to 88). Cronbach’s Alpha for the IES-R in this study was 0.94. Depressive symptoms were assessed by the Center for Epidemiologic Studies depression scale (CES-D) (45), which includes 20 items representing four subscales of depressive symptomatology (negative affect, positive affect, somatic symptoms, and interpersonal problems). Respondents were asked to rate each item on a Likert scale of 0–3 (0 = not at all, 1 = sometimes, 2 = most of the time and 3 = all the time) while referring to the past 7 days. The possible range for a CES-D score is between 0 and 60. Cronbach α for this sample was 0.79. Dissociative symptoms were assessed by the Dissociative Experience Scale (DES) (46), which is used to rate dissociative experiences on an 11-point frequency scale (0 = never; 100 = always). The total score is the average of the 28 items’ scores (score range 0–100). Cronbach α for this sample was 0.89. Protective factors

Satisfaction with Life was measured by Cantril’s Self Anchoring Scale (SAS) (47). Participants were presented with a vertical ladder of 11 rungs, where the top (number 10) and the bottom (number 0) represented the best and worst possible conditions of one’s life, respectively. The participants were asked to indicate on which rung they believed that they stood at the present time. Perceived Self Efficacy was assessed by the question: “How well do my personality characteristics help me cope with extreme situations?” on a five point Likert scale (1 = not at all, 2 = a little bit, 3 = moderately, 4 = much, 5 = very much). Similar single item measures for perceived self-efficacy are known in the literature (48). Perceived Family support was assessed by the question: “How well does my family help me cope with extreme

situations?” on a five point Likert scale (1 = not at all, 2 = a little bit, 3 = moderately, 4 = much, 5 = very much). Similar single item measures for perceived family support are known in the literature (49). Dependent variable

Professional quality of life was measured by the Professional Quality of Life Scale – Revised (ProQOL) (17) which is composed of three discrete subscales. The first subscale measures burnout. Higher scores on this subscale represent a greater risk for burnout. We used a shorter version of the burnout subscale representing hospital personnel issues. The second subscale measures compassion fatigue. Higher scores indicate greater levels of compassion fatigue. The third subscale measures compassion satisfaction. Higher scores on this subscale represent greater satisfaction. The ProQOL is a 30-item self-report measure in which respondents were instructed to indicate how frequently each item was experienced in the previous 30 days. Each item is anchored by a 6-item Likert scale (0 = never, to 5 = very often). Cronbach α for the subscales are reported as α=.85 for compassion fatigue, α = .73 for the modified burnout subscale, and α = .86 for compassion fatigue subscale. These results are similar to those reported earlier with a relatively lower reliability in the burnout subscale (.72 in the original sample devising the questionnaire) (17). Statistical methods

First, a preliminary correlation matrix was conducted in order to view the association between the study variables. Afterwards, three sets of hierarchical multiple regression were conducted, each one corresponding respectively to an outcome variable (burnout subscale, compassion fatigue subscale, compassion satisfaction). The hierarchical regressions had three steps. The first step consisted of socio-demographic variables (age, gender, martial status). The second step consisted of risk factors (PTSD symptoms, depressive symptoms, dissociative symptoms) and the third consisted of protective factors (life satisfaction, personal attributes, family support). A preliminary analysis was conducted for potential multicolinearity. Applying the rules used in the literature stating that tolerance of less than 0.20 and/or variance inflation factor (VIF) of 5 and above indicate a multicollinearity problem (50). The preliminary analysis of the hieratical regressions yielded tolerance ranging from 0.472-0.898 and VIF of 1.138-2.117. These results indicated that there was no multicollinearity problem. 177

Predictors of Professional Quality of Life among Physicians in a Conflict Setting

with CF (β = .594; t = 4.419; p <.001). See Table 3 for more details. Hypothesis 1 was partially confirmed as the correlation Life satisfaction was negatively associated with burnmatrix revealed a positive association between PTSD out (r = -.497; p < .001). Moreover, this result becomes symptoms and CF (r = .627; p < .001) and burnout (r = more salient when looking at the hierarchical multiple .389; p < .01). The same was true for depressive symptoms regression results. Only psychological factors were that were positively associated with CF (r = .339; p < .01) associated with burnout while mental health variables and burnout (r = .438; p < .001). However, dissociative were not. To be specific, life satisfaction was negatively symptoms were positively associated only with CF (r = associated with burnout (β = -.436; t = -4.293; p <.001) along with perceived family support (β = -.203; t = .318; p < .01). See Table 2 for more details. Looking at the hierarchical multiple regression, -2.533; p <.05). However, contrary to our expectation, only PTSD symptoms were significantly associated perceived self-efficacy was positively associated with burnout (β = .298; t = 2.702; p <.01). See Table 4 for more results. Table 2. Correlation Matrix of the Study Variables (n=97) Affirming our second hypothesis, life satisfaction was Compassion compassion positively associated with CS (r = .463; p < .001) along Fatigue Burnout satisfaction with perceived family support (r = .224; p < .05). See Scale Scale scale Table 2 for more details. The results of the hierarchical Age .011 -.194 .201 multiple regression support the correlation matrix as Gender .163 -.021 .141 life satisfaction was positively associated with higher Marital status .066 .119 -.071 compassion satisfaction (β = .493; t = 4.419; p <.001). PTSD symptoms .627*** .389*** .036 See Table 5 for more details. Depressive symptoms .339** .438*** -.004 Hypothesis 3 was partially confirmed, as life satisfacDissociative symptoms .318** .140 .028 tion did not predicted compassion fatigue. However, life Life Satisfaction -.207 -.497*** .463*** satisfaction predicted burnout (β = .436; t = -4.293; p <.001) Perceived self-efficacy -.033 .209 .140 and compassion satisfaction (β = .493; t = 4.419; p <.001). Perceived family support .045 -.040 .224* In sum, the results partially supported Hypothesis 1-4. The most intriguing result was that mental health fac*p< .05, **p<.01, ***p<.001 tors were not associated with burnout and that perceived self-efficacy was positively Table 3. Hierarchical Multiple Regression Predicting Compassion Fatigue correlated with burnout. Among Physicians (n=97) Results

Step 1: Model R = .220; Model R2 = .048 Predictors

Standardized β (Ba)

Age

-.026 (-.017)

Gender Marital status

Step 2: Model R = .629; Model R2 = .396 R2 change = .348***

Standardized β (Ba)

-.219

<.01

-.179 (-.117)

-1.463

.032

.198 (3.341)

1.752

.04

.203 (3.434)

2.056*

.041

.088 (1.139)

.748

<.01

.027 (.351)

.272

<.01

Risk Factors PTSD symptoms Depressive symptoms Dissociative symptoms

.594 (.328) -.084 (-.080) -.010 (-.047)

4.363*** -.656 -.089

0.353 <.01 <.01

Protective Factors Life Satisfaction Perceived self-efficacy Perceived family support

-.080 (-.354) -.125 (-.498) -.002 (-.007)

-.762 -1.131 -.017

<.01 .016 <.01

a = Unstandardized B. Gender was coded as 0 = men; 1 = women; Marital status was coded as 0 = married/cohabitation; 1 = not married/cohabitation * p< .05; ** p<.01; ***p<.001

178

Discussion The present study aimed to explore the associations between various risk and protective factors and components of hospital personnel’s professional quality of life, namely compassion fatigue, burnout, and compassion satisfaction. Our first hypothesis was that lower mental health will be best associated with the negative aspects of professional quality of life (compassion fatigue and burnout), and it was partially affirmed. When examined independently, each of the three risk factors was indeed positively correlated to CF, and two (post-traumatic and depressive symptoms) were positively correlated to

Yeela Haber et al.

interaction between symptom clusters (dissociative, depressive and post-traumatic) and the complex primary and secondary Step 2: Model R = .673; 2 traumatic exposure that exists in this popuStep 1: Model R = .232; Model R = .453 Model R2 = .054 R2 change = .399*** lation group. Similarly, Meadors and colStandardized Standardized leagues (52) revealed that among pediatric Predictors β (Ba) T R2 β (Ba) t R2 healthcare providers a significant overlap Age -.208 (-.111) -1.675 .04 -.116 (-0.62) -.934 .01 existed between the terms of posttrauGender .024 (.337) .209 <.01 -.007 (-.092) -.069 <.01 matic stress disorder (PTSD), secondary Marital status .056 (.601) .460 <.01 -.046 (-.491) -.467 <.01 traumatic stress (STS), compassion fatigue Risk Factors (CF), burnout (BO) and compassion satPTSD symptoms .165 (.074) 1.324 .03 isfaction (CS). Depressive symptoms .159 (.128) 1.241 .03 Dissociative symptoms .017 (.056) .161 <.01 Integrating hypotheses 2-4 which addressed a correlation between satisfacProtective Factors Life Satisfaction -.436 (-.1570) -4.293*** .19 tion with life, perceived self-efficacy and Perceived self-efficacy .298 (.963) 2.702** .09 perceived family support and compassion Perceived family support -.278 (-.861) -2.533* .08 fatigue, burnout and compassion satisfaca = Unstandardized B. tion, these hypotheses were partially supGender was coded as 0 = men; 1 = women Marital status was coded as 0 = married/cohabitation; 1 = not married/cohabitation ported and show a distinct differentiation * p< .05; ** p<.01; ***p<.001 between life satisfaction and compassion satisfaction along with the negative associTable 5. Hierarchical Multiple Regression Predicting Compassion Satisfaction ation between life satisfaction and burnout. Among Hospital Personnel (n=97) These findings suggest that compassion Step 2: Model R = .547; satisfaction might be one aspect of life Step 1: Model R = .223; Model R2 = .299 satisfaction that is more related to health 2 2 Model R = .050 R change = .249** care providers who target themselves to Standardized Standardized a 2 a 2 fulfill their mission. In other words, physiPredictors β (B ) T R β (B ) t R cians feel satisfaction from elements such Age .179 (.153) 1.460 .02 .212 (.181) 1.676 .04 as doing their work well, helping others, Gender .123 (2.570) 1.073 .03 .055 (1.153) .514 <.01 working with their colleagues, being able Marital status .034 (.567) .282 <.01 .072 (1.192) .654 <.01 to contribute to society or feeling high Risk Factors competency. A similar result was found PTSD symptoms .044 (.034) .310 <.01 Depressive symptoms .183 (.221) 1.278 .03 among 226 emergency physicians (53). Dissociative symptoms .013 (.061) .100 <.01 An interesting finding was that perProtective Factors ceived self-efficacy was positively correLife Satisfaction .493 (2.828) 4.419*** .24 Perceived self-efficacy .064 (.324) .526 <.01 lated to burnout. Greenglass et al. (54) Perceived family support .141 (.674) 1.148 .02 have suggested that individual skills such as a = Unstandardized B. coping ability affect the degree of burnout Gender was coded as 0 = men; 1 = women experienced. In their study among nurses Marital status was coded as 0 = married/cohabitation; 1 = not married/cohabitation * p< .05, ** p<.01, *** p<.001 they revealed that nurses who utilized control coping (proactive efforts to change the situation), had more positive feelings about their burnout. However, when taking into account their comprofessional accomplishments. Greenglass and Burke (55) bined effect, only PTSD symptoms remained positively associated with CF. This suggests a complex model of also reported that escape coping (efforts to get the person interactions between the factors. Post-traumatic stress away from the situation) was associated with higher levels symptoms include, alongside trauma-specific symptoms, of burnout, including more emotional exhaustion and symptoms of a depressive nature and of a dissociative cynicism. Escape coping appears to be another symptom of distress rather than a coping strategy as it is consistently nature (e.g., 51). It may be that the association found associated with psychological symptomatology (56, 57). in the combined model of PTSD and CF reflects the Table 4. Hierarchical Multiple Regression Predicting Burnout Among Hospital Personnel (n=97)

179

Predictors of Professional Quality of Life among Physicians in a Conflict Setting

Thus, one may assume that physicians who perceive themselves as using more control-oriented coping tactic rather than an avoidant or an escape-oriented coping tactic, will be able to cope more effectively with burnout. Finally, Spickard et al. (30) view family support as an important barrier against burnout. Limitations

There are several limitations to this study. First, we used a convenience sample and consequently our respondents may not represent the population of hospital personnel. Second, Israeli citizens are chronically exposed to national security threats such as wars and terrorist bombings which indubitably, has an effect on coping capabilities. For the most part, studies have found a harmful effect of exposure to stress (e.g., 58), but there is also some evidence that traumatic exposure may have an immunizing effect (59, 60). Either way, Israeli hospital personnel are more likely to differ in their stress reactions from other hospital personnel worldwide who have experienced less exposure to direct and indirect traumatic events. A third limitation is the possible confounding of primary traumatization with secondary traumatization. Previous research has attempted to differentiate the two constructs and found it a difficult task (61, 62). That said, perhaps such an attempt should be made whenever measuring ST, especially when the secondary traumatic exposure is not limited to a single, defined event. The present study adds to the knowledge of professional quality of life in the understudied population of physicians. The findings highlight the importance of positive individual traits and positive work environment to improve quality of life and prevent pathologies among physicians. Practical support as well as emotional and psycho-educational support may help physicians structure their workload so that they will cope better. Conclusions Theoretically, if one understands the reasons for low job and low life satisfaction, one can institute policies that may improve job satisfaction, improved physician retention, more equitable distribution of physician services, and ultimately, better care for the patients (63). The message to mental health professionals from this study is that elevating hospital physician’s life satisfaction will be a good indicator for positive mental health, compassion satisfaction and a good barrier against the detrimental effects of burnout. 180

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psychological functioning. J Res Personality 2007; 41: 139-154. 44. Weiss DS, Marmar CR. The Impact of Event Scale – revised. In: Wilson JP, Keane TM, editors. Assessing psychological trauma and PTSD. New York, N.Y.: Guilford, 1997: pp. 399-411. 45. Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. Appl Psychol Meas 1977; 1: 385-401. 46. Bernstein EM, Putnam FW. Development, reliability, and validity of a dissociation scale. J Nerv Ment Dis 1986; 174: 727-735. 47. Cantril H. The pattern of human concerns. New Brunswick, N.J.: Rutgers University, 1965. 48. Schwarzer R, Fuchs R. Self-efficacy and health behaviors. In: Conner M, Norman P, editors. Predicting health behavior: Research and practice with social cognition models. Buckingham, U.K.: Open University, 1996: pp. 163-169. 49. Johansson E, Larsson GA. Model for understanding stress and daily experiences among soldiers in peacekeeping operations. International Peacekeeping 1998; 5: 124-141. 50. O’Brien RM. A caution regarding rules of thumb for variance inflation factors. Qual Quant 2007; 41: 673-690. 51. Flannery RB. Psychological trauma and posttraumatic stress disorder: A review. Int J Emerg Ment Health 1999; 1: 135-140. 52. Meadors P, Lamson A, Swanson M, White M, Sira N. Secondary traumatization in pediatric healthcare providers: compassion fatigue, burnout, and secondary traumatic stress. Omega 2009-2010; 60: 103-128. 53. Sreenivas R, Wiechmann W, Anderson CL, Chakravarthy B, Menchine M. Compassion, satisfaction and fatigue in emergency physicians. Ann Emerg Med 2010; 56: S51. 54. Greenglass E, Burke RJ, Ondrack M. A gender-role perspective of coping and burnout. Applied Psychology: An International Review 1990; 39: 5-27. 55. Greenglass E. Burke RJ. Hospital downsizing, individual resources and occupational stressors in nurses. Anxiety Stress Coping 2000; 13: 371-390 56. Latack JC. Coping with job stress: Measures and future directions for scale development. J Appl Psycho 1986; 71: 377-385. 57. Greenglass E. Gender, work stress and coping: Theoretical implications. J Soc Behav Personality 1995; 10: 121-134. 58. Turner RJ, Wheaton B, Lloyd DA. The epidemiology of social stress. Am Sociol Rev 1995; 60: 104-125. 59. Ben-Ezra M, Palgi Y, Essar N, Sofer H, Haber Y. Acute stress symptoms, dissociation, and depression among rescue personnel 24 hours after the Bet-Yehoshua train crash: The effects of exposure to dead bodies. Prehosp Disaster Med 2008; 23: 461-465. 60. Gelkopf M, Berger R, Bleich A, Silver RC. Protective factors and predictors of vulnerability to chronic stress: A comparative study of 4 communities after 7 years of continuous rocket fire. Soc Sci Med 2012; 74: 757-766. 61. Weiniger CF, Shalev AY, Ofek H, Freedman S, Weissman C, Einav S. Posttraumatic stress disorder among hospital surgical physicians exposed to victims of terror: A prospective, controlled questionnaire survey. J Clin Psychiatry 2006; 67: 890-896. 62. Zimering R, Gulliver SB, Knight J, Munroe J, Keane TM. Posttraumatic stress disorder in disaster relief workers following direct and indirect trauma exposure to Ground Zero. J Traum Stress 2006; 19: 553-557. 63. Thommasen H, van der Weyde MP, Michalos AC, et al. Satisfaction with work and quality of life among British Columbia’s physicians: A review of the literature. BCMJ 2002; 44: 188-195.

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Somatization and Psychiatric Symptoms among Hospital Nurses Exposed to War Stressors Menachem Ben-Ezra, PhD,1 Yuval Palgi, PhD,2 Amit Shrira, PhD,3 and Yaira Hamama-Raz, PhD1 1

School of Social Work, Ariel University, Ariel, Israel Department of Gerontology, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel 3 Interdisciplinary Department of Social Sciences, Faculty of Social Sciences, Bar-Ilan University, Ramat Gan, Israel 2

Introduction

Abstract Objective: Research regarding nurses’ reactions during armed conflict is scarce. The current study compared somatization and psychiatric symptoms of exposed and unexposed hospital nurses in two studies. Method: Two studies were conducted during 2009 and included a survey of two random samples of hospital nurses (exposed vs. unexposed), one conducted during the Gaza War, and the other conducted six months later. The design was repeated cross-sectional study. Results: In Study 1, exposed nurses had higher level of PTSD symptoms, depressive symptoms and psychosomatic symptoms. In Study 2, exposed nurses did not differ from unexposed nurses in the level of PTSD symptoms and depressive symptoms. However, in Study 2, unexposed nurses reported a higher level of psychosomatic symptoms (10.68 vs 5.62) compared to the exposed group. Moreover, multivariate analysis of covariance revealed a significant interaction effect of Exposure X Study (F = 12.838; p < 0.001; ηp2 = .076; Observed power = 0.945) for somatization. Conclusions: These results are in line with Selye’s general adaptation syndrome and the allostatic model. This may suggest that nurses exposed to continuous severe stress that ended and then returned from the exhaustion phase back to daily work stress may have undergone an oscillation period (distress to Eustress).

Address for Correspondence: menbe@ariel.ac.il

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Nurses who practice in general hospitals face heavy workloads, occupational stress, ethical dilemmas, and conflicting demands as part of their everyday life (1). These may result in psychological stress, psychiatric morbidity and psychosomatic symptoms (1, 2). While these stressful conditions are well studied in general hospitals, less is known when nurses are exposed to continuous severe stress. However, on some uncommon occasions, hospital personnel were exposed to extreme conditions and stress due to the treatment of terror victims (3, 4), and being exposed to harsh conditions and mass victims of natural disaster such as Haiti’s earthquake in 2010 (5). Not much is known about hospital personnel in the midst of direct exposure to warrelated stress and in its aftermath. Studies on hospital personnel during war add another important factor to the above extreme conditions by its immediate threat to life and the life of colleagues (6, 7). These studies have shown that there was an increase in the level of post-traumatic stress disorder (PTSD) symptoms and depressive symptoms along with significant comorbidity of PTSD symptoms and depressive symptoms. This extreme situation led to extreme workload and stress on hospital personnel due to overwhelming mass of casualties and severe injuries, while the hospital itself was targeted by rockets and missiles. Another important factor that is not widely measured among hospital personnel is somatic symptoms. Previous studies found an association between stress and somatization (8-10). Somatization is the tendency to experience and communicate psychological distress in the form of physical symptoms (11). Based on the above, there is rationale to investigate somatization among hospital personnel who work under extreme circumstances (e.g., working in an unsheltered hospital targeted by rockets during war).

Menachem Ben-Ezra, PhD, School of Social Work, Ariel University, Ariel 40700, Israel.

Menachem Ben-Ezra et al.

Moreover, the potential for impairment in functioning as a result of the psychosomatic symptoms in the context of extreme stress is understudied among nurses. This is important as nurses conduct important tasks that can be fatal if conducted incorrectly. In the current study, we compared the psychosomatic symptoms and psychiatric symptoms (PTSD symptoms and depressive symptoms) of randomly sampled hospital personnel directly exposed to war-related stress during the Gaza War to those of unexposed hospital personnel. This comparison was conducted on two occasions; the first sampling took place three weeks after the beginning of the war (when the war was still raging; Study 1) and the second took place six months after the end of the war (Study 2). The current study encompassed more factors than previous research (3, 4, 6, 7, 12, 13), including additional background characteristics, and markers of psychosocial functioning. These additional factors gave us a broader scope of the mental state of exposed hospital personnel. The conceptual theory for this study was derived from Selye’s general adaptation syndrome (GAS) (14, 15). The general adaptation syndrome has three stages. Stage one alarm. The stressor is perceived as threat and lead to stress reactions. These reactions involve arousal of sympathetic nervous systems, hormonal system via the hypothalamicpituitary-adrenal (HPA) axis and along with cortisol secretion. Stage two – resistance. When the stressor continues, the person endeavors to cope with the stress. This process is energy depleting and the adaptation to stress is temporary. Stage three – exhaustion. When the body resources are depleted, there is a decline in functioning due to the inability to cope with the stress. The longer stage three takes,

the more severe the consequences will be. Manifestations of both psychological and physiological symptoms may appear. These may lead to physical and mental disorders. Another conceptual theory relevant to this study is the allostasis model (16). This model postulates that homeostasis is the regulation of the body to a balance. However, allostasis proposes maintenance of stability outside of the normal homeostatic range where the organism will adapt to chronic demands. This has both protective and damaging effects on the body. In the short run, allostasis is essential for adaptation, maintain of homeostasis, and survival. Yet, over time there is an allostatic load that will have both mental and physical toll. Studies showed that job stress among nurses is related to the GAS model and the allostatic load model (17-21). Based on previous research, we derived the following hypotheses: First, according to Seyle’s GAS model, nurses exposed to prolonged severe stress will be more exhausted and strained, meaning they will exhibit higher level of psychosomatic symptoms and psychiatric symptoms (depressive and PTSD symptoms) in comparison to nurses who were not exposed to severe stress. Secondly, based on Seyle’s GAS model, it is expected that when the prolonged and severe stress will cease, nurses who were previously exposed, will show similar level of psychiatric and psychosomatic symptoms compared with those who were not exposed. Method Event

On 28 December 2008, an armed conflict erupted between Israel and Gaza. During the war more than 750 rockets

Table 1. Demographic and dependent variables for Study 1 and Study 2 Study 1 (During Gaza War) Exposed Group (n=46)

Unexposed Group (n=41)

Test Statistics

Study 2 (Six Months After the Gaza War) P Value

Exposed Group (n=45)

Unexposed Group (n=31)

Test Statistics

P Value

Age, years (SD)

38.37 (9.55)

38.29 (9.17)

t= 0.037

P = 0.970

38.98 (10.04)

39.39 (9.92)

t= -0.176

P = 0.861

Gender, Women, No. (%)

41 (89.1)

37 (90.2)

χ2 = 0.169

P = 0.866

42 (93.3)

29 (93.5)

χ2 = 0.037

P = 0.971

Marital status, Married, No. (%)

36 (78.3)

24 (58.6)

χ2 = 3.895

P = 0.048

26 (57.8)

24 (77.4)

χ2 = 3.105

P = 0.078

Income, No. (%) Below average Average Above average

28 (60.9) 13 (28.2) 5 (10.9)

15 (36.6) 21 (51.2) 5 (12.2)

χ2 = 1.965

P = 0.049

16 (35.6) 18 (40.0) 11 (24.4)

15 (48.4) 11 (35.5) 5 (16.1)

χ2 = 1.192

P = 0.233

IES-R Score, mean (SD)

26.28 (12.68)

16.93 (14.43)

t = 3.220

P = 0.020

21.00 (13.89)

16.00 (11.86)

t = 1.635

P = 0.106

CES-D Score, mean (SD)

17.22 (7.46)

13.78 (7.71)

t = 2.112

P = 0.038

13.27 (6.84)

13.61 (8.11)

t = --0.201

P = 0.841

PSP Score, mean (SD)

11.24 (7.21)

7.37 (7.21)

t= 2.501

P = 0.014

5.62 (6.75)

10.68 (8.93)

t= -2.810

P = 0.006

Abbreviations: IES-R, Impact of Event Scale – Revised; CES-D, Center Epidemiologic Studies Depression; PSP, Psychosomatic Problems Scale

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were launched into southern Israel, approximately 100 of which targeted the city of Ashkelon. During this time, the unsheltered Barzilai Medical Center in Ashkelon treated 616 people (193 Israeli soldiers, and 423 Israeli and Palestinian civilians) admitted as a result of the armed conflict while under direct rocket attack. Apart from southern Israel, the rest of the country was not within missile range. Design

Two studies were conducted in different periods, thus forming a repeated cross-sectional design. The first study took place three weeks after the beginning of the war while the war was still raging (Study 1); the second study took place six months after the end of the war (Study 2). Participants

Two studies with separate groups of participants were conducted. In Study 1, participants were comprised of hospital personnel selected at random from two hospitals during the week of January 12-15, 2009 (three weeks after the war began). The response rate in our study was 85% at Barzilai Medical Center (exposed) and 90% at Sourasky Medical Center (unexposed). Those who declined were asked about their reasons for refusal. A lack of time was the most frequent reason given for not participating. The two hospitals were the Barzilai Medical Center in Ashkelon (exposed nurses group; N = 46) and the Sourasky Medical Center in Tel Aviv (Unexposed nurses group; N = 41). Only participants who volunteered and gave their consent were interviewed. In Study 2, participants were nurses randomly selected from the same two hospitals during the week of July 19-22, 2009, six months after the war ended. The response rate was 82% at Barzilai Medical Center (previously-exposed nurses; N = 45) and 87% at Sourasky Medical Center (unexposed; N = 31). The participants in Study 2 were Figure 1. PTSD symptoms among exposed and unexposed nurses in Study 1 and Study 2

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not the same participants as in study 1 (i.e., exposed during the war but did not participate in Study 1). Exposed nurses and their families (in both Study 1 and Study 2) resided in the greater Ashkelon area, while the unexposed nurses and their families resided in the greater Tel Aviv area. Nurses from Barzilai Medical Center in both studies worked there during the war and were exposed to direct rocket attacks. Nurses in Study 1 did not participate in Study 2, thus rendering each study independent. Each participant who consented was interviewed in person and guaranteed complete anonymity. Instruments Independent variables

The instruments used in both studies were identical for the purpose of replication. Each participant was interviewed for background characteristics (age, gender, marital status, income). The following demographic variables were coded as following: Gender (1 = men; 2= women), marital status (1 = not married; 2 = married), and income (1 = below average; 2 = average; 3 = above average). War-related exposure was coded as (1 = unexposed, Sourasky Medical Center; 2 = exposed, Barzilai Medical Center). Figure 2. Depressive symptoms among exposed and unexposed nurses in Study 1 and Study 2

Figure 3. Psychosomatic symptoms among exposed and unexposed nurses in Study 1 and Study 2

Menachem Ben-Ezra et al.

Dependent variable

Post-traumatic stress disorder symptoms were assessed by the impact of event scale-revised (IES-R) (22), which includes 22 items in three subscales (intrusion, avoidance, and hyperarousal). Respondents were asked to rate each item on a Likert scale of 0–4 (0 = not at all, 1 = a little bit, 2 = moderately, 3 = quite a bit, and 4 = extremely) while referring to the past seven days. The possible range for IES-R score is between 0 and 88. Internal reliability was excellent (Cronbach α = .913 and .918 for Study 1 and Study 2, respectively). Depressive symptoms were assessed by the center for epidemiologic studies depression scale (CES-D) (23), which includes 20 items representing four subscales of depressive symptomatology (negative affect, positive affect, somatic symptoms, and interpersonal problems). Respondents were asked to rate each item on a Likert scale of 0–3 (0 = not at all, 1 = sometimes, 2 = most of the time, 3 = all the time) while referring to the past seven days. The possible range for a CES-D score is between 0 and 60. Internal reliability was very good (Cronbach α = .836 and .829 for Study 1 and Study 2, respectively). Psychosomatic symptoms were measured by the Psychosomatic Problems Scale (PSP) (24). The PSP is an eight-item scale and it is scored by summation of responses (raw scores) across the following eight items: “had difficulty in concentrating,” “had difficulty in sleeping,” “suffered from headaches,” “suffered from stomach aches,” “felt tense,” “had little appetite,” “felt sad” and “felt giddy.” The response categories for all of these items, which are in the form of questions, are (0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = very often). The categories are ordered in terms of implied frequency in the past week and the greater the frequency, the greater the psychosomatic distress. Justification of the scoring procedure was examined by psychometric analysis using the Rasch model (9). Cronbach’s alpha coefficient was .932 and .953 for Study 1 and 2 respectively. Statistical analysis

In both studies the two groups (exposed vs. unexposed) were compared for psychosomatic symptoms using t-tests. Following the basic examination, changes in psychosomatic symptoms in each group were examined (Study 1 vs. Study 2 for the exposed and unexposed groups respectively) using t-tests. Multivariate analysis of covariance (MANCOVA) was then conducted, with the IES-R, CES-D, and PSP scores as the dependent variable. The independent variables were exposure to war-related stress (exposed vs. unexposed) and study (Study 1 vs.

Study 2). The covariates were background demographics (age, gender, marital status, income). The MANCOVA included effect size estimates (partial eta square). All analyses were performed using SPSS statistical software (version 16.0, SPSS Inc, Chicago, IL). Results Comparison of exposed and unexposed nurses In Study 1, the two groups differ in the background demographics marital status and income. Nurses in the exposed group had higher proportion of being married (χ2 = 3.895; P = 0.048) and lower income (χ2 = 1.965; P = 0.049) in comparison to nurses in the unexposed group. In Study 1, There was a significant differences in the level of PTSD symptoms (t = 3.220; p= 0.002), depressive symptoms (t = 2.112; p = 0.038) and psychosomatic symptoms (t = 2.501; p = 0.014) between the exposed and unexposed group showing more symptoms among nurses in the exposed group. In Study 2, nurses in the previously exposed group had lower level of psychosomatic symptoms in comparison to nurses in the unexposed group (t= -2.810; p = 0.006). Comparison between studies Nurses in the exposed group in Study 1 had higher depressive and psychosomatic symptoms in comparison to nurses in the previously exposed group in Study 2 (t = 2.632; p = 0.010) and psychosomatic symptoms (t = 3.835; p <0.001). No differences were found between Study 1 and Study 2 for nurses in the unexposed group. The MANCOVA revealed an interaction effect of Exposure X study for psychosomatic symptoms (F = 12.838; p < 0.001; ηp2 = .076; Observed power = 0.945). In Study 1, nurses in the exposed group had higher psychosomatic symptoms during exposure to severe stress (Gaza War) than the unexposed nurses group. This tendency was inverted in Study 2, in which nurses in the previously exposed group had lower level of psychosomatic symptoms in comparison to the unexposed group. Another main effect was found, exposure to war related stress (F = 11.589; p = 0.001; ηp2 = .070; Observed power = 0.915). Nurses in the exposed group and previously exposed group had higher level of PTSD symptoms in comparison to the unexposed group. Discussion The results suggest that exposure to severe stress takes its toll on nurses by increasing the level of psychiatric and 185

Somatization and Psychiatric Symptoms among Hospital Nurses Exposed to War Stressors

psychosomatic symptoms. In line with our first hypothesis, exposure to prolong and extreme stress does exhaust the nurses as predicted by Selye’s GAS model (14-17). This should not be surprising as nurses are strained and pressured in their daily work. Nurses conduct medical procedures with accuracy as part of their medical profession. Additionally, they tend the ill and the wounded with empathy and sympathy and maintain close relations with the patients. This emotional task is part of the profession. However, in times of prolonged extreme stress (with immediate threat to life of oneself, family, colleagues, and patients), the combination of physical and psychological burdens depletes the nurses’ resources rapidly. This is also in line with other studies which measured nurses during time of war, and found that nurses were more vulnerable than physicians (6, 7). The explanation given by the researchers was that hospital physicians, contrary to nurses, are firmer with their patients as part of their profession due to time constraints. Having less psychological burden and emotional investment in forms of empathy and sympathy may lead to lower level of emotional distress. This is in line with the fact that physicians tend to use more detachment coping mechanisms contrary to nurses (6, 7). Our second hypothesis was partially confirmed. The results revealed that six months after the end of the war, the nurses in the exposed hospital had similar levels of psychiatric symptoms (i.e., PTSD symptoms and depressive symptoms). This is in line with Selye’s GAS model and the Allostatic model that when the stressor is absent, no reservoirs are depleted and the person functions within daily life parameters. However, we found surprising results regarding psychosomatic symptoms. Ending the prolonged and severe stress led to an oscillation period, meaning moving from distress to Eustress (15). Psychosomatic symptoms that are related to biological factors (activation of the HPA axis as function of exposure level) have been reduced dramatically when compared to the unexposed nurses group. One explanation for these unexpected results may be related to the difference between psychosomatic symptoms and psychiatric symptoms. While psychosomatic symptoms are directly related to biological factors (autonomic nervous and endocrine systems), psychiatric symptoms are involved in more complex brain activities. These were reduced to a lesser extent and did not exhibit an oscillation period. Theses symptoms are mediated via more complex cortical systems and thus indirectly related. In sum, the exposure to severe stress will affect both psychosomatic symptoms and psychiatric symptoms alike. However, when the prolonged severe stress will come to an end, there will be a different 186

pattern between psychosomatic symptoms and psychiatric symptoms. Both have been reduced, whereas psychosomatic symptoms have been reduced more saliently. The current study has several limitations: First and foremost, the small number of nurses that participated in the study. Due to the emergency condition, it was extremely difficult to find and interview nurses. This problem is reported in other studies (5-7). The second limitation is that no longitudinal study was conducted due to the need for anonymity, specifically requested by the study participants. However, the use of random sampling in the two studies may have reduced this limitation to some extent. Indeed, participants in Study 1 and Study 2 did not differ in their demographic background. Moreover, the fact that exposed nurses had similar exposure histories (all exposed nurses in both studies were working at the hospital during the war) may also lend strength to this study’s conclusions. The third limitation is that no actual psychiatric diagnosis was made. The fourth limitation is that although all the nurses were exposed to the main life threatening stressor of rocket attacks in an unsheltered hospital, other potential stressors such as workload and family burden were not assessed, hence losing important individual differences in the cumulative stress that might have led to more variance in the exposure group. Time constraints and the raging war did not enable a thorough clinical assessment of psychosomatic symptoms, and also affected the scope of the questionnaire battery that was used. On the other hand, as psychiatric symptoms were assessed in an unsheltered hospital that was being targeted by rockets, it is possible that the extreme circumstances enhanced the reliability of the psychosomatic problem scale, reducing the former limitation to some extent. As it is likely that hospital nurses will be affected by similar crises in the future, longitudinal studies targeting the same hospital personnel are needed. Future studies should perform prospective assessments of hospital personnel during wartime crisis and investigate ways to enhance their resilience and reduce their vulnerability, as recommended by other studies (4-7). Future studies should also document the nature of wartime exposures (patient contact versus personal threat of injury or death) in order to assess the relative effect of different exposure types. References 1. Tyler PA, Cushway D. Stress in nurses: The effects of coping and social support. Stress Med 1995;11:243-251. 2. Weinberg A, Creed F. Stress and psychiatric disorder in healthcare professionals and hospital staff. Lancet 2000;355:533-537. 3. Firth-Cozens J, Midgley SJ, Burges C. Questionnaire survey of post-

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Food Insecurity Among Psychiatric Patients and Welfare Clients in Israel Roni Kaufman, PhD,1 Julia Mirsky, PhD,1 Eliezer Witztum, MD,2 and Nimrod Grisaru, MD2 1

Department of Social Work, Faculty of Humanities and Social Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel Faculty of Health Sciences, Ministry of Health Mental Health Center, Ben-Gurion University of the Negev, Beer Sheva, Israel

Abstract Background: Twenty-two percent of households in Israel experience food insecurity, and it is especially widespread in socio-economically distressed strata. Although their low socio-economic status renders psychiatric patients at risk for food insecurity, this issue has thus far been ignored in both practice and research. Objective: To explore food insecurity among psychiatric patients in comparison with welfare-services clients in order to raise awareness of food insecurity in this population. Method: 114 respondents were recruited from among patients admitted to the emergency room and hospitalized in a mental health center in Beer Sheva; 555 respondents were recruited from among low-income clients of welfare service agencies in the Beer Sheva area. All respondents were surveyed with a self-report questionnaire and with the Food Security Core Survey Module (FSCSM). Results: Forty percent of psychiatric patients and 59% of welfare-services clients reported food insecurity. The use of formal and informal support systems was lower among food-insecure psychiatric patients than among food-insecure welfare clients. Conclusions: Psychiatric patients appear to be a risk population for food insecurity; therefore planned interventions and specific food programs are called for.

Introduction The development of pockets of food insecurity and hunger in wealthy Western countries such as the U.S., Australia,

Canada, and Israel has been linked to the decline of the welfare state and shifting economic and social policies (1, 2). The recent global economic crisis led to an unprecedented increase in the rate of food insecurity in the U.S. (3). In 2008, 14.9% of US households fell into the food-insecure category â&#x20AC;&#x201C; the highest recorded rate since 1995, when the first national food security survey was conducted (4). A national study in Israel shows that 22% of Israeli households experience food insecurity (5).The increase in rates of food insecurity and concomitant findings on its negative impact on psychiatric patients make it necessary to identify populations at risk and to develop community programs and interventions to promote their food security. A recent Israeli governmental report (5) indicated that the spread of the food insecurity problem was related to major cutbacks in social security benefits and in government investment in social budgets, the erosion of employment income in the wake of changes in the labor market, and the significant rise in food prices. For example, between 2000 and 2006, government expenditures for health, welfare and educational services were reduced by 11% (6). In general, the governmentâ&#x20AC;&#x2122;s response to the problem has been to rely on community and voluntary activity, a policy that has led to more soup kitchens and food distribution centers (7). Food security means that all people at all times have access to enough food for an active and healthy life (8). It is considered a basic human right under several covenants of international law, which state that nutritionally safe foods need to be accessible in socially acceptable ways. Food-secure individuals and families should not have to resort to emergency food supplies, begging, stealing, and/ or scavenging for food (4, 9, 10). In 1995 a survey using a new instrument to measure food security was undertaken in the U.S. The scale, Food

Address for Correspondence: Roni Kaufman, PhD, Department of Social Work, Faculty of Humanities and Social Sciences, Ben-Gurion University of the Negev, POB 653, Beer Sheva 84105, Israel â&#x20AC;&#x2020; ronika@bgu.ac.il

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Security Core Survey Module, made it possible to classify households as “food secure,” “food insecure without evidence of hunger,” or “food insecure with evidence of hunger” (9). The Core Module does not measure the nutritional quality or safety of the food consumed. However, studies have found a link between the level of food security and food quality and safety (11). Unlike malnutrition, which characterizes many underdeveloped countries (12), food insecurity is not lifethreatening; it does, however, affect daily functioning as well as the physical, social and psychological well-being of individuals and families. Food insecurity reduces the short- and long-term physical and mental health status of individuals and families and causes hunger, fatigue and illness (13). Research shows that food insecurity is linked to impaired cognitive and physical ability, school and work absenteeism, and poor involvement in social activities. It has been linked to family instability, poor mental and physical health, and behavioral problems such as delinquency, crime and drug abuse (9). At-risk groups suffer higher rates of diet-related problems throughout life, including low-birth-weight babies, childhood and infant anemia, low immunity from infectious diseases, obesity, hypertension, Type 2 Diabetes, heart disease, and stroke (14). It has further been suggested that food insecurity leads to eating disorders and that the poor quality of free food distributed among the homeless and impoverished may contribute to excessive consumption and subsequent obesity (15). Food insecurity tends to be higher among clients of social welfare agencies, recipients of welfare benefits, the unemployed, new immigrants, alcohol-dependent or drug-addicted individuals, and the homeless (16-21). While there is a relatively large amount of research on the association between food insecurity and physical health, studies on the relationship between food insecurity and mental health are scarce. Research in the U.S. links food insecurity to a wide range of poor health outcomes, including psychological outcomes (15, 22-25). Elevated levels of depression and psychological distress were identified among food-insufficient households in a nationally representative data set from Canada (25). In a representative population sample in South Africa, a strong association was found between the presence of DSM-IV disorder and food insecurity (26). Research conducted in general clinics at medical centers in five states (N=5306) showed a positive association between food insecurity and maternal depression screen status (27). Smaller-scale studies on psychiatric patients and

persons with mental disorders showed an association between various mental problems (such as depression and psychotic spectrum disorders) and food insecurity (15, 28, 29). An earlier Israeli study conducted among patients who sought help at an emergency psychiatric unit showed that food-insecure patients exhibited a higher level of psychological distress than food-secure patients (30). Although a number of studies have explored the relationship between mental illness and distress and food insecurity (15, 22-30), none have presented rates of food insecurity among psychiatric populations, and the present study is the first to do that. In the present study we compare the food insecurity of psychiatric patients to that of welfare services clients, two groups that share similarly low socio-economic status (7). We also explore factors associated with food insecurity among the mentally ill respondents, as well as the role of public and community support in promoting their food security. Method Respondents

The study included two samples: 114 adult respondents recruited from psychiatric patients who had been admitted to the Beer Sheva Mental Health Center’s emergency unit and hospitalized for up to two weeks and treated pharmacologically. All patients admitted to the unit between January 2003 and March 2004 were included in the sample. As part of the admission process to the unit, the patients were asked, by the chief nurse, whether they are willing to participate in the study. All those approached agreed to participate (100% response rate). The high response rate was achieved thanks to: a) exclusion of non-Hebrew speaking patients and welfare clients who comprised 10% of the unit’s patients, and b) engagement of all nurses of the unit in the research and their close assistance to respondents with the questionnaire. The respondents were surveyed by means of a self-report questionnaire. The respondents’ diagnoses were obtained from their personal admission files. The diagnoses were based on the regular procedures of the unit: an intake clinical interview with a psychiatrist on duty who formulated an ICD-10 diagnosis (31). Over half of the participants were diagnosed with schizophrenia, schizotypal and delusional disorders, one-third were diagnosed with mood disorders, and the remainder with stress-related and somatoform disorders – syndromes associated with physiological 189

Food Insecurity Among Psychiatric Patients and Welfare Clients in Israel

disturbances, physical factors, substance use and abuse, and disorders of adult personality and behavior. The second sample comprised 555 low-income clients of 20 welfare service agencies in the Beer Sheva area. All clients who applied to any of these services during the month of December 2002 were included in the sample. The respondents were surveyed by means of a self-report questionnaire. Social work students, trained specifically for this project, administered the questionnaire and were available for inquiries. Instruments

Food insecurity was measured by means of a short version of the Food Security Core Survey Module (FSCSM) (32). This instrument (see Appendix A) is widely used to measure food insecurity and hunger (9, 33). It comprises six questions about having money to buy food, affording nutritious and balanced meals, skipping meals because food could not be afforded, etc. Based on the FSCSM, households or individuals can be classified as “Food Secure,” “Food Insecure without evidence of hunger,” or “Food Insecure with evidence of hunger.” The cut-off point used in this study to determine food insecurity was the one specified by the creators of the instrument (9). The instrument was translated into Hebrew using a translation-back translation method. Internal and test-retest reliability of the Hebrew version of the 6-item FSCSM was assessed in a previous study (N=20) and found satisfactory (Cronbach alpha coefficient 0.77 and Guttman split-half coefficient 0.97, test-retest validity = 0.96) (7). In addition, data were collected on age, gender, place of birth, education, marital status, employment status and sources of income from salaries and pensions, public support (social security benefits), and community support from informal networks and charity. The project was approved by the Human Subjects Research Review Committee of the Beer Sheva Mental Health Center (Helsinki committee). All respondents provided written “informed consent” authorization.

the two groups’ size difference. Furthermore, since three comparisons were performed on each variable, differences were considered significant only when p<0.016 (0.05\3). Results The results reveal that food insecurity is less widespread among psychiatric patients than among welfare services clients (40% vs. 59%) (Table1). As compared to welfare services clients, psychiatric patients showed higher rates of unemployment (84% vs. 59%) and partner’s unemployment (71% and 51%, respectively), but lower rates of married status (26% and 52%), lower support from family and friends (33% vs. 55%) and from charity (16% and 40%). No difference was found between the groups in the rate of their reliance Table 1. Comparison between psychiatric patients and clients of welfare services on food-security status and selected demographic characteristics

Background characteristics and the level of food security in the two samples were compared. In addition, food-secure and food-insecure psychiatric patients were compared in respect of their background characteristics and the utilization of community support; descriptive statistics, chi square and t-test analyses were used. The Levene test of equality of variance was performed in order to ensure that differences between the two groups did not derive from 190

Variables

Values

Food security status

Food secure Food insecure

59.6% (68) 40.4% (46)

40.9% (226) 59.1% (326)

0.000

Age1

Years

Mean = 37.29 SD = 12.17

Mean = 41.79 SD = 13.05

0.001

Mean = 2.26 SD = 1.69

Mean = 3.11 SD = 1.88

0.005

Average number of children (below 18)2

Data Analysis

1 2

Clients of welfare services (N=555)

Psychiatric patients (N=114)

Employment status

Employed Unemployed

15.9% (18) 84.1% (95)

41.4% (223) 58.6% (315)

0.000

Education

Less than 12 years 12 years and more

75.9% (85)

81.9% (384)

0.191

24.1% (27)

18.1% (85)

Marital status

Married Single

26.3% (30) 73.7% (84)

52.2% (286) 47.8% (262)

0.000

Partner’s employment

Working Not working

86.7% (26) 13.3 (4)

57.1 (160) 42.9 (120)

0.003

Receiving social security benefits

Yes No

61.6% (69) 38.4% (43)

68.7% (358) 31.3% (163)

0.179

Receiving support from family/ friends

Yes No

33.3% (38) 66.7% (76)

54.8% (298) 45.2% (246)

0.000

Receiving charity

Yes No

15.8% (18) 84.2% (96)

39.6% (215) 60.4% (60.4)

0.000

Levene’s test for equality of variances: F=.016, p<.899 (ns) Levene’s test for equality of variances: F=3.253, p<.072 (ns)

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Table 2. Comparison between food-secure and food-insecure psychiatric patients Variables

Values

Age1

Years

Average no. of children (below 18)2

1 2

Food secure (N=68)

Food insecure (N=46)

Mean=37.11 SD=12.45

Mean=37.57 SD=11.89

0.845

Mean=2.29 SD=1.93

Mean=2.22 SD=1.35

0.914

Table 3. Comparison between food-insecure psychiatric patients and food-insecure welfare services clients: use of public and community support and selected demographic characteristics

Employment status

Employed Unemployed

22.1% (15) 77.9% (53)

11.1% (5) 88.9 (40)

0.215

Education

Less than 12 years 12 years and more

73.5% (50) 26.5% (18)

79.5% (35) 20.5% (9)

0.617

Marital status

Married Single

27.9% (19) 72.1% (49)

23.9% (11) 76.1% (35)

0.793

Partner’s employment

Employed Unemployed

94.7% (18) 5.3% (1)

72.7% (8) 27.3% (3)

0.249

Receiving social security benefits

Yes No

59.7% (40) 40.3% (27)

64.4% (29) 35.6% (16)

0.758

Receiving support from family/ friends

Yes No

17.6% (12) 82.4% (56)

56.5% (26) 43.5% (20)

0.000

Receiving charity

Yes No

10.3% (7) 89.7% (61)

23.9% (11) 76.1% (35)

0.090

Food-secure and food-insecure psychiatric patients

The only significant difference between food-secure and food-insecure psychiatric patients was that the latter relied significantly more regularly on family and friends’ support (56% as compared to 18%), yet they remained food-insecure (Table 2). They also seemed to rely more often on charity (24% vs. 10%), but this difference was not statistically significant. Similarly, the apparent tendency to a higher rate of unemployed spouses among the food-insecure patients (27% as compared to 5% among the food secure) showed no statistical significance. Interestingly, no differences were found between food-secure and food-insecure patients in respect to social security benefits and other variables. Food- insecure psychiatric patients and foodinsecure welfare clients

Some interesting differences emerged when food-insecure psychiatric patients and welfare clients were compared (Table 3).

Values

Age

Years

Average no. of children (below 18)2

Levene’s test for equality of variances: F=.351, p<.555 (ns) Levene’s test for equality of variances: F=.158, p<.693 (ns)

on social security benefits. The analysis showed neither ethnic nor gender differences.

Variables

1 2

Psychiatric patients (N=46)

Clients of welfare services (N=326)

Mean=37.6 SD = 11.9

Mean=41.6 SD = 11.8

0.029

Mean=2.2 SD =1.4

Mean=3.2 SD =2.0

0.040

Employment status

Employed Unemployed

11.1% (5) 88.9% (40)

32.5% (103) 67.5% (214)

0.006

Education

Less than 12 years 12 years and more

79.5% (35) 20.5% (9)

85.2% (231) 14.8% (40)

0.458

Marital status

Married Single

23.9% (11) 76.1% (35)

50.5% (163) 49.5% (160)

0.001

Partner’s employment

Employed Unemployed

23.9% (11) 76.1% (35)

36.9% (69) 63.1% (118)

0.137

Receiving social security benefits

Yes No

64.4% (29) 35.6% (16)

83.4% (256) 16.6% (51)

0.004

Receiving support from family/ friends

Yes No

56.5% (26) 43.5% (20)

77.6% (250) 22.4% (72)

0.006

Receiving charity

Yes No

23.9% (11) 76.1% (35)

58.9% (189) 41.1% (132)

0.000

Levene’s test for equality of variances: F=.103, p<.748 (ns) Levene’s test for equality of variances: F=.3.370, p<.068 (ns)

Food-insecure psychiatric patients relied less regularly on the support of family and friends than did food-insecure welfare clients (56% vs. 78%) and even less on charity (24% as compared to 59%) and on social security benefits (64% and 83%, respectively). Psychiatric patients were younger than welfare clients, less often employed (11% vs. 33%), and more often single (24% as compared to 51%). No differences were found between the groups in the employment status of spouses, which was low in both groups. Discussion Israel has developed and instituted policies to create a safety net to address the health and social welfare needs of its citizens. The present study shows that as far as food security is concerned, this safety net is inadequate. A significant portion of those studied (40%-59%) were food insecure. In comparison to the general population in Israel and the U.S., psychiatric patients appear to be more than twice at risk for food insecurity, especially if their spouses 191

Food Insecurity Among Psychiatric Patients and Welfare Clients in Israel

are unemployed. One possible explanation for this finding is that existing public support does not seem to ensure their food security. In comparison to another high-risk group – clients of welfare services – psychiatric patients underutilize vital community support networks such as family, friends, and charity food-distribution organizations. This pattern may be attributed to the patients themselves as well as the psychiatric and community services. On the one hand, it is likely that the impairment of social functioning and social skills that accompanies mental illness limits the ability of psychiatric patients to effectively use informal support systems such as family and friends (34). On the other hand, psychiatric and community services personnel who are not aware of the problem of food insecurity and have limited knowledge of how to properly address it cannot help these patients to utilize existing support systems. In sum, high rates of food insecurity have been reported in Israel (22% among the general population and 60.8% among recipients of welfare benefits), U.S.A. (14.9% among the general population and 60.8% among recipients of welfare benefits), Canada (9.2% among the general population and 55.5% among recipients of welfare benefits) and other western countries (4, 5, 35) with especially high rates among risk groups such as recipients of welfare benefits, the unemployed, and new immigrants (16-21). Therefore, it is the responsibility of psychiatric services, especially those located in the community, to enhance their patients’ knowledge of and access to available food resources. Since food insecurity may negatively affect the mental state of psychiatric patients and their rehabilitation, preventive measures are called for. First and foremost, the issue of food security needs to be included in the psychiatric evaluation. Secondly, psychiatric staff need to be informed of existing community responses and services in order to refer their patients to them. In Israel, specifically, it should be recognized that food-supply organizations are limited in terms of number, location, and the extent of resources available to address the growing problem of food insecurity (5). Therefore programs specifically tailored for the psychiatric population need to be implemented in collaboration with mental health services and community food organizations. A special effort should be made to expand the ability of psychiatric patients to use informal support systems (36). Finally, as the right to food security approach suggests (9, 37-39), the failure of national governmental action calls for developing joint interdisciplinary action on the part 192

of all community professionals serving high-risk populations such as psychiatric patients, welfare clients, people with drug addictions and others. Local and national coalitions (40) need to be established, including psychiatrists, physicians, social workers, nurses, public health experts, dietitians, and community activists. Among other activities, such coalitions could collect information on the extent of food insecurity in local communities and in various risk groups and make this information available to politicians, policy makers and managers in order to promote the food security of patients. The prospective nature of this study, together with its relatively small sampling taken in one location and at one point in time, limit the degree to which its findings may be generalized. Nevertheless, they do alert clinicians and researchers to the need to study the problem of food security among psychiatric patients in larger samples, multicenter and longitudinal designs. Qualitative studies are also needed in order to learn how food-insecure patients interact with community support systems relating to food. References 1. Eisinger PK. Towards an end to hunger in America. Washington: Brookings Institute, 1998. 2. Riches G. Hunger and the welfare state: Comparative perspectives. In: Riches G, editor. First world hunger: Food security and welfare politics. London: MacMillan, 1997. 3. Gordon RA, KaestnerR, Korenman S, Abner K. The child and adult care food program: Who is served and why? Soc Serv Rev 2011; 85: 359-400. 4. Nord M, Andrews MS, Carlson S. Household food security in the United States, 2008. Economic Research Report no. 83. Washington, DC: USDA, Economic Research Service 2009. 5. Ministry of Social Affairs and Social Services. Report of the InterMinisterial Committee for Examining the State’s Responsibility to Ensure the Food Security of its Citizens, 2008 (in Hebrew). 6. Kop Y. Israel: Social economic review. Jerusalem: Taub Center for Social Policy Studies, 2006. 7. Kaufman R, Slonim-Nevo V. Food insecurity and hunger among disadvantaged populations in the Negev: Findings from an exploratory research study. Social Security 2004; 65: 33-54 (in Hebrew). 8. Food and Agriculture Organization of the United Nations. Report of the World Food Summit. Rome: FAO, 1996. 9. Holben DH. An overview of food security and its measurement. Nutrition Today 2002; 37: 156-162. 10. Bickel G, Nord M, Price C, Hamilton W, Cook J. Guide to measuring household food security. Alexandria, Va.: US Dept. of Agriculture, Food and Nutrition Service, 2000. 11. Kendall A, Olson CM, Frongillo EA. Relationship of hunger and food insecurity to food availability and consumption. J Am Diet Assoc 1996; 96: 1019-1024. 12. Seipel MO. Social consequences of malnutrition. Soc Work 1999; 44: 409-504. 13. Blaylock JR, Blisard WN. Food security and health status in the United States. Applied Economics 1995: 27: 961-966. 14. James WPT, Nelson M, Ralph A, Leather S. Socioeconomic determinants of health: The contribution of nutrition to inequalities in health. Behavioral Med J 1997; 314: 1545-1549.

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15. Siefert K, Helfin C, Corcoran ME. Food insufficiency and physical and mental health in a longitudinal survey of welfare recipients. J Health Soc Behav2004; 45: 171–186. 16. Darnton-Hill I, Ash S, Mandryk J, Mock P, Ho NT. Food sources of homeless men in Sydney. Aust J Nutrition Diet 1990; 47: 13-9. 17. Evans NS, Dowler EA. Food, health and eating among single homeless and marginalized people in London. J Human Nutrition Diet 1999; 12: 179-199. 18. Wiecha JL, Dwyer JT, Dunn-Strohecker M. Nutrition and health services needs among the homeless. Public Health Report 1991; 106: 364-374. 19. Booth S, Smith A. Food security and poverty in Australia: Challenges for dietitians. Aust J Nutrition Diet 2001; 58: 150-157. 20. Himmelgreen DA, Perez-Escamilla R, Segura-Millan S, Romero-Daza N, Tanasescu M., Singer M. A comparison of the nutritional status and food security of drug-using and non-drug-using Hispanic women in Hartford, Connecticut. Am J Physical Anthropology 1998; 107: 351-361. 21. Kaufman R, Isralowitz R, Reznik A. Food insecurity among drug addicts in Israel: Implications for social work practice. J Soc Work Pract Addiction 2005; 5: 21-32. 22. Hamelin AM, Habicht JP, Beaudry M. Food insecurity: Consequences for the household and broader social implications. J Nutr 1999; 129: 525-528. 23. Alaimo K, Olson CM, Frongillo EA. Family food insufficiency, but not low family income, is positively associated with dysthymia and suicide symptoms in adolescents. J Nutr 1999; 132: 719-725. 24. Heflin CM, Siefert K, Williams DR. Food insufficiency and women’s mental health: Findings from a 3-year panel of welfare recipients. Soc Sci Med 2005; 61: 1971-1982. 25. Vozoris NT, Tarasuk VS. Household food insufficiency is associated with poorer health. J Nutr 2003; 133: 120-126. 26. Sorsdahl K, Slopen N, Siefert K. Household food insufficiency and mental health in South Africa. J Epidemiol Comm Health 2011; 65: 426-431. 27. Casey P, Goolsby S, Berkowitz C, Frank D, Cook J, Cutts D, Black MM, Zaldivar N, Levenson S, Heeren T, Meyers A. Children’s sentinel nutritional assessment program study group: Health status, maternal depression, changing public assistance, food security and child. Pediatrics 2004; 113: 298-304. 28. Bettigole E, Kovasznay B, Chung M, Farina J, Balkosk V. Hunger and mental illness (letter). Psychiatric Serv 1997; 48: 543-544. 29. Melchior M, Caspi A, Howard LM. Mental health context of food insecurity: A representative cohort of families with young children. Pediatrics 2009; 124: 564-572. 30. Grisaru N, Kaufman R, Mirsky J, Witztum E. Food insecurity and mental health: A pilot study of patients in a psychiatric emergency unit in Israel. Comm Mental Health J 2011; 47: 513-519. 31. World Health Organization, The ICD-10 classification of mental and behavioral disorders: Clinical descriptions and diagnostic guidelines 1992. 32. U.S. Department of Agriculture. http://www.ers.usda.gov /Briefing/ FoodSecurity/ www.ers.usda.gov/Briefing/Food Security/ surveytools/ FS_SHORT.doc 1999.

33. Blumberg SJ, Bialososky K, Hamilton WL, Briefel RR. The effectiveness of a short form of the household food security scale. Am J Public Health 1999; 89: 1231-1234. 34. Maulik PK, Eaton WW, Bradshaw CP. The role of social network and support in mental health service use: Findings from the Baltimore ECA study. Psychiatric Serv 2009; 60: 1222-1229. 35. Kirkpatrick SI, Tarasuk, V. Food Insecurity in Canada: Considerations for monitoring. Can J Public Health 2008; 99:324-327 36. House JS, Landis KR, Umberson D. Social relationship and health. Science 1988; 241: 540-545. 37. Chilton M, Rose D. Framing health matters. A rights-based approach to food insecurity in the United States. Am J Public Health 2009; 99: 1203-1211. 38. Bellows A, Hamm M. International effects on and inspiration for community food security policies and practices in the USA. Critical Public Health 2003; 13: 107-123. 39. Riches G. Food banks and food security: Welfare reform, human rights, and social policy: Lessons from Canada. Soc Policy Admin 2002; 36:648-663. 40. Butterfoss FD. Coalitions and partnerships in community health. San Francisco: Jossey Bass, 2007.

Appendix:

Food Security Core Survey Short Form of the 12-Month Food Security Scale http://www. ers.usda.gov/briefing/foodsecurity/surveytools/ 1. ‘‘The food that I bought just didn’t last, and I didn’t have money to get more.’’ Was that often, sometimes, or never true for you in the last 12 months? (1) Often true (2) Sometimes true (3) Never true 2. ‘‘I couldn’t afford to eat balanced meals.’’ Was that often, sometimes, or never true for you in the last 12 months? (1) Often true (2) Sometimes true (3) Never true 3. In the last 12 months, did you ever cut the size of your meals or skip meals because there wasn’t enough money for food? (1) Yes (2) No 4. How often did this happen – almost every month, some months but not every month, or in only 1 or 2 months? (1) Almost every month (2) Some months but not every month (3) Only 1 or 2 months 5. In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money to buy food? (1) Yes (2) No 6. In the last 12 months, were you ever hungry but didn’t eat because you couldn’t afford enough food? (1) Yes (2) No

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Isr J Psychiatry Relat Sci - Vol. 50 - No 3 (2013)

Health-related Quality of Life Changes and Weight Reduction After Bariatric Surgery vs. a Weight-loss Program Laura Canetti, PhD, 1 Yoel Elizur, PhD, 2 Yair Karni, MMedSc,3 and Elliot M. Berry, MD, FRCP4 1

Department of Psychology, Hebrew University of Jerusalem, Jerusalem, Israel, and Department of Psychiatry, Hadassah Hebrew University Medical Center, Jerusalem, Israel 2 School of Education, Hebrew University of Jerusalem, Jerusalem, Israel 3 Weight-loss Program Derech Hakosher, Beerotaim, Israel 4 Departments of Human Nutrition and Metabolism, Braun School of Public Health, Hadassah Hebrew University Medical Center, Jerusalem, Israel

Abstract Background: The present study compared the outcome of bariatric surgery against a uniform high-level weightloss program which included vigorous physical exercises, behavior modification and nutritional advice. Method: 44 subjects who underwent bariatric surgery and 47 subjects participating in a weight-loss program completed the Medical Outcomes Study Short Form36 (SF-36), the Mental Health Inventory (MHI) and the Rosenberg Self-Esteem scale, prior to surgery/diet and one year afterwards. Results: Post-surgery subjects had a greater mean weight loss (34.70% ± 11.94) than subjects in the weight-loss program, even though their weight reduction was also clinically significant (9.23% ± 8.31). Post-surgery subjects showed significant improvements in SF-36, MHI, and selfesteem. The diet group improved in SF-36 total score, physical functioning, health perceptions, and vitality scales. Limitations: Differences in background variables and short follow-up. Conclusions: Surgery outcomes were significantly better in terms of both weight reduction and psychological adjustment compared to highly motivated participants in a prestigious, cutting edge weight-loss program.

Address for Correspondence: laurac@mscc.huji.ac.il

194

Introduction As obesity is a continually growing problem in our society, unremitting efforts are being made to improve treatment outcome. Conventional treatments (i.e., a low calorie diet plus moderate exercise) and bariatric surgery are the two main approaches offered to people suffering from obesity. Weight-loss programs which integrate a balanced diet, behavior modification and physical activity are currently considered the most effective in weight reduction (1-3). Bariatric surgery, which has become more sophisticated and safer, produces large weight losses and has good long-term results (4, 5). Despite significant advances in both procedures, research has highlighted some unresolved difficulties. Weight-loss programs succeed in the short term, but not in the long run (6), while bariatric surgery is an invasive procedure and some subjects may experience protracted medical and/or emotional complications (7-9). Mainly for these reasons, weight-loss programs are considered inferior for people with severe obesity since their weight loss is insufficient, while bariatric surgery is not recommended for overweight or mildly obese people for whom surgery risks are considered unwarranted. Accordingly, current treatment guidelines recommend bariatric surgery for individuals with BMI ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 with medical comorbidities and who failed diet programs, while weight-loss programs of diet, physical activity and behavior treatment are recommended for persons with BMI ≥ 30 kg/m2 or BMI ≥ 25 kg/m2 with medical comorbidities (10).

Laura Canetti, PhD, Department of Psychology, Hebrew University of Jerusalem, Jerusalem 91905, Israel.

Laura Canetti ET AL.

The present study compared two groups of individuals who were treated according to the NIH guidelines. Our sample consisted of a two group convenience sample: a moderate to severely obese group of people who underwent bariatric surgery and an overweight to moderately obese group of people who participated in a conventional weight-loss program. The examination of outcome can be used to reflect on clinical recommendations regarding the most appropriate treatment for obese individuals. Such data are important since there are only a few studies that did such a comparison except for a large Swedish intervention study that demonstrated a dramatic improvement in the life quality of post-surgery subjects in contrast to minor improvements in conventionally treated controls (11, 12). However, in this research the treatment for the conventional cases was not standardized and treatment regimens varied according to local practices (11); hence, it was not possible to establish uniformity of treatment or to know what other component beyond the dieting part characterized the control program. A further aim of the present study was to establish a uniform treatment for the conventional weight-loss program: all participants in the conventional treatment took part in an intensive program that included vigorous physical exercises, behavior modification of eating habits, and nutritional counseling. This program was carried out in a prestigious institution – the Wingate Institute – which is also an academic center for physical education and sport. Unlike participants in the bariatric surgery group, whose operation was covered by health insurance services, participants in the dieting group had to pay for the program. Consequently, a unique contribution of the present study is the comparison of bariatric surgery against a uniform high-level treatment program accessed by motivated patients willing to engage in a very intensive program whose mild to moderate level of obesity makes their assignment to a weight-loss nonsurgical intervention consonant with current treatment guidelines. In addition, the comparison of gastroplasty to a weight reduction program with an emphasis on physical exercise has not been previously reported in the literature. The term health-related quality of life refers to the “physical, psychological, and social domains of health, seen as distinct areas that are influenced by a person’s experiences, beliefs, expectations and perceptions” (13). Weight loss has been shown to improve the quality of life in obese persons undergoing a variety of treatments. Because changes in quality of life reflect the individual’s subjective evaluation health, and not only relates to actual weight loss, we wanted to explore the differential impact

of each technique on the psychological adjustment of the individual. According to the above-mentioned studies, we expected improvements in the quality of life following bariatric surgery. On the other hand, it might be possible that despite less weight reduction, conventional program subjects will benefit from the gradual reduction in weight, a greater sense of control and greater fitness obtained after a period of intensive physical activity. The purpose of our study was threefold: first, to replicate with an Israeli sample and to extend previous comparative outcome studies; second, to assess the impact of weight loss on health-related quality of life and to measure this construct not only by the standard measures of quality of life (the SF-36) – the usual procedure in previous outcome studies – but also by using mental health and self esteem measures. And third, given the documented advantages of bariatric surgery in terms of greater weight loss over a short period of time, to compare the surgical procedure to a carefully chosen uniform weight-loss program that was comprehesive, intensive, and whose participants were highly motivated. We expected to replicate the finding of a greater weight loss in the surgery group but also hypothesized that benefits in terms of health-related quality of life would be observed in both groups, despite differences in weight loss. Method Study design

The present study compared participants who underwent bariatric surgery against individuals who participated in a weight-loss program. All participants, 51 in each group, were weighed and assessed with questionnaires at the start of the study. The sampling was consecutive but not randomized: participants were recruited among applicants to bariatric surgery at the surgery department of Hadassah University Medical Center and among participants of a commercial program for weight reduction at the Wingate Institute. At the surgery department a nurse approached each surgery candidate who was fluent in Hebrew, all but one accepted to participate in the study. All participants attending the Wingate Institute program were asked to participate, 80% agreed to take part in the study. The study was approved by the Ethical Committee of the Hadassah University Medical Center. All participants signed an informed consent. Forty-four of the surgery group and 47 of the diet group were weighed and assessed one year later. No significant differences on initial measures were found between drop outs and the 195

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others. The surgery participants underwent one of two procedures: 37 underwent Silastic Ring Vertical Banded Gastroplasty (SRVG) and 7 underwent Laparoscopic Adjustable Gastric Banding (LAGB). The weight-loss program lasted 12 months: The first one-month stage of the program took place at the Wingate Institute every morning from 7.00 am to 12.30 am and included three hours of regular strenuous physical exercises six days a week, a daily lecture on health issues, frequent nutritional advice, behavior modification training and a suggested diet of 1200-1800 kcal/day. In this program, no drugs were prescribed. Participants had breakfast and lunch at the Institute, in order to enhance adherence to the recommended diet. In the second stage, participants were instructed to perform at home four times a week any kind of physical activity, at least one hour long. Once a week, participants attended the Institute for nutritional consultation, weight monitoring, and progress evaluation. Measures A socio-demographic questionnaire asked about age, marital status, country of origin, education, income and years of duration of obesity. Height and weight measurements were recorded to calculate BMI (body mass index). The Medical Outcomes Study Short Form-36 (SF-36) is a well-established measure of quality of life for people with health problems (14). This 36 item questionnaire includes eight scales: 1) limitations in physical activities because of health problems, 2) limitations in usual role activities because of physical health problems, 3) bodily pain, 4) general health perceptions, 5) vitality, 6) limitations in social activities because of physical or emotional problems, 7) limitations in usual role activities because of emotional problems and 8) general mental health. In our study, psychometric support was found for the use of a total. Higher scores reflect better health status. The Hebrew version was validated in a large community survey (15). In the present study the internal consistency of the scales varied from α = .69 to α = .90. The total score was found to have a high internal consistency (α = .91). The Mental Health Inventory (MHI) is a 38 item questionnaire composed of two inversely correlated scales: psychological distress, and psychological well being. Psychometric support was found for the use of a total score (16). Higher scores in the distress and well being scales reflect higher psychological distress or higher psychological well being respectively. Higher scores in the 196

total score reflect higher well being. The Hebrew version was tested in a large community study that confirmed its hierarchical structure and demonstrated a high internal consistency (α = .96) and external validity (17). In the present study we found the same excellent internal consistency for the total scale and the two subscales (α = .96.). The Rosenberg Self Esteem (RSE) scale (18) is a 10 item questionnaire by which respondents evaluate their characteristics, abilities, self-satisfaction, self respect and self-dignity. Higher scores reflect poor self-esteem. The RSE has excellent psychometric properties. It was translated into Hebrew (19) and has been frequently used in Israeli studies. In the present study, we found high internal consistency (α = .89). Results Demographic data and initial measures of participants who completed annual follow up are presented in Table 1. As can be seen, the surgery and the diet group differed in Table 1. Initial differences in socio-demographic and outcome measures between the surgery and the diet group Surgery ( n =44)

Diet (n =47)

Gender, (%) Female Male

38 (86.4%) 6 (13.6%)

31 (66.0%) 16 (34.0%)

0.03

Age, mean years (SD)

33.8 (9.5)

43.7 (11.3)

<0.001

Marital status, (%) Married Single divorced/widowed

27 (61.4%) 14 (31.8%) 3 (6.8%)

34 (72.3%) 9 (19.1%) 4 (8.6%)

Education, mean years (SD)

13.1 (1.7)

14.6 (2.2)

<0.001

Country of origin, (%) Israel Asia-Africa Western countries East Europe

31 (70.5%) 6 (13.6%) 5 (11.4%) 2 (4.5%)

42 (89.3%) 1 (2.1%) 2 (4.3%) 2 (4.3%)

Income (SD)

3.11 (1.0)

4.2 (0.9)

<0.001

Years of obesity (SD)

12.5 (6.7)

14.4 (7.7)

Weight in kg (SD)

126.32 (24.98)

100.60 (24.02)

<0.001

Weight range (kg)

98 - 230

63 - 170

BMI (SD)

45.50 (8.11)

35.32 (6.73)

<0.001

MHI (SD)

172.95 (29.56)

168.30 (27.70)

SF-36 (SD)

64.18 (17.00)

70.43 (12.63)

0.049

RSE (SD)

1.75 (0.56)

1.87 (0.48)

Two-tailed Student t tests for independent samples and χ2 tests were used. SD: standard deviation, ns: not significant, MHI: Mental Health Inventory, SF-36: Medical Outcomes Study Short Form-36, RSE: Rosenberg Self Esteem scale.

Laura Canetti ET AL.

a number of socio-demographic variables: in the surgery group subjects were younger, more likely to be women, less educated and with lower income as compared to the diet group. The surgery participants weighed more and their quality of life was poorer than participants in the weight loss group. Participants who underwent surgery had a mean weight loss of 34.7% (45 kg or 16 BMI units). SRVG participants lost significantly more weight (M = 48.05 kg, SD = 23.02) compared to the LAGB group (M = 29.29 kg, SD = 23.62), Mann-Whitney: Z = 2.46, p = .015. Since there were no significant differences between these procedures in other outcome variables, all surgery participants were considered for statistical analyses as one group. The surgery group improved significantly in all outcome measures except psychological distress which remained

Graph 1. Means preoperatively and after one year follow-up

unchanged (see Table 2 and Graph 1). Comparisons between the surgery group and a representative Israeli sample (17) in MHI scores yielded no significant differences at onset. However, at one-year follow-up, the Table 2. The surgery group: Means (and standard deviations) total MHI and the well being scores of the surgery preoperatively and after one year follow-up (n=44) group were higher than those of the community sample (t(647) = 2.22, p < .05 and t(647) = 3.62, 1-year Community Before follow- Mean p < .001 respectively). difference 95% CI p norm surgery up The comparisons in SF-36 quality of life Weight (kg) 126.32 81.25 45.07 37.8 – 52.3 <.001 scores at the start of the study between the (24.98) (15.91) (23.87) surgery group and a representative Israeli BMI 45.50 29.30 16.19 13.6 – 18.8 <.001 (8.11) (5.51) (8.41) sample (15) showed lower scores in the surgery MHI: total 172.95 179.73 -6.77 -14.2 – 0.6 .036a 169.87 group on three scales: physical functioning, score (29.56) (29.79) (24.39) (28.32) role physical, and bodily pain (t(2,072) = 4.4, MHI: Psych. 51.98 49.32 2.66 -1.6 – 6.9 ns 49.91 p < .001, t(2,072) = 1.24, p < .05 and t(2,072) = distress (16.62) (17.22) (13.84) (18.23) 2.93, p < .001, respectively). The surgery group MHI: Well 56.93 61.05 -4.11 -8.0 – -0.2 .038 53.71 being (14.31) (13.51) (12.76) (12.96) also scored higher on two scales: health percepSF-36: total 64.18 83.78 -19.59 -24.1 – -15.1 <.001 tions and mental health (t(2,072) = -2.55, p < .02, score (17.00) (10.19) (14.92) and t(2,072) = -2.14, p < .05, respectively). After Physical 59.09 96.82 -37.23 -44.4 – -31.0 <.001 77.3 one year, the surgery group showed higher scores functioning (24.00) (6.39) (22.11) (26.6) than the community norm in all SF-36 scales: Role 57.39 93.18 -35.80 -48.8 – -22.7 <.001 71.3 physical (40.56) (21.13) (42.93) (40.8) physical functioning, role physical, bodily pain, health perception, vitality, social functioning, role Bodily pain 58.33 79.04 -20.71 -30.4 – -11.0 <.001 71.6 (27.75) (26.38) (32.02) (29.8) emotional, and mental health (t(2,072) = -4.86, Health 72.16 83.18 -11.02 -17.1 – -4.9 <.001 62.9 p < .001, t(2,072) = -3.55, p < .001, t(2,072) = perceptions (23.73) (15.06) (20.13) (23.8) -1.65, p < .05 one-tailed, t(2,072) = -5.63, p < .001, Vitality 51.82 68.52 -16.70 -22.9 – -10.5 <.001 56.9 t(2,072) = - 3.36, p < .01, t(2,072) = -2.73, p < .01, (22.00) (18.57) (20.32) (2.8) t(2,072) = -2.38, p < .02, and t(2,072) = -3.78, p < Social 74.43 92.90 -18.47 -28.1 – -8.8 <.001 81.8 functioning (34.09) (17.96) (31.72) (26.8) .001, respectively). Role 82.58 93.94 -11.36 -22.3 – -0.4 .042 81.1 Individuals who participated in the weightemotional (36.29) (20.68) (35.90) (35.7) loss program had a significant mean weight loss Mental 74.18 79.55 -5.36 -11.7 – 0.9 .046a 67.1 of 9.23% (10 kg or 4 BMI units). There was no (21.7) health (20.26) (17.83) (20.68) significant improvement in their well being or RSE 1.75 1.53 0.21 0.06 – 0.37 .009 (0.56) (0.56) (0.51) psychological distress. Improvement was significant in three of the eight SF-36 scales, and Two-tailed paired Student t tests were used. a one-tailed test in the total SF-36 score. There was no significant 197

Quality of Life and Weight Reduction After Bariatric Surgery vs. Weight-loss Program

change in self-esteem (see Table 3 and Graph 2). No significant differences in MHI were found between the diet group and the community at onset and one-year follow-up. Also, there were Community no differences in the SF-36 scores at the beginnorm ning (except role emotional, which was lower in the diet group, t(2,075) = 2.06, p < .05) and at one-year follow-up (except health perceptions which was higher in the diet group, t(2,075) = -3.67, p < .001). 169.87 (28.32) As shown in Table 4, the surgery group had 49.91 a greater weight loss in absolute (kg) and rela(18.23) tive terms (percentage of weight loss and BMI). 53.71 There was a significant difference in well being (12.96) due to a greater improvement in the surgery group compared to no improvement in the diet group. The same results were found for self77.3 (26.6) esteem. Although the two groups improved in the SF-36 total score, physical functioning, and 71.3 (40.8) vitality scales (see Tables 2 & 3), improvement 71.6 in the surgery group was greater. As for the pain (29.8) and role physical scales that indicated problems 62.9 at onset only for surgery participants, follow-up (23.8) scores showed their significant improvement. 56.9 Since the two groups differed in a number (2.8) of demographic variables, regression analyses, 81.8 (26.8) with control for age, education and income, were used to predict difference scores of the outcome 81.1 (35.7) variables. We also controlled initial weight, which 67.1 was correlated with improvement in quality of (21.7) life and self-esteem but not for gender and country of origin because they were not correlated with the outcome variables. Since differences between groups may occur due to error variance of difference scores and differences at baseline, we made a correction for this bias by first entering the baseline level of the predicted outcome variable; in the second step we entered the treatment (surgery vs. diet) as a dummy variable and then the interaction between them. A significant treatment variable therefore means that the difference between the groups does not stem from error variance due to the use of difference scores. The regression analyses confirmed the results presented in Table 4 except for bodily pain.

Table 3. The diet group: Means (and standard deviations) before the program and after one year follow-up (n=47) Before surgery

1-year followup

Mean difference

Weight (kg)

100.60 (24.02)

90.60 (20.03)

BMI

35.32 (6.73)

MHI: total score

95% CI

10.00 (10.85)

6.8 – 13.2

<.001

31.88 (5.79)

3.44 (3.61)

2.4 – 4.5

<.001

168.30 (27.70)

168.45 (27.44)

-0.14 (22.19)

-6.7 – 6.4

MHI: Psych. distress

52.04 (14.24)

51.11 (15.32)

0.94 (12.54)

-2.7 – 4.6

MHI: Well being

52.34 (14.48)

51.55 (13.71)

0.79 (11.48)

-2.6 – 4.2

SF-36: total score

70.43 (12.63)

75.46 (15.74)

-5.03 (10.74)

-8.2 – -1.9

.002

Physical functioning

79.79 (20.38)

84.79 (20.43)

-5.00 (17.23)

-10.1 – -0.06

.026a

Role physical

76.06 (30.38)

82.98 (30.44)

-6.91 (35.24)

-17.3 – 3.4

Bodily pain

76.36 (20.28)

76.36 (23.24)

0.00 (23.63)

-6.9 – 6.9

Health perceptions

68.51 (21.21)

75.74 (20.95)

-7.23 (22.36)

-.13.8 – -0.7

.032

Vitality

56.17 (19.54)

62.66 (23.68)

-6.49 (17.90)

-11.7 – -1.2

.017

Social functioning

80.59 (26.17)

81.91 (24.42)

-1.33 (28.34)

-9.7 – 7.0

Role emotional

70.21 (38.22)

76.60 (35.38)

-6.38 (39.71)

-18.0 – 5.3

Mental health

70.89 (19.70)

72.09 (22.01)

-1.19 (14.61)

-5.5 – 3.1

RSE

1.87 (0.48)

1.84 (0.52)

0.04 (0.34)

-0.07 – 0.14

Two-tailed paired Student t tests were used. a one-tailed test

Graph 2. Means before diet and after one year follow-up

Discussion The results of this study showed greater improvement following bariatric surgery vs. a conventional treatment. The 198

Laura Canetti ET AL.

Table 4. Comparison between the surgery and the diet group in difference scoresa Surgery (n=44)

Diet (n=47)

% of weight loss

34.70 (11.94)

9.23 (8.31)

<0.001

Weight (kg)

-45.07 (23.87)

-10 (10.85)

<0.001

BMI

-16.19 (8.41)

-3.44 (3.61)

<0.001

MHI: total score

6.77 (24.39)

0.15 (22.19)

MHI: Psych. distress

-2.66 (13.84)

-0.94 (12.54)

MHI: Well being

4.11 (12.76)

-0.78 (11.48)

0.028 b

SF-36: total score

19.59 (14.92)

5.03 (10.74)

<0.001

Physical functioning

37.73 (22.11)

5.00 (17.23)

<0.001

Role physical

35.80 (42.93)

6.91 (35.24)

<0.001

Bodily pain

20.71 (32.02)

0.00 (23.63)

<0.001

Health perceptions

11.02 (20.13)

7.23 (22.36)

Vitality

16.70 (20.32)

6.49 (17.90)

0.013

Social functioning

18.47 (31.72)

1.33 (28.34)

0.008

Role emotional

11.36 (35.90)

6.38 (39.71)

Mental health

5.36 (20.68)

1.19 (14.61)

RSE

-0.21 (0.51)

-0.04 (0.34)

0.027 b

Two-tailed Student t tests for independent samples were used. ns, not significant. a the score after one-year follow-up minus the score before surgery/diet b one-tailed test

superior effects of surgery over the weight-loss program related not only to weight loss but were consistent across all outcome measures. Post-surgery subjects improved in terms of mental health, self-esteem and the physical and emotional aspects of quality of life, while the diet group only reported improvement in their physical condition. The enhanced effects of surgery were essentially unchanged when controlling for group differences in initial weight, age, education and income. These findings are especially significant since it is the first time that bariatric surgery has been compared to a uniform high-level weight-loss program, whose participants were highly motivated treatment seekers with mild to moderate level of obesity that was fitting with their assignment to a conventional weight-loss program. The mean weight loss following bariatric LAGB is similar to previous findings but the weight loss after SRVG is greater than previously reported (5). These bariatric procedures were the most popular when the study was carried out. While LAGB is still a very common technique, SRVG has been found to have long-term complications – mainly staple line disruption (20) – and is now rarely done. However, as our study was only oneyear follow-up, no medical complications were reported

in this short lapse of time and great weight losses were obtained – similar to the weight losses attained nowadays by the more advanced techniques. Moreover, we must emphasize that the quality of the weight-loss program rather than the quality of the bariatric techniques was the focus of our study and that the conclusions reached refer to bariatric surgeries in general. As for the weight-loss program, the mean loss of 10 kg at one-year follow-up is better than usually reported for such programs, indicating that it is indeed a highquality program. By comparison, commercial programs like “Weight Watchers” reported a mean weight loss of 5 kg at one-year follow-up (21). Our better results might reflect the general improvements in the field of weight-loss programs and specific qualities of this program such as the intensity of the initial phase and the high emphasis on physical exercise. Our findings are similar to those of the Swedish study (11): weight loss differences between the groups were large (30 kg after surgery vs. 1.2 kg after diet). Hence, our study shows that group differences remain meaningful even when bariatric surgery is compared with an updated weight reduction program that incorporates the latest advances in obesity treatment. In the Swedish study (11) the weight loss in the diet group was minimal while in our study it was meaningful: the reason might be that since the Swedish study followed group matching procedures, the conventionally treated participants had a mean BMI of 39.3 at baseline, and thus their referral to a weight-loss program was not their best option according to accepted clinical recommendations. In comparison, participants in the present study conventional treatment had a mean BMI of 35 at baseline, thus making their assignment to a weight-loss program more appropriate, i.e., raising their chances to succeed in this treatment. Including lower BMI individuals in this program was also dictated by the fact that this was a strenuous exercise program which was not suitable for seriously obese individuals. The lack of differences in mental health between participants in both groups and a normative community sample is consonant with community studies that did not find considerable psychopathology among obese individuals in general (22, 23). Interestingly, studies of obese persons seeking dietary or surgical treatments showed them to be generally more depressed and anxious than their normal weight counterparts (24, 25), especially women with class III obesity (BMI ≥ 40) (26). In this study such an effect was not present. Our contrasting 199

Quality of Life and Weight Reduction After Bariatric Surgery vs. Weight-loss Program

results may be explained by the argument that obesity is a chronic condition that often begins in childhood or adolescence, and consequently, people adapt to it in the same way that they adapt to other chronic conditions (27). This reasoning fits the present study since our participants have been obese for more than 10 years on the average. Curiously, even though the mental health scores of the surgery participants were similar at onset to community norms, their psychological well being was significantly higher than the norm at one-year follow-up. This finding, which is consistent with previous reports (11, 28), appears to reflect an elevation in mood that usually follows the large weight loss and improved physical functioning that occurs after bariatric surgery. The surgery groupâ&#x20AC;&#x2122;s improvement in all quality of life measures corroborates previous research that used the SF-36 (25, 28) or similar scales (11). These results support the hypothesis that poor quality of life, especially in terms of physical functioning, is a consequence of obesity and consequently, and can be meaningfully improved by bariatric surgery. Participants in the weight-loss program mainly improved in the total score of quality of life, but, on the whole, their scores remained in the normative range. The improvement in vitality, physical functioning, and health perceptions underlines the importance of weight loss, even if moderate compared to bariatric surgery. The diet group reported a weight loss of 9.23% of their initial body weight. It is known that even modest weight loss (i.e., 5%-10% of initial body weight) significantly improves the metabolic disorders associated with obesity by reducing insulin, blood pressure, fatty acids and triglycerides, and protects against certain cancers, osteoarthritis, and cardiovascular disease (29). The group comparison showed that the surgery participants had lower initial and higher follow-up scores in the physical measures of quality of life than those who participated in the weight-loss program. On emotional measures, the superior effects of surgery were found in scales that assessed positive mood (well being and vitality), self-esteem, and social functioning. Together with previous findings of improved self-image following bariatric surgery (30) and the lack of similar improvement following a weight-loss program (31), these findings suggest that moderate weight loss is insufficient for improvement in self-esteem, mental health and other emotional aspects of quality of life. In conclusion, at one-year follow-up, both approaches were effective to a different degree: bariatric surgery led to a large weight loss, while the effect of a dieting and 200

physical exercise program was moderate but clinically significant. Surgery patients also experienced a greater improvement in terms of physical and emotional aspects of health-related quality of life. Moderate weight losses, although health-improving, did not enhance self-esteem and mental health. These results were obtained in spite of the differences between the groups: the diet group included highly motivated participants, paying out of pocket for their program, while the surgery participants were of lower socio-economic status and their surgery was covered by insurance. Furthermore, participants in the study received the treatment of choice according to present guidelines for the treatment of obesity. The results should be cautiously interpreted in lieu of the present studyâ&#x20AC;&#x2122;s limitations. There were differences in demographic variables, and despite the fact that we controlled for them, still it may have had an impact on the results. The normative samples might have been also different in terms of background variables, but we have no data to adjust for them. The short extent of follow-up may explain the mood elevation in the surgery group, which could reach its zenith at the one-year follow-up. At one-year, large weight losses in the surgery group had a greater impact on health-related quality of life including self-esteem and mental health, and we did not find any psychological advantage for the diet programâ&#x20AC;&#x2122;s gradual weight loss. It will be of interest in future studies to examine whether participants of a long-term diet program who show large weight loss comparable to the post-surgery weight loss manifest similar or even greater improvement in their physical and/or mental health than their bariatric surgery counterparts. Acknowledgements We thank Prof. Yona Manny, from the Department of Surgery, Hadassah Medical Center for his kind cooperation with this research.

Disclosure The authors declare that they have no conflict of interest.

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University, 1965. 19. Nadler A, Mayseless O, Peri N, Chemerinsky A. Effects of opportunity to reciprocate and self-esteem on help-seeking behavior. J Pers 1985;53:23-35. 20. Schouten R, Wiryasaputra DC, van Dielen FM, van Gemert WG, Greve JW. Long-term results of bariatric restrictive procedures: a prospective study. Obes Surg 2010;20:1617-1626. 21. Heshka S, Anderson JW, Atkinson RL, Phinney SD, Greenway F, Hill JD, Miller-Kovack K, Pi-Sunyer FX. Self-help weight loss versus a structured commercial program after 1 year: A randomized controlled study [Addendum]. FASEB Journal 2000;17:37. 22. Friedman MA, Brownell KD. Psychological correlates of obesity: Moving to the next research generation. Psychol Bull 1995;117:3-20. 23. John U, Meyer C, Hans-Jurgen R, Hapke, U. Relationships of psychiatric disorders with overweight and obesity in adult general population. Obes Res 2005;13:101-109. 24. Fitzgibbon ML, Stolley MR, Kirschenbaum DS. Obese people who seek treatment have different characteristics than those who do not seek treatment. Health Psychol 1993;12:342-345. 25. Kolotkin RL, Crosby RD, Rhys Williams G. Health-related quality of life varies among obese subgroups. Obes Res 2002;10:748-756. 26. Wadden TA, Butryn ML, Sarwer DB, Fabricatore AN, Crerand CE, Lipschutz PE, et al. Comparison of psychological status in treatment seeking women with class III vs. class I-II obesity. Surg Obes Relat Dis 2006;2:138-145. 27. Cassileth BR, Lusk EJ, Hutter R, Strouse TB, Brown LL. Concordance of depression and anxiety in patients with cancer. Psychol Rep 1984;54:588-590. 28. Schok M, Geenen BA, van Antwerper T, de Pieter BA, Brand N, van Ramshorst B. Quality of life after laparoscopic adjustable gastric banding for severe obesity: Postoperative and retrospective preoperative evaluations. Obes Surg 2000;10:502-508. 29. Blackburn GL. Weight loss and risk factors. In: Fairburn CG, Brownell KD, editors. Eating disorders and obesity: A comprehensive handbook. New York: Guilford, 2002: pp. 484-489. 30. Dymek MP, Le Grange D, Neven K, Alverdy J. Quality of life after gastric bypass surgery: A cross-sectional study. Obes Res 2002;10:1135-1142. 31. Bryan J, Tiggerman M. The effect of weight-loss dieting on cognitive performance and psychological well-being in overweight women. Appetite 2001;36:147-156.

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Isr J Psychiatry Relat Sci - Vol. 50 - No 3 (2013)

Israeli Psychiatrists Report on Their Ability to Care for Individuals with Intellectual Disability and Psychiatric Disorders Shirli Werner, PhD,1 Itzhak Levav, MD, Msc,2 Mike Stawski, MD, BS, MRCPsych,3 and Yakov Polakiewicz, MD, MHA4 1

Paul Baerwald School of Social Work and Social Welfare, The Hebrew University of Jerusalem, Jerusalem, Israel Ministry of Health, Jerusalem, Israel 3 Schneider Children’s Medical Center in Israel, Petah Tikva, Israel 4 Mental Health Center, Tirat Hacarmel, Israel 2

Abstract Background: The Convention on the Rights of Persons with Disabilities enshrines the right of people with intellectual disability to optimal mental health services. However, the literature suggests that psychiatrists’ ability to meet such a standard is questionable. Psychiatrists’ self-assessment regarding their training, knowledge and skills in working with this population was examined, as well as the availability of continuous education resources. Methods: A questionnaire was completed by 256 psychiatrists working within the public sector in Israel. Results: Training in the field was very low; average level of self-perceived knowledge and skills was found to be slightly below the midpoint of the scale, while actual knowledge, as assessed through a case vignette, was found to be low for all psychiatrists, in particular for general psychiatrists. Discussion: Results point to an urgent need to increase the level of knowledge and skills of psychiatrists and improve the level of services offered to people with intellectual disabilities and mental health problems. Various options for achieving this are presented.

INTRODUCTION Dual diagnosis (DD) refers to the coexistence of intellectual disability (ID) and psychiatric disorder. The reported

overall prevalence rate of ID ranges between 1% to 3% of the global population (1, 2). Developed countries have consistently shown the prevalence rate of psychiatric disorder among people with ID to be significantly higher than people without ID. For example, a British study found a point prevalence rate of 39% of ICD-10 diagnoses among children between 5 to 15 years old with ID living in the community (3). Similarly, a study in Western Australia cross-linked population-based psychiatric and ID registers and found a life-time prevalence rate of 32% of co-occurring ID and psychiatric disorder (4). However, this study only took into account people with DD who had been treated in the public mental health system, a likely conservative estimate (4). As another example, a population-based study conducted in the U.K. has found a 40.9% point-prevalence of clinically diagnosed mentalill health among adults with intellectual disabilities (5). There are no Israel-based epidemiological data on the rate of DD. As of 2009, approximately 34,000 individuals, or about 0.5% of the population, have been legally defined as having ID (6). However, this is an administrative estimate based on those people known to the Ministry of Social Affairs. Assuming that the prevalence rate of mental health problems among people with ID among Israelis is as in other countries; between 10,000 and 27,000 Israelis have a combination of ID and psychiatric disorder. Most countries, including Israel, have assumed responsibility for the treatment, wellbeing and quality of life of individuals with DD by signing the UN Convention on the Rights of Persons with Disabilities (CRPD). The CRPD was signed by 153 nations and ratified by 118 by August of 2012 (Israel, which signed the CRPD on March

Address for Correspondence: Dr. Shirli Werner, The Paul Baerwald School of Social Work and Social Welfare, The Hebrew University of Jerusalem, Mount Scopus, Jerusalem 91905, Israel shirlior@mscc.huji.ac.il

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30, 2007, has yet to ratify it). Signing the convention indicates the intention of a country to be bound by the treaty and refrain from acts that would contravene it (7). Recall that the Preamble of the CRPD emphasizes “the importance of mainstreaming disability issues”. Further, it stresses the need to “provide persons with disabilities with the same range, quality and standard of free or affordable health care and programs as provided to other persons” (Article 25). Recently, the European Regional Office of the World Health Organizations (EURO/WHO), to which Israel belongs, has reaffirmed its support of the CRPD by adopting the European Declaration on the Health of Children and Young People with Intellectual Disabilities and their Families (November 2010) (8). This Declaration states unequivocally that children and young people with ID have the same rights to health and social care, education, vocational training, protection and support as other children and young people. Thus, to achieve optimal quality of life for individuals with ID, equal opportunities are to be assured for stimulating and fulfilling lives in the community and with their families. This requires, inter alia, equal access to health and mental health care, including specialist care when needed. It follows from both the CRPD and the 2010 EURO/ WHO Declaration that mental health services are especially important for individuals with ID, given the relatively high risk for mental disorders among them (5, 9). Accordingly, psychiatrists should be aware of this high comorbidity, and be able to properly diagnose and care for these individuals to the same extent than they do with regard to individuals without ID (equality) or even more, given the heightened needs of individuals with DD (equity). Currently, people with DD in Israel are cared for within the general mental health services, the assumption being that these services can adequately meet the compounded needs of this patient group. The validity of this assumption has not been assessed in practice. One way to explore it would be to assess how well psychiatrists regard themselves to be equipped to provide proper diagnosis and care (10). This question is highly pertinent, as psychiatrists in various studies have reported that their residency training in the field of ID is very limited (11). For example, in a study conducted among Queensland psychiatrists in Australia, 88% reported that they had received no training relating to mental health needs of adults with ID within the past 12 months (12). This is in contrast with Article 4 of the CRPD, which states that: “state parties undertake

to promote the training of professionals and staff working with persons with disabilities in the rights recognized in the present Convention, so as to better provide the assistance and services guaranteed by those rights” (7). During the 1990s, two surveys conducted in Australia focused on the attitudes and perceptions of psychiatrists, psychiatrists-in-training and medical officers (13, 14). Participants in these studies felt inadequately trained and expressed concerns that people with DD are receiving inadequate care in the hospital and community setting (13, 14). About a decade later three additional studies were conducted based on the same questionnaire. In one of these studies, conducted in Australia, training and education in the assessment and diagnosis of mental illness in adults with ID was found to be highly needed. Further, these psychiatrists also noted the need for evidencebased guidelines for psychotropic drug use as well as advice regarding service options for this population (12). Two other studies examined the knowledge of Australian general psychiatrists and U.K. learning disability psychiatrists (15, 16), and compared the findings between these two groups (16). U.K. psychiatrists compared with their Australian counterparts reported a higher level of disagreement with the statement that “mental health needs are uncommon in adults with ID” and with the statement that “there is seldom the need to investigate psychiatric symptoms in adults with severe ID.” Furthermore, U.K. psychiatrists were more confident than their Australian peers in adopting a developmental approach when working with adults with ID. An additional study, conducted in Canada, utilized a focus group design, and found that psychiatric staff in emergency room hospitals felt they lacked information on available services, knowledge and experience necessary to serve this population adequately (17). No study has so far examined the current level of training and knowledge in the field of the dual diagnosis of ID and psychiatric disorders in Israel, nor the specific educational resources available to local psychiatrists working in the public sector. The objective of this study was to explore psychiatrists’ self-assessment regarding their training, knowledge and skills in the field of ID and psychiatric disorders, and the continuous education resources which are available in their places of work. This study was conducted with a grant provided by the Israel National Institute for Health Policy Research and full results of the entire study can be found in the grant report (18). 203

Psychiatrists Ability to Care for Intellectual Disability and Psychiatric Disorders

METHODS

Figure 1. Description of Case Vignettes

POPULATION AND SAMPLING

General psychiatry vignette Meni, a 50-year-old man with Down syndrome, has been living in a hostel for people with intellectual disability for the past 10 years. He is brought to the psychiatric outpatient department with a complaint by his carers of “not being himself” over about the past year. He has been unwilling to follow his normal routine of attending a sheltered work setting; has not partaken in social activities in the hostel, and has possibly lost some skills (but this last point is not definite).

The research population included all psychiatrists (N=870) working in the public sector, as per the estimation our research team made based on a telephone inquiry to all the public sector units. Our target sample included psychiatrists working in all those settings that agreed to participate in the study (n=679) Data were collected from a total of 256 psychiatrists that were working during the period of April 2010 through February 2011 in all psychiatric hospitals; 43 of the 73 clinics; and 5 of the 13 general hospitals in the country. The response rate was 38% (n= 256), if the denominator is based on our target sample (n=679), or 29.5%, if based on the total number of psychiatrists in the public sector (N=870) QUESTIONNAIRE Data were collected via a self-administered questionnaire. Demographic and professional background variables included age, gender, number of years since completion of psychiatric residency, current position (psychiatristsin-training, fully-qualified psychiatrists, fully-qualified psychiatrist who are directors), and percentage of working hours dedicated to people with ID. Self-assessed knowledge and skills: Participants were asked to report if they had received any previous training in the diagnosis and treatment of people with DD (yes or no), and rate their agreement on the need to improve the current state of training, on a scale ranging from 1 (strongly disagree) to 5 (strongly agree). Further, participants were asked to report their self-assessed knowledge and skills on the diagnosis and treatment of people with DD, measured by a Likert scale, ranging from 1 (very low level of skills/ knowledge) to 5 (very high level of skills/ knowledge). Objective knowledge: Participants were given two clinical vignettes (tailored to a general psychiatrist or child and adolescent psychiatrist) (see Figure 1). The vignette detailed a hypothetical patient with ID referred for psychiatric treatment. Respondents were asked to provide the three most likely causes for the patient’s problems (open question). Further, from a list of six options, they were asked to select the two preferred initial actions. The face validity of the vignettes and the correct answers (i.e., three most likely causes and the two correct actions) were determined by independent consultation with three psychiatrists working in the field of DD. For 204

In your opinion, what are the three most likely causes for Meni's condition? Correct answers (determined via consultation): 1. Dementia 2. Depression 3. Hypothyroidism Based on the above information, your two preferred initial actions would be to: 1. Initiate treatment with medication (which one?) 2. Take a detailed history. 3. Refer to a neurologist. 4. Politely explain that this is not something that psychiatrists deal with, and refer to the ID section within the Ministry of Welfare. 5. Perform a blood test (which one?) 6. Developmental testing/ IQ testing Child/ adolescent psychiatry vignette Yossi is an 11-year-old boy attending a school for mildly intellectually disabled children. He is brought to you because he “cannot sit still,” is at times destructive of property and, at times, mildly aggressive. His attention span is about 5 minutes, even for activities that should be fairly interesting. In your opinion, what are the three most likely causes for Yossi's condition? Correct answers (as determined by consultation): 1. Attention deficit / hyperactivity disorder 2. Anxiety / depression / emotional disturbance 3. Inappropriate school placement (related answers, such as "wrongly assessed level of ID" were considered acceptable, since they suggested an understanding of a possible educational misplacement, rather than a primary psychiatric problem). Based on the above information, your two preferred initial actions would be to: 1. Initiate treatment with medication (which one?) 2. Take a detailed history. 3. Refer to a neurologist. 4. Politely explain that this is not something that psychiatrists deal with, and refer to the ID section within the Ministry of Welfare. 5. Perform a blood test (which one?) 6. Developmental testing/ IQ testing

the general psychiatry vignette, the likely causes were: dementia, depression and hypothyroidism; and the two correct preferred actions were to take a detailed case history and to take a blood test to examine for possible hypothyroidism. For the child/ adolescent vignette the likely causes were ADHD, and anxiety/depression or management condition: improper school placement. The two correct initial actions were to take a detailed history and to request a developmental assessment.

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Sources of continuous education: Participants were asked to evaluate what proportion of learning resources (books, journals, seminars, staff meetings, journal clubs, and research projects) in their work place was devoted to DD. Rankings were: 0-1%, 2-5%, 6-20%, > 20% or not relevant (when the specific learning resource was not available within the work setting). Using the same rankings, they were also asked to judge what proportion of each of the learning resources should be devoted to DD. Procedure: To recruit potential participants, a letter was sent to the directors of all psychiatric hospitals, community psychiatric clinics and psychiatric departments in general hospitals explaining the study’s aims and methods with the request to facilitate the participation of all psychiatrists (qualified psychiatrists and psychiatrists-in-training) in the self-administered survey. Questionnaires were only distributed to psychiatrists working in departments whose directors granted permission. Various means were used to enhance participation, including the use of the Israel Psychiatric Association website to remind potential participants to complete the questionnaire. ETHICAL CONSIDERATIONS The study’s protocol was approved by the Ethics Committee of the School of Social Work and Social Welfare at the Hebrew University of Jerusalem. STATISTICAL ANALYSES The overall mean of subjective (self-perceived) knowledge and skills was examined. For objective knowledge (as assessed by the vignettes), the percentage of psychiatrists answering each of three correct responses was calculated. Further, the total number of correct answers concerning the possible causes of the problem presented was calculated (scores ranged from 0 to 3). Differences in subjective knowledge, skills and objective knowledge according to participants’ demographic and professional background variables and their work settings were examined via one-way ANOVA for categorical variables. For this purpose, psychiatrists’ age was dichotomized into “younger” (aged up to 48 years) and “older” (aged 49 years and above). Percentage of work time dedicated to people with ID was dichotomized into “up to 5%” and “5% or more.” Hierarchical regression models were utilized to examine which of the demographic and professional background variables were the strongest predictors of subjective knowledge and skills, and of objective

knowledge. Only those variables that were significant at the bivariate level were used in these regressions. In the last step of the analyses, we mapped the distribution of the availability of educational resources as perceived currently and optimally, and utilized McNemar’s tests to examine differences between both. RESULTS Psychiatrists working in different settings were represented in the sample; their position in the setting was stratified into: heads of psychiatric hospitals, heads of inpatient or outpatient units, qualified psychiatrists in non-managerial positions, and psychiatrists-in-training, 53.6% were men. The average age was 47.9 years, with a range from 28 to 68 years. Excluding psychiatrists currently in training, participants were on average 14.1 years (SD=8.4) post-residency. Of the respondents, 10.2% stated that they did not dedicate any time to working with people with ID; 60.2%, that they were spending up to 5.0% of their working time with these patients, and 29.4% more than 5.0% of their time (Table 1). KNOWLEDGE AND SKILLS Of the respondents, 90.2% stated that they did not possess specific training in the diagnosis and treatment of people with DD, but 86.9% ”strongly” or “very strongly Table 1. Psychiatrists by Demographic and Professional Background Variables (N=256) N

97 98 59

38.2 38.6 23.2

General psychiatry

205

80.7

Child and adolescent

19.3

Outpatient clinic in a psychiatric hospital

22.1

Outpatient psychiatric clinic in a general hospital / community clinic

23.7

Inpatient ward in a psychiatric hospital

116

45.8

Inpatient psychiatric ward in a general hospital

4.7

Other settings

3.6

Yes

17.0

186

83.0

Work position Director of hospital, clinic or department Fully-qualified psychiatrist Psychiatrist-in-training Field of psychiatric practice

Main place of work

Specialized unit for autism or ID in the facility

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Table 2. Psychiatrists by Level of Subjective Knowledge and Skills and Objective Knowledge and by Background Characteristics Subjective Knowledge

Clinical Skills

Objective Knowledge (general psychiatrists)

Objective Knowledge (child psychiatrists)

Mean (SD)

t-test or ANOVA

Mean (SD)

t-test or ANOVA

Mean (SD)

t-test or ANOVA

Mean (SD)

t-test or ANOVA

Gender Women Men

2.82 (0.71) 3.03 (1.00)

1.93*

2.89 (0.76) 3.01 (1.02)

1.07

1.33 (0.76) 1.27 (0.74)

0.55

1.94 (0.56) 2.14 (0.77)

1.09

Age in yrs. Younger (28-48) Older (49-68)

2.73 (0.85) 3.14 (0.89)

3.73***

2.71 (0.89) 3.19 (0.86)

4.31***

1.42 (0.67) 1.17 (0.80)

2.31*

2.03 (0.72) 2.00 (0.59)

0.18

Years of experience (Fully qualified) 1 to 9 10 to 17 18 to 36

3.10 (0.69) 3.21 (0.90) 3.05 (0.86)

0.67

3.04 (0.66) 3.25 (0.93) 3.10 (0.82)

1.13

1.37 (.71) 1.10 (.79) 1.18 (.69)

1.68

2.23 (.60) 2.00 (.77) 2.07 (.46)

0.47

Field of practice General Child / adolescent

2.88 (0.87) 3.10 (0.97)

1.56

2.90 (0.89) 3.11 (0.93)

1.43

Not relevant

Time dedicated to people with ID Up to 5% More than 5%

2.79 (0.88) 3.27 (0.83)

3.99***

2.81 (0.91) 3.31 (0.78)

4.07***

1.24 (.72) 1.45 (.80)

1.78

2.00 (.60) 2.04 (.73)

0.22

Training in the field of DD No Yes

2.86 (0.85) 3.63 (1.01)

4.09***

2.87 (0.85) 3.75 (0.99)

4.75***

1.32 (.74) 1.29 (.77)

0.12

1.98 (.66) 2.11 (.60)

0.56

Position at work Trainee psychiatrists Fully qualified psychiatrists Directors

2.31 (0.79) 3.18 (0.77) 3.10 (0.87)

23.61***

2.34 (0.88) 3.17 (0.80) 3.15 (0.83)

21.58***

1.25 (.72) 1.21 (.76) 1.53 (.74)

2.83

2.11 (.57) 2.10 (.64) 1.80 (.77)

1.15

Facility has a specialized unit for people with autism or ID No Yes

2.91 (0.93) 3.05 (0.70)

0.87

2.95 (0.92) 2.97 (0.84)

0.13

1.24 (0.76) 1.59 (0.73)

2.25*

1.91 (0.68) 2.13 (0.64)

1.08

Not relevant

*p<.05; **p<.01; ***p<.001

agreed” that there is need to improve the current state of training. Overall, the mean level of subjective knowledge was 2.9 (SD=0.9) and of skills were 3.0 (SD=0.9), (of a maximum of 5) indicating that respondents’ subjective rating of their knowledge and skills were slightly below the midpoint of the scale. Further, 28.6% and 30.4% of the psychiatrists reported that they possess low levels of knowledge and skills, respectively. Of all participants, 187 (91%) answered the general psychiatrists’ vignette; 54, the child/ adolescent psychiatrists’ vignette; 20 answered both; and 10 answered neither. Of the general psychiatrists, 71.4% noted depression as a likely cause, 54.6%, dementia and 4.3%, raised the possibility of hypothyroidism. Putting these finding together, only four psychiatrists (2.1%) gave three correct causes; 76 (40.6%), two; 79 (42.2%), one; and 28 (15.0%), failed to correctly name any of the three most likely causes which had been derived by consensus as described above. As for the preferred course of action, 213 provided answers (i.e., although some did not provide 206

answers for the cause, they did provide an answer for preferred action). Of these psychiatrists, 187 (87.8%) selected taking a detailed history while only 17 (8.0%) pointed to the correct blood test. As for the child/ adolescent vignette, 52 (96.3%) suggested the possibility of ADHD; 36 (66.7%), of anxiety; and 21 (38.9%), of inadequate school placement. Putting these findings together, 12 participants (22.2%) provided all three consensus-derived causes; 31 (57.4%), two; and 11 (20.4%), one. As for the preferred course of action, 50 psychiatrists (92.6%) selected taking a detailed history while 23 (42.6%) pointed to the need to request a developmental assessment. Table 2 shows differences in subjective knowledge and skills and objective knowledge according to demographic and professional background variables. Higher levels of subjective knowledge and skills were found among male psychiatrists, and those who were older, dedicated more time to individuals with ID, had had previous training in the field of DD, or had a higher position in the hier-

Shirli Werner et al.

archy. A higher rate of correct answers to the general psychiatry case vignette questions was found among younger psychiatrists and among psychiatrists working in settings that have a specialized unit for people with ID. No differences were found in objective knowledge of the child case vignette according to any of the demographic and professional background variables. The regression models predicting subjective knowledge and skills and objective knowledge are shown in Table 3. The strongest predictors of subjective knowledge and skills were the psychiatrists’ position at work, time dedicated to individuals with ID and having had training in the field of DD. All variables in the model were predictive of 26% of the variance in knowledge, and 29% of the variance in clinical skills. As for objective knowledge among general psychiatrists, 4% of the variance was predicted by being of younger age and working in an institution with a specialized unit for individuals with ID. As none of the variables examined were predictive of objective knowledge of child/ adolescent psychiatrists at the bi-variate levels, this variable was not further examined in the regression models. EDUCATIONAL RESOURCES IN THE WORK SETTING Table 4 shows the proportion of educational resources devoted to individuals with ID in places of work as Table 3. Predictors of Subjective Knowledge, Skills and Objective Knowledge

Variable

Knowledge (n=237)

Clinical skills (n=234)

Objective knowledge (general psychiatrists – n=164)

Demographic background variables Gender (women vs. men) Age (younger vs. older)

0.09 0.09

--0.14

---0.15*

Professional background variables Proportion of work time dedicated to people with ID (up to 5% vs. more than 5%) Training in the field of DD (No vs. yes) Position at work (psychiatrists-in-training vs. fully - qualified and directors) Setting with specialized unit (No vs. yes)

0.26***

0.27***

---

0.22***

0.27***

---

0.32***

0.30***

---

0.16*

R²

0.26

0.29

0.04

17.19***

24.25***

4.07*

reported by the participating psychiatrists, as well as their opinion about what should be optimal. In general, psychiatrists reported a low percentage of resources being devoted to people with ID. For example, 35% and 48%, respectively, reported that 0-1% of the library books and journals were dedicated to DD. The availability of resources was especially low with regard to staff meetings, journal clubs and research projects (between 68% and 72% reported a virtual absence of these in their places of work [0-1%]), and most participating psychiatrists considered the availability of relevant learning resources in their work settings sub-optimal. The McNemar test showed a significant difference between the current and the optimal situation in each of the learning resources examined. For example, around 80% reported that 2-20% of library books and journals should be dedicated to DD, while around 85% reported that this proportion should exist for seminars, meetings and journal clubs. Table 4. Learning Resources in the Work Setting: Perception of the Current and Optimal Situations Resources

Current situation N (%)

Optimal situation N (%)

McNemar test

Library books 0-1% 2-5% >6% Not relevant

N=224 (34.8) 78 (34.8) 78 (12.5) 28 (17.9) 40

N=211 (3.3) 7 (37.9) 80 (49.3) 104 (9.5)20

130.4***

Journals 0-1% 2-5% >6% Not relevant

N=229 (47.6) 109 (30.6) 70 (10.0) 23 (11.8) 27

N=212 (6.6) 14 (43.9) 93 (42.5) 90 (7.1) 15

136.8***

Seminars 0-1% 2-5% 6-20% 20%< Not relevant

N=250 (71.6) 179 (16.4) 41 (2.8) 7 (3.6) 9 (5.6) 14

N=230 (7.4) 17 (59.6) 137 (26.1) 60 (3.5) 8 (3.5) 8

170.0***

Staff meetings 0-1% 2-5% >6% Not relevant

N=249 (63.1) 157 (24.1) 60 (7.6) 19 (5.2) 13

N=228 (8.8) 20 (57.9) 132 (29.4) 67 (3.9) 9

148.0***

Journal clubs 0-1% 2-5% >6% Not relevant

N=247 (71.3) 176 (13.0) 32 (7.7) 19 (8.1) 20

N=223 (8.5) 19 (57.8) 129 (29.6) 66 (4.0) 9

158.3***

Research projects 0-1% 2-5% >6% Not relevant

N=234 (67.5) 158 (10.7) 25 (6.8) 16 (15.0) 35

N=211 (14.7) 31 (43.1) 91 (30.3) 67 (11.8) 25

121.5***

***=p<.001

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Psychiatrists Ability to Care for Intellectual Disability and Psychiatric Disorders

Two important differences in the learning resources were reported. First, a higher percent of journal clubs dedicated to the field of DD was found in settings that have specialized units for people with autism or ID, compared to other settings (χ2 (3)=9.35, p<.05). Specifically, 81.1% of the psychiatrists working in settings without specialized units reported that none or almost none (0-1%) of the journal clubs in the previous year were dedicated to DD, compared with 57.6% of psychiatrists working in settings with a specialized unit. Second, a higher percent of seminars in the DD field was reported by child/ adolescent psychiatrists than by general psychiatrists (χ2 (3)=9.76, p<.05). Specifically, 79.4% of the latter reported that 0-1% of seminars were dedicated to DD, compared with 62.2% of child/ adolescent psychiatrists. To complete this picture, 13.8% of general psychiatrists reported that 2-5% of seminars were dedicated to this topic as compared with 33.3% of child/ adolescent psychiatrists. DISCUSSION This study aimed to examine the current level of training, knowledge and skills regarding dual diagnosis (intellectual disability comorbid with psychiatric disorders) as reported by psychiatrists working in the public sector. The study also aimed to map the current state of educational resources in the field available to psychiatrists in public settings. Our findings show that training in DD was very low. Additionally, around a third of the participants reported of low level of knowledge and skills. Our study added the use of a clinical vignette to tap objective knowledge which pointed to a more worrisome picture. The findings showed that both child/ adolescent and general psychiatrists do not feel competent in the field. These findings mirror those obtained in other countries among psychiatrists, with regard to both a low level of knowledge (15-17) and a lack of training (11). Those studies, however, did not utilize objective measures. Finally, the availability of relevant learning resources was very low. Importantly, the psychiatrists themselves perceived a need for additional learning resources and for a higher level of training in the field of DD in general. The discrepancy between subjective and objective ratings (subjective, around the mid-point of the scale and objective, lower) is a matter of concern, since psychiatrists who see themselves as having average abilities appear to actually possess lower levels of knowledge/skills. The above results indicate that the current state of training and knowledge of psychiatrists working within public 208

sectors in Israel needs to be upgraded if we wish to provide individuals with DD with proper care. The low level of knowledge/skills may be attributed to the lack of formal training and available ongoing educational resources. Several differences in knowledge according to demographic and professional variables are worth discussing. First, it is noticeable that child/adolescent psychiatrists had a higher level of objectively assessed knowledge, indicating that general psychiatrists are in greater need of additional training. Second, although older psychiatrists assess themselves as having a higher level of knowledge and skills than did younger psychiatrists, the case vignettes showed that this self-perception may not reflect reality adequately. This finding reinforces the need for ongoing training among psychiatrists at all levels of seniority, as has been stressed in other previous studies (15). Limitations The study results must be examined in light of several limitations. First, the sample included the views of a minority (about 30%) of all psychiatrists in the public sector. Possibly the psychiatrists who responded were more interested in the subject than non-respondents. Thus, if there is a bias, it is likely to be in the direction of higher levels of training and knowledge among respondents - though this cannot be stated with certainty. Further, it should be noted that this response rate is similar, or higher, than that obtained in other studies among psychiatrists (e.g., 15, 19, 20). Secondly, the sampling method was not random, although an attempt was made to get to most of the psychiatrists working in the public service. Thirdly, available learning resources, attitudes, self-perceived and objectively assessed knowledge and skills regarding other populations of patient were not examined. Thus, it is difficult to know whether there are similar deficiencies in other areas of psychiatry. Fourthly, and most importantly, our study utilized a selfreport questionnaire; psychiatrists’ knowledge and skills in real-life situations were not examined. Conclusion The results of this study are a call for action addressed to all professional bodies relevant to psychiatric training. The findings point to a need to begin (or strengthen) developing and implementing a proper across-the-board training program. One strategy to improving the current situation may be by employing a “horizontal” approach, attempting to raise

Shirli Werner et al.

the level of knowledge/ skills in the field of dual diagnosis among psychiatrists. However, as we learn from a study conducted in Australia, it seems that current mainstream services fail to meet the needs of this population (15). A second possibility is to provide care within dedicated or specialized services. This option is supported by studies pointing to the advantages of this model over the generic service model (16). However, specialist models contradict the normalization principle, and may lead to a lower level of services, particularly in countries with limited numbers of psychiatrists (21). Given the pros and cons of both the horizontal approach (generic services) as well as the dedicated (specialized) services, a third option may be appropriate in Israel. In this model, which is also supported by the findings of Torr et al. (15) from Australia, the training and care would be provided by a cadre of tertiary service specialists within the generic services. These experts would provide training/supervision to psychiatrists within the generic services to improve services for people with mild or moderate ID affected by more common and less severe problems, while taking direct clinical responsibility for people with severe ID and/or affected by complex problems. Acknowledgement: This research was conducted with a grant provided by the Israel National Institute for Health Policy Research. We would also like to thank the psychiatrists who participated in the study.

References 1. Harris J. Intellectual disability: Understanding its development, causes, classification, evaluation, and treatment: Oxford University, 2006. 2. Dua T, Mascarenhas M N, Mathers C D, Maulik P K, Saxena S. Prevalence of intellectual disability: A meta-analysis of population-based studies. Res Dev Disabil 2011;32:419-436. 3. Emerson E. The prevalence of psychiatric disorders in children and adolescents with and without intellectual disabilities. J Intellect Disabil Res 2003;47:51-58. 4. Morgan VA, Leonard H, Bourke J, Jablensky A. Intellectual disability cooccurring with schizophrenia and other psychiatric illness: Populationbased study. Br J Psychiatry 2008;193:364-372. 5. Cooper SA, Smiley E, Morrison J, Williamson A, Allan L. Mental ill-

health in adults with intellectual disabilities: Prevalence and associated factors. Br J Psychiatry 2007;190:27-35. 6. Gorbotov R, Ben-Moshe E, Ben-Simchon M. People with mental retardation. In: Tzeva Y, editor. Review of social services 2009 (in Hebrew). Jerusalem: Ministry of Social Affairs and Social Services, 2010: pp. 367-400. 7. UN General Assembly. Convention on the Rights of Persons with Disabilities: Resolution; adopted by the General Assembly, 24 January 2007. 8. World Health Organization. European Declaration on the health of children and young people with intellectual disabilities and their families: Better health, better lives. EUR/51298/17/6. Romania, 2010. 9. Dosen A, Day K. Treating mental illness and behavior disorders in children and adults with mental retardation. Washington, DC: American Psychiatric, 2001. 10. Patterson MH, Higgins RN, Dyck DG. A collaborative approach to reduce hospitalization of developmentally disabled clients with mental illness. Psychiatr Serv 1995;46:243-247. 11. Burge P, Ouellette-Kuntz H, McCreary B, Bradley EA, Leichner P. Senior residents in psychiatry: Views on training in developmental disabilities. Can J Psychiatry 2002;47:568-571. 12. Edwards N, Lennox N, White P. Queensland psychiatrists’ attitudes and perceptions of adults with intellectual disability. J Intellect Disabil Res 2007;50:75-81. 13. Lennox N, Chaplin R. The psychiatric care of people with intellectual disabilities: The perceptions of trainee psychiatrists and psychiatric medical officers. Aust N Z J Psychiatry 1995;29:632-637. 14. Lennox N, Chaplin R. The psychiatric care of people with intellectual disabilities: The perceptions of consultant psychiatrists in Victoria. Aust N Z J Psychiatry 1996;30:774-780. 15. Torr J, Lennox N, Cooper SA, Rey-Conde T, Ware RS, Galea J, et al. Psychiatric care of adults with intellectual disabilities: Changing perceptions over a decade. Aust N Z J Psychiatry 2008;42:890-897. 16. Jess G, Torr J, Cooper SA, Lennox N, Edwards N, Galea J, et al. Specialist versus generic models of psychiatry training and service provision for people with intellectual disabilities. J Appl Res Intellect Disabil 2008;21:183-193. 17. Lunsky Y, Bradley EA, Durbin J, Koegl C. A comparison of patients with intellectual disability receiving specialized and general services in Ontario’s psychiatric hospitals. J Intellect Disabil Res 2008;52:1003-1012. 18. Werner S, Levav I, Stawski M, Polakiewicz Y. Psychiatrists’ knowledge, abilities and attitudes regarding treatment of persons with dual diagnosis: Israel National Institute for Health Policy Research, 2011. 19. Szabo CP, Kohn R, Gordon A, Levav I, Hart GAD. Ethics in the practice of psychiatry in South Africa. S Afr Med J 2000;90:498-503. 20. Alfonso CA, Olarte SW. Contemporary practice patterns of dynamic psychiatrists – survey results. J Am Acad Psychoanal Dyn Psychiatry 2011;39 7-26. 21. World Health Organization. Mental Health Atlas. 2011 [cited 2012] Available from: http://whqlibdoc.who.int/publications/2011/ 9799241564359_eng.pdf

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Isr J Psychiatry Relat Sci - Vol. 50 - No 3 (2013)

The Effects of the Survival Characteristics of Parent Holocaust Survivors on Offsprings’ Anxiety and Depression Symptoms Yael Aviad-Wilchek,PhD,1 Diana Cohenca-Shiby, PhD,2 and Yehuda Sasson, MD3 1

Department of Behavioral Sciences, Ariel University, Israel Department of Criminology, Ariel University, Israel 3 “Fearless Institute” for virtual technology. 2

Introduction

Abstract Aim: This paper examines symptoms of anxiety and depression of Holocaust survivors’ (HS) offspring as a function of their parents’ age, gender, and survival situation (whether the survivor parent was alone or with a relative during the war). Method: The 180 adults (142 with two parent survivors; 38 with a single parent survivor) who participated in this study completed (a) a measure of state-trait anxiety, (b) a measure of depression symptoms, (c) a sociodemographic questionnaire was divided into three sections: information about the participant, about his mother and about his father. Results: Participants whose mothers were aged 18 or younger during the war and survived alone report more symptoms of anxiety and depression than participants whose mothers were the same age yet survived in the company of relatives. Participants whose mothers were aged 19 or older and survived either alone or in the company of relatives, exhibited fewer symptoms of anxiety and depression. The survival situation was the only predictor related to the fathers. There were no significant differences between participants with one or two HS parents. Discussion: Although this study is based on a relatively small sample, it highlights the relationship between the parents’ survival situation and symptoms of anxiety and depression among their offspring.

Address for Correspondence: aviadyael@walla.co.il

210

In the decades following WWII evidence emerged demonstrating that Holocaust trauma and its consequences had affected not only the survivors themselves, but also their offspring. This evidence triggered many studies, conducted mainly by therapists, on clinical populations of the “second generation,” who came for psychotherapy because they had experienced problems or emotional difficulties (1, 2). Freyberg (3) noted that most of their complaints involved phobias, depression, increased anxiety, psychosomatic disorders, and identity confusion. Many empirical studies have since been conducted on non-clinical populations. Recent studies indicate that several mood disorders, most of which fall into the normal range of personality and behavior, clearly distinguish between the “second generation” and control groups. These disorders are mainly a tendency towards post-traumatic disorder (4, 5), difficulties with separation-individuation (6), difficulties with coping under pressure, personality problems, neurotic conflicts, anxiety, and depression (1, 2). However, such studies have not produced conclusive findings. One explanation for the inconsistent findings may be the fact that the second generation, as well as the survivors themselves, cannot be considered homogeneous groups (7, 8). In fact, the term “second generation,” which refers to children who were born after 1945 and who have (or had) at least one parent who is a Holocaust survivor, encompasses diverse personal situations and subgroups (9). In acknowledgement of this heterogeneity, researchers have begun to study cross-sections of the second generation. The findings are more clearly identifiable when focusing on subgroups of Holocaust survivor offspring

Yael Aviad-Wilchek, PhD, Department of Criminology, Ariel University Center, POB 3, Ariel, 40700 Israel.

Yael Aviad-Wilchek et al.

(HSO). Solomon (10) emphasized that research based on a differential distinction between subgroups may provide a clearer picture. Thus, Okner and Flaherty (11) found lower levels of anxiety, depression, and demoralization in families where parents spoke to their children about their experiences during the Holocaust, compared to children whose parents did not share their Holocaust experiences. Scharf (12) also found higher levels of psychological symptoms among adolescents with two Holocaust survivor (HS) parents, compared to adolescents with only one HS parent. DeGraf (13) found that HSO Israeli soldiers showed higher levels of personality disorders and criminal tendencies than other soldiers. Yehuda et al. (14) found that members of the second generation who develop PTSD are children of survivors who themselves suffer from PTSD. Additional studies examined the relationship between survivors’ gender and their level of functioning in later life and the impact on the “second generation syndrome.” The results showed that male survivors experienced the war period differently than female survivors. Therefore, we assume that HS parents’ gender will have a different impact on their offspring (15, 16). In recent years, the relationship between survivors’ age and level of functioning in life was examined as well. The findings show a direct relationship between survivors’ young age and high levels of vulnerability, reflected in high levels of anxiety, a tendency to pessimism, and distrust human beings (17-19). These conclusions served as the rationale for the current study. The study attempts to trace the different influences of parents’ survival situation (whether the survivor parent was alone or with a relative during the war) on the second generation’s symptoms of anxiety and depression, based as stated on the assumption that if we focus on subgroups of the second generation (and not on the second generation as a single unit) we will be able to arrive at more meaningful findings. We assume that the combination of the following factors: age, survival situation, and gender of survivor parents, will have a different effect on the psychological vulnerability of their children. Therefore, we hypothesized that HSO of survivors who were 18 years old or younger by the end of the war will exhibit higher levels of anxiety and depression than HSO of survivors who were older. We assume that the younger the parent, the emotional trauma of their offspring will be greater. Another hypothesis is that HSO whose HS parent was alone will exhibit higher levels of anxiety and depression than HSO whose HS parent was in the

company of a relative during the war. We assume that the presence of a significant other during the war helped survivors feel more secure, enabling them to get through the survival situation in a better emotional state. We also hypothesized that HSO whose mothers were HS will exhibit higher levels of anxiety and depression than HSO whose fathers were HS. We assume that because traditionally the mother is the principal caregiver and she has also more interactions with the children, her impact on the HSO will be higher. Method Participants

The sample included 180 adult HSO. Respondents were sampled in a number of ways. Most of the participants were sampled at conferences and meetings related to the Holocaust during the years 2006 to 2008. They were also contacted through the researcher’s social connections, and the researcher personally contacted suitable participants, presenting the research and suggesting that they take part in it. The response was maximal. Questionnaires were mailed to Members of the Second Generation Organization’s home, completed there and mailed back to the researchers (approximately 10%). We did not distribute questionnaires through organizations that treat pathological cases (such as “Amcha”). This is a random sample that does not represent the entire Second Generation population. Respondents volunteered to take part in the research based on their personal interest and with no compensation. The subjects represent a relatively wide range of demographic characteristics: 142 participants (78.9%) had two survivor parents, while 38 participants (21.1%) had a single survivor parent. Some participants lacked the requested information about their parents (two mothers and 12 fathers). Participants were between the ages of 23 and 64 (M = 51.47, SD = 7.30); 125 were female (69.4%) and 55 male (30.6%). Most participants were born in Israel (N = 147, 81.7%). The distribution of participants’ schooling was as follows: high school (N = 29, 17.6%), Bachelor’s degree (N = 91, 55.1), Master’s or PhD degree (N = 45, 27.3%). Most lived in cities (N = 143, 86.7%), while a minority lived in rural areas (N = 22, 13.3%). Most participants were married (N = 135, 77.1%). Approximately one fourth were either single (N = 18, 10.3%), divorced, or widowed (N = 22, 12.6%). Participants had up to seven children (M = 2.72, SD = 1.33). 211

Survival characteristic of holocaust survivors and offsprings' anxiety and depression symptoms

Measures Participants were asked to complete three questionnaires: • The State-Trait Anxiety Inventory (20). The inventory comprises two sets of 20 items each. The trait scale addresses how the respondent generally feels and the state scale addresses the respondent’s feelings at that moment. According to studies, test-retest correlations were calculated at .54 for the state scale and .86 for the trait scale. The questionnaire was translated into Hebrew (21) and was found valid and reliable. In the Hebrew version, the two scales showed satisfactory Cronbach’s internal reliabilities (state scale: α=.89; trait scale: α =.88). In the current study, both scales show a high degree of homogeneity in terms of inter-item correlation coefficients (state anxiety: α=.94; trait anxiety: α =.92). • The Beck Depression Inventory (22), designed to assess the severity of depression in adolescents and adults. Responses to the 21 items are scored on a rating scale ranging from 0 to 3. The inventory was translated into Hebrew (23) and validated for use in Israel. The internal reliability of the original version was α = .83, and of the Hebrew version α = .76. In the current study, internal reliability was α=.84. • A socio-demographic questionnaire, divided into three sections: information on the participants, and two sections focusing on participants’ mother and father survival characteristics like: age at the end of the war, whereabouts during the war (ghetto, in hiding, Siberia, concentration camp) and survival condition (whether the survivor parent was alone or with a relative during the war). Procedure Most of the participants completed the questionnaires individually at meetings or conferences. Participants, who received the questionnaires by mail, received also a letter with the invitation to participate in the research. They were told that the goal of the study was to understand better the Second Generation Syndrome. They were asked to answer the questions sincerely and honestly. The instructions were written in the questionnaires themselves; however, respondents were given the possibility of asking questions or e-mailing the researchers regarding the clarity of the instructions. Respondents returned the completed questionnaires in a sealed envelope with no identifying details. In this way anonymity was maintained. 212

The study was approved by the Ethical Committee of Bar-Ilan University, which also conform to those of the American Psychological Association. Statistical analyses

First, the study variables were examined and were found to be positively skewed, with right tails. Departure from the normal distribution was acceptable (skewness = 0.74 to 1.41, SE=0.18). State and trait anxiety ranged from 1 to 4 with acceptable standard deviations (0.59 and 0.55 respectively), while depression ranged from 0 and 1.57, with a mean of 0.34 (SD=0.30). The three dependent variables were highly correlated (r=.73 to r=.83, p<.001), yet serving as dependent variables in the two analyses of variance multicollinearity did not pose a problem. Second, correlations between the dependent variables (state anxiety, trait anxiety, and depression symptoms) and major demographic variables were examined, showing the need to control for participants’ age while testing the research hypotheses. Age was used as a covariate, and thus hypotheses were examined with MANCOVAs. The two MANCOVAs used the parents’ age group during the Holocaust and family companions during the Holocaust as two independent variables (2x2 two way MANCOVA), and Bonferroni adjustment for multiple comparisons was used as well. In all cases dependent variables were state anxiety, trait anxiety, and depression. Planned post hoc comparisons for significant interactions used Estimated Marginal Means. Results The maximum age of participants’ parents during the Holocaust was 48, with a mean age of 16.48 years (SD = 7.79) for mothers and 21.68 years (SD = 8.44) for fathers (parents’ age was calculated as their mean age in 1939 and 1945); 103 mothers (57.2%) and 62 fathers (34.4%) were still alive at the time of the study. Over one half of survivor parents, 55% of mothers and 55% of fathers, had a chronic illness, and 11.7% of mothers and 5.6% of fathers had a psychiatric illness. Of the mothers, approximately 30% had been during the war in the company of their siblings, slightly over one quarter with their parents, and slightly over one quarter alone. Of the fathers, nearly one half survived alone, and approximately one fifth survived in the company of a sibling. Trait anxiety was found to correlate inversely with age (r = -.20, p < .01): Younger participants experienced more symptoms of anxiety. Neither respondents’

Yael Aviad-Wilchek et al.

nor the parents’ schooling was related to the research variables, and neither was parents’ whereabouts during the Holocaust (ghetto, in hiding, Siberia, concentration camp). Similarly, no differences were found between HSO with one or two survivor parents. In light of these relationships, the research hypotheses were examined, controlling for participants’ age. When the mother is the survivor. Table 1 shows means and standard deviations for offspring’s symptoms of anxiety and depression by mother’s age and survival situation (whether the survivor parent was alone or with a relative during the war). MANCOVA was significant for the interaction between mother’s survival situation and age (F(3,135) = 2.66, p < .05, η2 = .06). Post hoc analyses showed that the multivariate difference was significant for children whose mothers were 18 or younger (F (3,135) = 4.12, p < .01, η2 = .08), but did not reach significance for children whose mothers were aged 19 or older (F (3,135) = 0.26, ns, η2 = .01). A univariate analysis of the differences revealed that for each variable, HSO whose mothers were aged 18 or younger and survived alone scored higher on symptoms of state anxiety (F(1,137) = 12.02, p < .001, η2 = .08), trait anxiety (F(1,137) = 8.04, p < .01, η2 = .06) and depression (F(1,137) = 8.55, p < .01, η2 = .05) than HSO whose mothers were the same age but survived in the company of a relative. Table 2 shows F tests for offspring’s symptoms of anxiety and depression by mother’s age and survival situation. No other analyses were significant. In summary, HSO whose mothers were 18 years old or younger and survived alone had more symptoms of anxiety and depression, while HSO whose mothers were 18 years old or younger and who survived in the company of a relative had significantly fewer symptoms of anxiety and depression. HSO whose mothers were 18 years old or younger and who survived alone reported having more symptoms of depression than all HSO subgroups. Table 1. Means and standard deviations for offspring’s symptoms of anxiety and depression by HS mothers’ age and survival situation (N=142) 18 years old and younger Alone (n=23)

With family (n=61)

Table 2. F tests for offspring’s symptoms of anxiety and depression by HS mothers’ age and survival situation Survival Situation F

With family (n=34)

Mean

State anxiety

2.23

0.56

1.76

0.51

1.85

0.51

1.92

0.64

Trait anxiety

2.09

0.53

1.75

0.46

1.82

0.43

1.91

0.60

Depression

0.48

0.33

0.27

0.32

0.27

0.39

0.31

η2

State anxiety

3.99*

.03

0.01

.001

7.24**

.05

Trait anxiety

1.95

.01

0.72

.005

5.93*

.04

Depression

1.94

.01

0.01

.001

6.57*

.05

*p<.05, **p<.01 Fcompanions (3,135)=1.39, n.s., η2=.03; Fage (3,135)=0.98, n.s., η2=.02; Fcompanions x age (3,135)=2.66, p<.05, η2=.06.

When the father is the survivor. Table 3 shows means and standard deviations for Offspring’s symptoms of Anxiety and Depression by Paternal’s Age and survival situation (whether the survivor parent was alone or with a relative during the war). MANCOVA was found significant for the main effect of survival in the company of a family member (F(3,147) = 3.79, p < .05, η2 = .07). Univariate analyses showed significant differences for state and trait anxiety, as well as for depression. Adult HSO whose fathers survived with others scored lower on all three variables than adult HSO whose fathers survived alone. Table 4 shows F tests for offspring’s symptoms of anxiety and depression by father’s age and survival situation. No other analyses were significant. Table 3. Means and standard deviations for offspring’s symptoms of anxiety and depression by HS fathers’ age and survival situation (N=154) 18 years old or younger Alone (n=26) Mean SD

19 years old or older

With family (n=33)

Alone (n=60)

With family (n=35)

Mean SD

State anxiety 2.14

0.63

1.78

0.58

1.91

0.61

1.72

0.42

Trait anxiety

2.11

0.63

1.74

0.51

1.89

0.53

1.66

0.35

Depression

0.41

0.34

0.29

0.25

0.35

0.30

0.23

0.20

Table 4. F tests for offspring’s symptoms of anxiety and depression by HS fathers’ age and survival situation Survival Situation

19 years old and older Alone (n=24)

η2

Survival Situation X Age

Age

State anxiety

Age

Survival Situation × Age

η2

7.84**

.05

1.20

.01

0.91

.01

Trait anxiety

11.28***

.07

0.41

.003

0.75

.01

Depression

7.26**

.05

3.58

.02

0.01

.001

*p<.05, **p<.01, ***p<.001 Fcompanions (3,147) = 3.79, p<.05, η2=.07; Fage (3,147) =1.55, n.s., η2=.03; Fcompanions x age (3,147) = 0.65, n.s., η2=.01.

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Survival characteristic of holocaust survivors and offsprings' anxiety and depression symptoms

Discussion Results show that adult offspring whose mothers were aged 18 or younger and survived alone reported more symptoms of anxiety and depression, while HSO whose mothers were 18 or younger but survived in the company of a family member reported fewer symptoms of anxiety and depression. HSO whose father survived alone reported more symptoms of anxiety and depression than HSO whose fathers survived in the company of a family member. These findings are expanded below. Effects of the mother’s age and survival situation and the HSO’s symptoms of anxiety and depression

The atrocities and cruelty of the Holocaust shattered children’s and adolescents’ world view and made it difficult for them to build their own identities (24). Although children’s ability to care for themselves increases when they reach adolescence, the Holocaust forced many adolescents to assume disproportionate responsibility for themselves and others, far beyond their abilities (25). Several researchers (26) believe that HS who were 18 or younger during the Holocaust should be considered children because they spent most of their childhood in the shadow of the war. During the Holocaust, adolescents assumed responsibility for their own lives and, in some cases, for the lives of their siblings as well, bearing a heavy burden for their age (25). Moreover, at this age, adolescents still need their parents to guide them and help them build their self-identity (27). Some researchers have suggested that young children may respond to trauma differently than adults due to their psychological immaturity, and consequently they seem to suffer less intensely from trauma compared to adults (28). Sigal and Weinfield (28), as well as other trauma studies not necessarily related to the Holocaust (e.g., 29), show that children sustain less injury from trauma than do adults. The explanation is that children have less intellectual or social maturity that would enable them to understand what happens to them in real time (28). Although young children may have experienced the trauma of the Holocaust less intensely than older children at the time, their experiences may still influence them later on in life. A series of studies found that survivors who experienced childhood trauma have adjustment difficulties as adults (e.g., 30, 31). Moreover, Mazor et al. (32) stated that many survivors who were children during the Holocaust maintain distinct levels of quality of life in different areas of their lives. Most appear to suc214

cessfully maintain a normal life, but beneath the surface they constantly struggle to cope with their traumatic memories and emotions from the past. Until the final decade of the 20th century, there was a biased assumption in Israel that survivors who were children during the Holocaust were “too young” to remember the traumatic events they lived through and therefore did not suffer from the consequences of the trauma (33). Therapists and adults typically sought to persuade children to forget their memories; children who wished to speak about their past and share their feelings were silenced (17, 18). This policy of forced denial stemmed from the desire to help children forget their traumatic past and focus on the future, and from the difficulties of other adults to cope with the memories of child survivors (26). In response, child survivors were forced to repress their own Holocaust memories and feelings (34). As a result of the therapeutic application of forced denial, young HS did not receive appropriate attention, treatment, or psychological assistance after the war. They grew to be adults and parents with unprocessed memories and feelings. Studies showed that children survivors of trauma become adults who lack a sense of pleasure or joy and lack a sense of vitality (35). It is conceivable that young HS became parents who passed this lifestyle on to their children. Nonetheless, it is important to remember that the findings of this study show that the parent’s age was significant only among HSO whose mother survivor was aged 18 or younger and survived the Holocaust alone: This HSO’s group reported higher symptoms of anxiety and depression. A study by Hogman (36) offers partial support for this finding. Hogman’s study (36) found that children (boys and girls between the ages of 0 and 11) who were in the company of their parents during the Holocaust showed higher levels of adjustment than children who were not. So, we can assume that children who receive support in times of crisis will be better psychologically equipped to deal with crisis in the future (37), and will usually apply these resources to future challenges (such as raising their own children). However, the mere presence of a family member is not sufficient to prevent severe emotional consequences. This may be the reason that even children of survivors who were in the company of a relative reported anxiety and depression symptoms, albeit at a lower level. Anxiety and depression symptoms of HSO whose mothers were aged 19 or older were not affected by mothers’ Holocaust survival circumstances. Probably, at age

Yael Aviad-Wilchek et al.

19 the survivor is sufficiently mature and self-sufficient and no longer has an essential need to be with her family (38). At the age of 19, girls no longer have illusions about their parents’ omnipotence, and they understand that they must take care of themselves. At this age, survivors were more mature and able to take care of themselves (39). Effects of fathers’ survival situation on their offspring’s symptoms of anxiety and depression

Studies indicate that traumas influence boys and girls differently. For example, research conducted by Hardin et al. (40) following a severe hurricane revealed that adolescent girls showed a higher level of psychological distress than adolescent boys one year after the trauma. Koopman et al. (41) found that women’s psychological responses to a huge fire incident were more intense than men’s responses to the same event. Wright et al. (42) compared the physical and psychological responses of adolescent boys and girls to stress and found that boys respond better than girls to stress related to academic and social achievements. Rim (15) found that boys and girls experienced the events of the Holocaust differently. Davidson (43) found that adolescent male survivors of concentration camps (who survived in the company of other adolescents boys) perceived the harsh conditions as a challenge and an opportunity to prove their independence and autonomy. Guilt feelings and a guilty conscience are prevalent among survivors. Survivors suffered from guilt for surviving the events while others did not (7, 19, 44). We assume that this element of guilt is stronger among boys, as boys are socialized to be strong and courageous (45), avoid expressing their feelings, and help their families when needed (46). In Israeli society, known for its “macho” culture, boys of a young age develop an ideal image of men as physically and mentally strong, self-controlled, and successful individuals who are expected to do everything to save their families in a crisis. Although this requires further examination, it seems that boys had guilt feelings not only because they survived while others did not, but also because they believed that they failed to help their families in an active and direct manner. Similar guilt feelings are found among survivors of other disasters (7, 46). During the Holocaust, sons assumed enormous responsibility for their family (36), based on the belief that it was their duty to protect their family. Men who failed to support their family suffered from disappointment that had a detrimental effect on their self-image (46). These feelings grew stronger fol-

lowing HS immigration to Israel, because Israeli society in the 1940s and 1950s, unaware of the extent of the Holocaust, accused survivors of allowing themselves to be led to their deaths “like sheep to the slaughter” (24, 47). Moreover, male survivors in particular found themselves struggling to survive in Israel because of the War of Independence, as well as because of the difficult physical conditions in Israel at the time. Despite their hope for a “better life” in Israel, they had to deal with many stressful situations, loss, terror attacks, and wars. All these stress factors may have made it more difficult for survivors to recover from the trauma of the Holocaust. In contrast, social norms allow and expect females to be “weak,” sentimental, and unrestrained. Women who have a mental breakdown or cease to function in times of crisis do not invite harsh social criticism (45). Internalization of feminine stereotypes and masculine stereotypes is also supported by Lichtman’s research (16). Thus, regardless of their age, boys who survived without the company of a family member suffered from guilt resulting from their failure to save their family. Those who survived in the company of a relative benefited from the same sense of security as did female survivors, but also from the feeling that they did not leave their relatives to die. Furthermore, if the survivor was a young male in the company of an older male, the younger survivor could attribute responsibility for his “failure” (to save other family members) to the adult relative or at least share the blame or responsibility with him. DeGraf (13) found that soldiers whose parent Holocaust survivors did not suffer personally from the persecution of the Holocaust, yet lost family members in the Holocaust, exhibited a higher level of neuroticism than soldiers whose parents has been concentration camp internees. In summary, the findings of this study show that symptoms of anxiety and depression among the second generation differed as a function of their parents’ survival circumstances. An important practical conclusion that arises from this study is the need to provide support and assistance to children who experience trauma and to prevent neglect of very young survivors of trauma. This conclusion is relevant today. We must remember that trauma victims of all ages, even when they seem to “function” and continue with their lives, may still be suffering from the effects of the trauma under the surface, and this could have an impact on their own children many years later. Although this study is a preliminary study based on a relatively small sample, it urges greater understanding of the relationship between parents’ childhood experiences 215

Survival characteristic of holocaust survivors and offsprings' anxiety and depression symptoms

and their impact on relationships with their loved ones, particularly their offspring. In view of the significance of the conclusions and their practical implications, further research is recommended. References 1. Kellermann NPF. Psychopathology in children of Holocaust survivors: A review of the research literature. Isr J Psychiatry Relat Sci 2001;38:36-47. 2. Kellermann NPF. Transmission of Holocaust trauma. In: Solomon M, Chaitin G, editors. Childhood in the shadow of the Holocaust. Tel Aviv: Hadekel, 2007: pp. 286-304 (Hebrew). 3. Freyberg JT. Difficulties separation - individuation as experienced by offspring of Nazi Holocaust survivors. Am J Orthopsychiatry 1980;50:87-95. 4. Felsen I, Erlich HS. Identification patterns of offspring of Holocaust survivors with their parents. Am J Orthopsychiatry 1990;60:506-520. 5. Yehuda R, Schmeidler J, Wainberg M, Binder-Brynes K, Duvdevani T. Vulnerability to posttraumatic stress disorder in adult offspring of Holocaust survivors. Am J Psychiatry 1998;155:1163-1172. 6. Brom D, Kfir R, Dasberg H. A controlled double-bind study on children of Holocaust survivors. Isr J Psychiatry Relat Sci 2001;38:47-57. 7. Helmreich WB. Against all odds: Holocaust survivors and the successful lives they made in America. New York: Simon & Schuster, 1996. 8. Kellermann NPF. Transmitted Holocaust trauma: Curse or legacy? The aggravating and mitigating factors of Holocaust transmission. Isr J Psychiatry Relat Sci 2008;45:263-271. 9. Wiseman H, Barber J. Communication between generations about the Holocaust and the patterns of relationships among Holocaust survivors. In: Solomon M, Chaitin G, editors. Childhood in the shadow of the Holocaust. Tel Aviv: Hadekel, 2007: pp. 394-417 (Hebrew). 10. Solomon M. Inter-generational effects as viewed through Holocaust Research in Israel. In: Solomon M, Chaitin G, editors. Childhood in the shadow of the Holocaust. Tel Aviv: Hadekel, 2007: pp. 304-336 (Hebrew). 11. Okner DF, Flaherty J. Parental communication and psychological distress in children of Holocaust survivors: A comparison between the US and Israel. Int J Soc Psychiatry 1988;35:265-273. 12. Scharf M. Long-term effects of trauma: Psychosocial functioning of the second and third generation of Holocaust survivors. Dev Psychopathol 2007;19:603-622. 13. DeGraf T. Pathological patterns of identification family of survivors of the Holocaust. Isr J Psychiatry Relat Sci 1975;13:335-363. 14. Yehuda R, Schmeidler J, Giller EL, Siever LJ, Binder-Brynes K. Relationship between post-traumatic stress disorder characteristics of Holocaust survivors and their adult offspring. Am J Psychiatry 1998;155:841-844. 15. Rim Y. Coping styles of (first- and second generation) Holocaust survivors. Pers Individ Dif 1991;12:1315-1317. 16. Lichtman H. Parental communication of Holocaust experiences and personality characteristics among second generation survivors. J Clin Psychol 1984;40:914-924. 17. Kestenberg JS. Child survivors of the Holocaust. Psychoanal Rev 1988;75:495-495. 18. Kestenberg JS. Memories from early childhood. Psychoanal Rev 1988;75:561-572. 19. Kellermann NPF. Diagnosis of Holocaust survivors and their children. Isr J Psychiatry Relat Sci 1999;36:55-64. 20. Spielberger C, Gorsuch RL, Lushene RE. State-Trait Anxiety Scale. Palo Alto, Cal.: Consulting Psychologists Press, 1970. 21. Tychman Y, Melnic H. Questionnaire to evaluate State-Trait Anxiety: Interrogator guide in Hebrew. Tel Aviv: University of Tel Aviv, 1979 (Hebrew). 22. Beck AT, Ward CH, Mendelson M, Mach JE, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961; 4:561-571.

216

23. Montag A. Validation of the Hebrew version of BDI. Unpublished doctoral dissertation. Haifa: Haifa University, 1979. 24. Davidson S. Holding on to humanity, the message of Holocaust survivors: The Shamai Davidson Papers (Chaitin I, editor). New York: University Press, 1992. 25. Durst N. Loss and development: Traumatization and psychological treatment of children of Holocaust survivors. In: Solomon M, Chaitin G, editors. Childhood in the shadow of the Holocaust. Tel Aviv: Hadekel, 2007:64-81 (Hebrew). 26. Krell R. Child survivors of the Holocaust: The elderly children and their adult lives. In: Glassner MI, Krell R, editors. And life is changed forever. Holocaust children remembered. Detroit, Mich.: Wayne State University, 2006: pp. 1-11. 27. Eidelstein A. A theoretical model to explain juvenile delinquency and social divergence among Ethiopian immigrants in Israel. Soc Educational Work Meeting 2001;14:25-47 (Hebrew). 28. Sigal JJ, Weinfeld M. Do children cope better than adults with potentially traumatic stress? A 40-year follow-up of Holocaust survivors. Psychiatry 2001;64:69-80. 29. Sack WH, Clarke GH, Kinney R, Belestos MS, Him C, Jeeley J. The Khmer adolescent project II: Functional capacities in two generation of Cambodian refugees. J Nerv Ment Dis 1995;183:177-181. 30. Cohen M, Brom D, Dasberg H. Child survivors of the Holocaust: Symptoms and coping after fifty years. Isr J Psychiatry Relat Sci 2001;38:2-3. 31. Hemmendinger J. The children of Buchenwald: After liberation and now. Echoes of the Holocaust 1994;3:40-51. 32. Mazor A, Gampel Y, Enright RD, Orenstein R. Holocaust survivors: Coping with post-traumatic memories childhood and 40 years later. J Trauma Stress 1990;3:1-14. 33. Solomon M, Chaitin G. Introduction. In: Solomon M, Chaitin G, editors. Childhood in the shadow of the Holocaust. Tel Aviv: Hadekel, 2007: pp. 15-21 (Hebrew). 34. Dasberg H. Adult child survivor syndrome: on deprived childhoods of aging Holocaust survivors. Isr J Psychiatry Relat Sci 2001; 38:13-26. 35. Gampel Y. Facing war, murder, torture and death in latency. Psychoanal Rev 1988;75:499-509. 36. Hogman F. Displaced Jewish children during Second World War: How they cope. J Humanistic Psychology 1983;23:51-66. 37. Raviv U, Katsnelson A. Crisis and change in child and family life. Netanya: Amichai, 2003 (Hebrew). 38. Blos P. The adolescent passage: Development issues. New York: International Press, 1979. 39. Hoffman JA, Weiss B. Family dynamics and presenting problems in college students. J Couns Psychol 1987;32:157-163. 40. Hardin SB, Weinrich M, Weinrich S, Hardin TL, Garrison C. Psychological distress of adolescents exposed to Hurricane Hugo. J Trauma Stress 1994;7:427-440. 41. Koopman C, Classen C, Spiegel D. Dissociative responses in the immediate aftermath of the Oakland/Berkeley firestorm. J Trauma Stress 1996;9:521-540. 42. Wright MR, Wright J, Frankenhaeuser M. Relationships between sex-related psychological characteristics during adolescence and catecholamine excretion during achievement stress. Psychophysiology 1981;18:362-370. 43. Davidson S. Massive psychic traumatization and social support. J Psychosom Res 1979;23:395-402. 44. Pynoos R, Nader K. Psychological first aid & treatment approach to children exposed to community violence: Research implications. J Trauma Stress 1987;14:445-473. 45. Williams JE, Best DL. Measuring sex stereotypes: A multinational study. Newbury Park, Cal.: Sage, 1990. 46. Granot T. Loss: Effects and ways to cope with it. Tel Aviv: Ministry of Defense, 2004 (Hebrew). 47. Segev T. The seventh million: The Israelis and the Holocaust. New York: Hill and Wang, 1993.

Book Reviews

Book reviews Elements of Culture and Mental Health Critical questions for clinicians Edited by Kamaldeep Bhui RCPsych Publications Paperback, 104 pages. ISBN 978-1-908020-49-9 Price: £15

his slim and elegantly designed paperback was both a cause for disappointment and for hope. The book addresses “mental health professionals” as its audience and I was elated to begin reading it as so many of my patients come from cultural backgrounds I know little about. However, the text is really aiming at psychotherapists and only three of 20 chapters are useful for psychiatrists working in public health settings. This was my disappointment. Hope – on the other hand – is to be found in the energy and spirit of each and every writer. This is best exemplified by the title of the foreword: “Desire and commitment: Essential ingredients to learning about culture and mental health.” The book is charged with positive energy and makes for a lively read. Yoram Barak, Bat Yam

large-scale survey by Vaughn and colleagues (cited by the authors) published in Comprehensive Psychiatry in 2010 data were derived from a nationally representative sample of U.S. residents 18 years and older. Structured psychiatric interviews (N = 43,093) were completed. The lifetime prevalence of fire setting in the U.S. population was 1.0%. Fire setting was significantly associated with a wide range of antisocial behaviors. Associations between lifetime alcohol and marijuana use disorders, conduct disorder, antisocial and obsessive-compulsive personality disorders, and family history of antisocial behavior and firesetting were significant. On reading this, I became even more interested in reading this book. Have I missed asking about firesetting throughout my years of practice? Have I been ignorant of a behavior with major human and financial costs? Is the prevalence different in Israel? Psychiatric morbidity is common among persons convicted of arson and among firesetters. In cases of arson the courts are inclined to call for psychiatric reports and it behooves us to develop a clear grasp of the motivation and dangerousness of particular patients. The book is helpful in teaching these distinctions. One of the last chapters of this interesting book focuses on treatment. Again, I was pleasantly surprised to learn that prevention programs are effective and put in place by many countries. All in all this is an interesting and educational book. I recommend it to all psychiatrists – to be read with a glass of sherry in front of a roaring fireplace during the winter months.

Firesetting and Mental Health: Theory, Research and Practice

Yoram Barak, Bat Yam

Geoffrey L. Dickens, Philip A. Sugarman and Theresa A. Gannon RCPsych Publications Paperback, 288 pages. ISBN: 978-1-908020-37-6 Price: £35

he publisher claims this book is “the only available specialist text on firesetting behavior in adults.” This may very well be true for adults, as the literature on firesetting in children and adolescents is advanced and rich with publications such as “Handbook on Firesetting in Children and Youth” and others. The authors wish to provide a “fresh, focused look at firesetting.” How relevant is this subject for the typical practicing psychiatrist? I confess I was surprised to learn that in a

Aging in Israel: Research, Policy and Practice Sara Carmel, editor New Brunswick, N.J.: Transaction Publishers, 2010, pp. 491

uring the course of the last 100 years western and westernized nations have been experiencing a process of rapid population aging. At the root of this process we can find several changing demographic trends, chief among which is the decline in the birth rate among affluent nations. This process is accelerated further by advances in modern medicine and healthcare which have significantly increased the average life span of people residing in developed states. 217

Book Reviews

These have resulted in major changes to the makeup of the age groups in the affected countries. The ratio of the age groups of children to young adults has dropped versus the age group of people over the age of 65. The State of Israel has not been exempted from this trend and is dealing with economic, social and healthcare challenges, not unlike those experienced by other developed nations facing similar demographic trends. In addition, Israel is also endowed with significant ethnic and cultural diversity which poses unique challenges. “Aging in Israel: Research, Policy and Practice” is a collection of papers covering a decade of publication from 1995 until 2005.The articles gathered are from diverse fields of study and from a variety of professional backgrounds, all touching on one aspect or another of the aging process. Some of the provided insights are of considerable value to readers interested in gaining more comprehensive understanding of the Israeli experiences of dealing with its uniquely diverse elderly population. The offering is of significant professional worth, since it provides meaningful analyses of the diverse mechanisms used by developed states to deal with the similar issues stemming from continued immigration and from an aging population. The compilation includes research on some uniquely Israeli phenomena such as aging in a kibbutz and the challenges of providing institutional care for elderly Holocaust survivors and for Israeli-Arab elders. In addition the editor has taken care to make the book accessible to an international audience by providing several comparative analyses of the social aspects of the aging process and the elderly population between Israel and other developed nations. Papers dealing with the specifics of caring for an elderly immigrant population and the predictors of longevity provide additional points of interest. The introduction by the editor is in itself a comprehensive and valuable review of the socio-demographic characteristics of the elderly population in Israel. “Aging in Israel: Research, Policy and Practice” provides valuable information to professionals and scholars involved with managing and studying the aging process. It is particularly recommended to those readers desiring to obtain a deeper understanding of the social research aspects of aging as well as the effects of an ageing population on a culturally and ethnically diverse society. This volume is of value, not only for readers based or focused on Israel, but through the inclusion of 218

comparative research papers, it can prove useful to an international reader audience with interest in longevity research and in the social and policymaking aspects of institutional care for the elderly. Shelly Tadger, Bat Yam

“Two Are Better Than One”: Case Studies in Brief Effective Therapy Seymour Hoffman Sky Books, 2011

“

Two are better than one for they get a greater return for their labor” (Eccleciastes, 4, 9).This quote from the foreword of this slim volume precedes the eleven chapters that describe in an absorbing manner the effective treatment by the author and his co-therapists of individuals, families and groups with a variety of symptoms, diagnoses and presenting problems, including anorexia, selective mutism, borderline personality and phobias. The book is divided into two parts. Part one presents case studies of the treatment of individuals, families and groups by two therapists using a dialectical co-therapy approach, while part two describes the brief successful interventions of consultants in cases of treatment impasses. The dialectical co-therapy approach involves two therapists who from the beginning of therapy take opposing views and roles in regard to the patient(s) until significant change is realized. The rationale and description of the treatment approach is clearly explained and detailed and one is readily impressed with its simplicity, parsimony and ability to achieve positive results in a relatively brief period of time which buttresses the author’s claim that in spite of the involvement of two therapists, the approach is economical. One can add that since cotherapy is frequently carried out by a senior and junior therapist (psychology intern, young social workers, psychiatric residents, etc), a unique and rich learning experience is also being provided. In the Dialectical Co-therapy Model presented by the author, the specific polarities that each patient experiences, that are at the root of his/her symptomatic behavior, are identified and mirrored by the co-therapists’ complementary roles/ interventions. As one dialectic is resolved, the method continues to focus on others which may emerge until change, growth and symptomatic relief are achieved.

Book Reviews

The orientation is eclectic and the interventions are highly creative, flexible, daring and frequently unconventional. Some therapists may be taken aback and critical of the manipulative aspects of the interventions and their influence on the therapeutic relationship. For example, I found it difficult to accept the attitude and behavior of the therapist toward the young girl that suffered from selective mutism as he consistently criticized and expressed lack of faith in her abilities and motivation to overcome her problems and symptoms. His critical and provocative attitude and behavior toward the patient seemed to me to be counter-therapeutic if not destructive. I was surprised to discover, that in the end, these “highly questionable” interventions produced positive change as she began speaking to her friends, strangers, and also to the two therapists. I found the discussion by the author on the use of manipulation in psychotherapy interesting and enlightening even though I subscribe to Chazan’s view that, “It is difficult to accept a method of therapy based on deliberate dishonesty. It is hard to believe that the deception has no long-term ill effects. Even if it succeeds, does the end justify the means?” (1). On the other hand, the author persuasively argues that treatment approaches that make use of placebos and paradoxical interventions popularized by such prominent strategic therapists as Haley, Madanes, Frankl, Zeig, Lankton, and Milton Erickson, to name a few, would be considered unethical and unacceptable. The paradoxical approach involves deceiving the client, as the therapist suggests a certain behavior but expects that the client will

do the opposite, in view of his resistance. To shore up his view, the author quotes Haley (2), who opines that if it is essential for the cure that deceit be used, it might be justified on that basis, and Foreman (3) who believes that paradox is an ethical technique with resistive clients and advises that the paradoxical approach be used only after other approaches have been unsuccessful. It is clear that the treatment approach presented can only be carried out by an experienced therapist working in tandem with a suitable colleague. Even though the author makes the point that the approach described is especially effective with taciturn, passive and highly resistant patients with limited motivation for psychotherapy, specific guidelines to determine when this treatment approach is indicated and when it is not, would have been helpful and appreciated. The innovative method of therapy presented in this slim book is an important addition to the armamentarium of therapists as it allows for treatment of patients who may be resistant to traditional modes of mental health treatment. The book is a pleasurable read and I highly recommend it to all therapists, irrespective of their orientation and discipline. 1. Chazan R. Book Review: Cotherapy with individuals, families and groups. Israel Journal of Psychiatry 2000; 37: 1. 2. Haley J. Problem-solving therapy. San Francisco: JosseyBass, 1976. 3. Foreman DM. The ethical use of paradoxical interventions in psychotherapy. Journal of Medical Ethics 1990; 16: 200-205. Hava Ben Shalom, Bnei Brak

219

‫לחדר מיון פסיכיאטרי בהשוואה ללקוחות שירותי רווחה‪.‬‬ ‫שיטה‪ :‬אוכלוסיית המחקר כללה ‪ 114‬חולים שפנו לחדר‬ ‫מיון במרכז לבריאות הנפש בבאר שבע ואושפזו שם‪ ,‬וכן‬ ‫‪ 555‬לקוחות של שירותי הרווחה באזור באר שבע‪ .‬הנשאלים‬ ‫התבקשו לענות על הגרסה המקוצרת של השאלון למדידת‬ ‫ביטחון תזונתי (‪.)Food Security Core Survey Module‬‬ ‫ממצאים‪ 40% :‬מהחולים שנבדקו ו–‪ 59%‬מלקוחות שירותי‬ ‫הרווחה דיווחו על מצב של חוסר ביטחון תזונתי‪ .‬נמצא כי‬ ‫החולים הפסיכיאטריים מסתייעים פחות ברשתות סיוע לא‬ ‫פורמליות (משפחה וקהילה) ופורמלית (קצבאות ביטוח לאומי)‬ ‫מאשר לקוחות שירותי הרווחה‪.‬‬ ‫מסקנות‪ :‬נמצא כי חולים פסיכיאטריים הם אוכלוסייה‬ ‫שהסיכון שלה לסבול מחוסר ביטחון תזונתי הוא גבוה‪ ,‬לכן יש‬ ‫צורך לשקול פיתוח של התערבויות מתוכננות לחיזוק רשתות‬ ‫התמיכה ולהנגשתן ושל תכניות הזנה ייחודיות‪.‬‬ ‫שינויים באיכות החיים וירידה‬ ‫במשקל לאחר ניתוח לקיצור‬ ‫קיבה לעומת תכנית הרזיה‬

‫ל‪ .‬קנטי‪ ,‬י‪ .‬אליצור‪ ,‬י‪ .‬קרני וא‪ .‬בארי‪ ,‬ירושלים‬

‫רקע‪ :‬מטרת המחקר הייתה להשוות בין תוצאות של ניתוח‬ ‫לקיצור קיבה לבין תכנית הרזיה ייחודית אשר כללה פעילות‬ ‫גופנית אינטנסיבית‪ ,‬שינוי התנהגותי וייעוץ תזונתי‪.‬‬ ‫שיטה‪ 44 :‬נבדקים שעברו ניתוח לקיצור קיבה ו–‪ 47‬נבדקים‬ ‫שהשתתפו בתכנית להורדה במשקל מילאו שאלון של איכות‬ ‫חיים (‪ ,)Short-Form Health Survey - SF-36‬שאלון בריאות‬ ‫נפשית (‪ )Mental Health Inventory - MHI‬ושאלון הערכה עצמית‬ ‫של רוזנברג (‪ )Rosenberg Self-Esteem Scale‬לפני הניתוח או‬ ‫הדיאטה ושנה לאחר מכן‪.‬‬ ‫תוצאות‪ :‬נבדקים לאחר ניתוח ירדו יותר במשקל‬ ‫(‪ )34.70%±11.94%‬בהשוואה לנבדקים בתכנית הרזיה‪ ,‬אם כי‬ ‫גם בקרב המשתתפים בתכנית ההרזיה הירידה במשקל הייתה‬ ‫משמעותית מבחינה קלינית (‪ .)9.23%±8.31%‬בקרב משתתפים‬ ‫שעברו ניתוח לקיצור קיבה חל שיפור משמעותי באיכות החיים‪,‬‬ ‫בבריאות הנפשית ובהערכה העצמית‪ .‬בקרב חברי הקבוצה‬ ‫שהשתתפה בתכנית להורדה במשקל חל שיפור באיכות החיים‬ ‫הן בציון הכולל והן בסולמות של תפקוד פיזי‪ ,‬תפיסה כללית של‬ ‫בריאות וחיוניות‪.‬‬ ‫מגבלות‪ :‬הקבוצות היו שונות מבחינת הנתונים הדמוגרפיים‬ ‫שלהן‪ ,‬והמעקב אחרי התכניות היה קצר ‪ -‬שנה בלבד‪.‬‬ ‫מסקנות‪ :‬תוצאות הניתוח היו באופן משמעותי טובות יותר‬ ‫גם במונחים של ירידה במשקל וגם במונחים של ההסתגלות‬ ‫הפסיכולוגית בהשוואה למשתתפים שהיו בעלי מוטיבציה‬ ‫גבוהה לקחת חלק בתכנית הרזיה חדשנית‪.‬‬

‫דיווחיהם של פסיכיאטרים ישראלים על יכולתם‬ ‫לטפל באנשים עם מוגבלות שכלית ואבחנה פסיכיאטרית‬ ‫שירלי ורנר‪ ,‬יצחק לבב‪ ,‬מייק סטבסקי ויעקב פולאקביץ‬

‫רקע‪ :‬אמנת האו"ם בדבר זכויותיהם של אנשים עם מוגבלויות‬ ‫מבססת את זכותם של אנשים עם מוגבלות שכלית לקבלת‬ ‫שירותי בריאות נפש ברמה גבוהה‪ .‬יחד עם זאת‪ ,‬הספרות מעלה‬ ‫ספק בדבר יכולתם של פסיכיאטרים לתת שירות ברמה זו‪.‬‬ ‫במחקר זה נבחן דיווח עצמי של פסיכיאטרים באשר להכשרתם‪,‬‬ ‫לרמת הידע ולמיומנויות שלהם בטיפול באנשים עם מוגבלות‬ ‫שכלית‪ ,‬כמו גם את קיומם של מקורות לימוד בתחום‪.‬‬ ‫שיטה‪ 256 :‬פסיכיאטרים העובדים בשירות הציבורי מילאו‬ ‫שאלון מחקר למילוי עצמי‪.‬‬ ‫ממצאים‪ :‬המשיבים דיווחו על מחסור רב בהכשרה‪ .‬כמו‬ ‫כן‪ ,‬המשיבים דיווחו על תפיסה עצמית של רמה ממוצעת של‬ ‫ידע ומיומנויות בתחום‪ ,‬אך נמצא כי הידע האובייקטיבי‪ ,‬כפי‬ ‫שנמדד על–ידי תיאור מקרה‪ ,‬היה נמוך בקרב כל הפסיכיאטרים‪,‬‬ ‫ובייחוד בקרב פסיכיאטרים כלליים‪.‬‬ ‫דיון‪ :‬הממצאים מצביעים על הצורך המיידי בהגברת רמת‬ ‫הידע והמיומנות של פסיכיאטרים בתחום זה ועל הצורך‬ ‫בשיפור רמת השירותים הניתנים לאנשים עם מוגבלות שכלית‬ ‫ומחלות פסיכיאטריות‪ .‬המאמר מספק כמה אפשרויות לשיפור‬ ‫המצב הקיים‪.‬‬ ‫הקשר שבין סיטואציית ההישרדות של ההורה‬ ‫(בגפו או עם קרובי משפחה) בזמן השואה‬ ‫לבין רמות החרדה והדיכאון של צאצאיו‬ ‫י‪ .‬וילצ'יק־אביעד‪ ,‬ד‪ .‬קואנקה־שיבי‪ ,‬י‪ .‬ששון‪ ,‬אריאל‬

‫מאמר זה בחן את רמות החרדה והדיכאון של בני הדור השני‬ ‫לשואה‪ ,‬כפונקציה של גיל ההורה הניצול‪ ,‬מינו וסיטואציית‬ ‫ההשרדות (בגפו או עם קרובי משפחה בזמן השואה)‪.‬‬ ‫נבדקים‪ 180 :‬נבדקים‪ ,‬בני הדור השני‪ 142 .‬צאצאים לשני‬ ‫הורים ניצולי שואה‪ ,‬כ–‪ 38‬צאצאים להורה ניצול אחד‪.‬‬ ‫ממצאים‪ :‬צאצאים לאמהות שהיו בנות ‪ 18‬ומטה ובגפן בזמן‬ ‫השואה הציגו את רמת החרדה והדיכאון הגבוהים ביותר בהשוואה‬ ‫לצאצאים לאמהות שהיו בנות ‪ 18‬ומטה אך היו במחיצת בני‬ ‫משפחה בתקופת המלחמה‪ .‬צאצאים לאמהות מעל גיל ‪ 19‬אשר היו‬ ‫בתקופת המלחמה לבדן או במחיצת קרוב משפחה‪ ,‬הציגו את רמת‬ ‫החרדה והדיכאון הנמוכים ביותר‪ .‬צאצאים לאבות ניצולי שואה‬ ‫לעומת זאת‪ ,‬המשתנה המנבא הרלוונטי היחידי היה השהות בגפם‬ ‫ללא קשר לגיל ההורה בזמן השואה‪.‬‬ ‫סיכום‪ :‬מחקר זה מחדד את הקשר שבין סיטואציית‬ ‫ההישרדות של ההורה לבין סימפטומים של חרדה ודיכאון‬ ‫בקרב ילדיו‪ ,‬בני הדור השני‪.‬‬

‫‪220‬‬

‫וכיצד השפיע עליהם יישום התערבות לשיפור החוסן האישי על‬ ‫ידי מורים‪.‬‬ ‫שיטה‪ 1,372 :‬ילדים משתי הקבוצות האתניות עברו הערכה‬ ‫של אירועי דחק בחיים‪ ,‬של סימפטומים ושל דאגה הורית‬ ‫לגבי הסתגלותם‪ .‬ההערכה נעשתה לפני התכנית במשך ‪16‬‬ ‫שבועות(‪ )T1‬ולאחר השלמתה (‪.)T2‬‬ ‫תוצאות‪ :‬הילדים הערבים דיווחו על סימפטומים חמורים יותר‬ ‫ב–‪ .T1‬בשלוש הקבוצות חלה ירידה משמעותית בסימפטומים‬ ‫ב–‪ ,T2‬לאותה הרמה‪ .‬שתי הקבוצות האתניות היו שונות ברמת‬ ‫הדאגה ההורית ובאופן שבו אירועי חיים מלחיצים השפיעו על‬ ‫הסימפטומים של הילדים‪.‬‬ ‫מסקנות‪ :‬תכניות בבתי־הספר שבמסגרתן מורים משמשים‬ ‫כמתווכים קליניים‪ ,‬יכולות להיות מודל בין תרבותי חסכוני‬ ‫ובעל ערך להתערבות לאחר טראומה המונית‪ ,‬הממתן את‬ ‫הפגיעות של מיעוטים אתניים‪.‬‬ ‫נבאי איכות חיים מקצועית בקרב רופאים באזור‬ ‫עימות‪ :‬תפקידם של גורמי סיכון והגנה‬ ‫י‪ .‬הבר‪ ,‬י‪ .‬פלגי‪ ,‬י‪ .‬חממה־רז‪ ,‬ע‪ .‬שרירא ומ‪ .‬בן־עזרא‪ ,‬תל־אביב‬

‫רקע‪ :‬בניגוד למקומות אחרים בעולם המערבי‪ ,‬רופאים ישראלים‬ ‫נחשפים לקרבנות טרור ומלחמה ‪ -‬אזרחים‪ ,‬חיילים או אנשי‬ ‫כוחות הביטחון‪ .‬במקרים מסוימים‪ ,‬הנפגעים הם קרובי משפחה‬ ‫או חברים של הרופאים המטפלים‪ .‬יתרה מזאת‪ ,‬לעתים במקרים‬ ‫של עימות מזוין הנובעים ממלחמה או טרור‪ ,‬יש איום ישיר על‬ ‫חיי הרופאים ובני משפחותיהם‪ .‬גוף הידע הבודק את הגורמים‬ ‫הקשורים לאספקטים שונים של איכות חיים כמו שחיקה‪,‬‬ ‫תשישות החמלה וסיפוק מהחמלה במקרים אלו‪ ,‬לוקה בחסר‪.‬‬ ‫מטרה‪ :‬במחקר זה נערכה השוואה בין סדרה של גורמי סיכון‬ ‫וגורמי הגנה הקשורים לשחיקה‪ ,‬תשישות החמלה וסיפוק מהחמלה‪.‬‬ ‫שיטה‪ :‬מדגם של כ–‪ 97‬רופאים ענה על כמה שאלונים שבהם‬ ‫נבדקו הגורמים שתוארו לעיל ושימשו כגורמים מנבאים (גיל‪,‬‬ ‫מין‪ ,‬מצב משפחתי‪ ,‬סימפטומים של הפרעה פוסט–טראומטית‪,‬‬ ‫סימפטומים דיכאוניים‪ ,‬סימפטומים דיסוציאטיביים‪ ,‬שביעות‬ ‫רצון מהחיים‪ ,‬תפיסת היעילות העצמית ותפיסת התמיכה‬ ‫המשפחתית) תוך שימוש ברגרסיות מרובות‪.‬‬ ‫תוצאות‪ :‬ממצאי המחקר מראים כי רמות גבוהות של‬ ‫סימפטומים פוסט–טראומטיים קשורות לרמות גבוהות של‬ ‫תשישות החמלה (‪ ,)β=.594; t=4.419; p<.001‬ורמה גבוה של‬ ‫שביעות רצון מהחיים קשורה לרמה נמוכה יותר של שחיקה‬ ‫(‪ .)β=-.436; t=-4.293; p<.001‬תוצאות דומות נצפו במקרה של‬ ‫רמות נמוכות של תפיסת התמיכה המשפחתית (‪β=-.203; t=-‬‬ ‫‪ .)2.533; p<.05‬נמצא קשר בין רמה גבוהה של תפיסת היעילות‬ ‫העצמית (‪ )β=.298; t=2.702; p<.01‬לרמות גבוהות של שחיקה‪.‬‬ ‫כמו כן‪ ,‬רמה גבוהה של שביעות רצון נמצאה קשורה לרמה גבוהה‬ ‫של סיפוק מהחמלה (‪.)β=.493; =4.419; p<.001‬‬ ‫מסקנות‪ :‬תוצאות המחקר מעלות את הסברה ששביעות‬ ‫רצון מהחיים היא מנבא הקשור לשחיקה ולסיפוק מהחמלה‪.‬‬ ‫‪221‬‬

‫תוצאות אלו מוצגות לאור החשיבות של שביעות רצון מהחיים‬ ‫כגורם מגן מפני שחיקה‪ ,‬וההשלכות שיש לכך על רופאים ועל‬ ‫קביעת מדיניות בבית החולים‪.‬‬ ‫סומטיזציה וסימפטומים פסיכיאטריים‬ ‫בקרב אחיות שנחשפו ללחצים‬ ‫הקשורים לעימות צבאי‬

‫מ‪ .‬בן־עזרא‪ ,‬י‪ .‬פלגי‪ ,‬ע‪ .‬שרירא וי‪ .‬חממה־רז‪ ,‬אריאל‬

‫מטרה‪ :‬הספרות המחקרית העוסקת בתגובות של אחיות‬ ‫שנחשפו ללחצים הקשורים לעימות צבאי היא מצומצמת‪.‬‬ ‫מטרת שני המחקרים היא להשוות בין אחיות שנחשפו לירי‬ ‫רקטות לבין אחיות שלא נחשפו לירי רקטות בכל הקשור לרמת‬ ‫הסומטיזציה והסימפטומים הפסיכיאטריים‪.‬‬ ‫שיטה‪ :‬שני מחקרים נערכו בשנת ‪ 2009‬וכללו שני מדגמים‬ ‫אקראיים של אחיות בתי חולים (אחיות שנחשפו ללחצים‬ ‫בעקבות עימות צבאי ואחיות שלא נחשפו ללחצים כאלו)‪.‬‬ ‫המחקר הראשון נערך בזמן מבצע עופרת יצוקה‪ ,‬והשני נערך‬ ‫כשישה חודשים לאחר מכן‪ .‬המחקר הוא מחקר רוחב חוזר‪.‬‬ ‫תוצאות‪ :‬במחקר הראשון בקרב אחיות שנחשפו לירי רקטות‬ ‫נראו רמות גבוהות יותר של סימפטומים פוסט–טראומטיים‪,‬‬ ‫סימפטומים של דיכאון וסימפטומים פסיכוסומטיים בהשוואה‬ ‫לקבוצת הביקורת‪ .‬במחקר השני לא נמצאו הבדלים בין האחיות‬ ‫שנחשפו לירי רקטות לאלו שלא נחשפו לכך במדדי הפוסט–‬ ‫טראומה והדיכאון‪ ,‬אך אצל האחיות שנחשפו לירי רקטות נמצאו‬ ‫רמות גבוהות יותר של סימפטומים סומטיים (‪ 10.68‬לעומת‬ ‫‪ .)5.62‬יתרה מזאת‪ ,‬תוצאות ניתוח השונות הראו אינטראקציה‬ ‫של חשיפה ‪ X‬מחקר (מדגם) (;‪F=12.838; p<0.001; ηp2=.076‬‬ ‫‪ )Observed power=0.945‬בכל הקשור לסימפטומים סומטיים‪.‬‬ ‫מסקנות‪ :‬תוצאות המחקר עולות בקנה אחד עם מודל‬ ‫ההתמודדות עם לחץ של סילייה והמודל האלוסטטי‪ .‬ניתן‬ ‫לשער שאחיות שנחשפו ללחץ חמור ומתמשך שהסתיים‪,‬‬ ‫ושעברו ממצב של מותשות בעת לחץ רב (הכולל לחצים נוספים‬ ‫על אלו המאפיינים אחיות בדרך כלל)‪ ,‬לרמת לחץ נמוכה יותר‬ ‫(שאינה כוללת את החשיפה המתמשכת ללחץ חמור של ירי‬ ‫רקטות)‪ ,‬יעברו ממצב של לחץ חמור למצב בר‪-‬התמודדות‪.‬‬ ‫ביטחון תזונתי בקרב צרכני שירותים‬ ‫פסיכיאטריים ולקוחות שירותי רווחה בישראל‬ ‫ר‪ .‬קאופמן‪ ,‬י‪ .‬מירסקי‪ ,‬א‪ .‬ויצטום ונ‪ .‬גריסרו‪ ,‬באר שבע‬

‫רקע‪ :‬בשנים האחרונות התפתחה בישראל בעיה של חוסר‬ ‫ביטחון תזונתי ורעב‪ .‬כ–‪ 22%‬ממשקי הבית בישראל סובלים‬ ‫מהבעיה‪ ,‬רובם משכבות מצוקה‪ .‬על אף שאנשים הסובלים‬ ‫מהפרעות פסיכיאטריות קשות שייכים בדרך כלל לשכבות‬ ‫מצוקה ולכן נמצאים בסיכון לסבול מחוסר ביטחון תזונתי‪,‬‬ ‫הפרקטיקה והמחקר בתחום התעלמו מן התופעה עד כה‪.‬‬ ‫מטרות‪ :‬כדי לעורר את המודעות לנושא‪ ,‬נבחנו במחקר זה‬ ‫חוסר הביטחון התזונתי ודרכי ההתמודדות עמו בקרב פונים‬

‫כתב עת ישראלי‬ ‫לפסיכיאטריה‬ ‫תקצירים‬ ‫הקשר בין תסמיני הפרעת דחק פוסט־טראומטית‬ ‫לתסמיני הפרעת דחק קיצוני שלא הוגדרה אחרת‬ ‫לאחר שבי מלחמה‬ ‫ג‪ .‬זרח וז‪ .‬סולומון‪ ,‬אריאל‬

‫רקע‪ :‬שבי מלחמה ידוע כגורם פתוגני לתסמיני הפרעת דחק‬ ‫פוסט–טראומטית (‪ )PTSD‬ולתסמיני הפרעת דחק קיצוני שלא‬ ‫הוגדרה אחרת (הד"ק)‪ ,‬הידועה גם בשם הפרעת דחק פוסט–‬ ‫טראומטית מורכבת‪ .‬יחד עם זאת‪ ,‬הקשר בין שתי ההפרעות‬ ‫הללו נותר לא ברור‪ .‬בעוד חוקרים אחדים מניחים כי שתי‬ ‫האבחנות הללו חופפות וחולקות אותם מנבאים‪ ,‬חוקרים‬ ‫אחרים מניחים ששתי ההפרעות בלתי־תלויות ושונות הן‬ ‫מבחינת מקורותיהן והן מבחינת הפגיעה התפקודית שהן‬ ‫גורמות לה‪ .‬במחקר זה ביקשו החוקרים להעריך את תסמיני‬ ‫‪ ,PTSD‬את תסמיני הד"ק ואת קשרי הגומלין ביניהן בקרב פדויי‬ ‫שבי וקבוצת השוואה מותאמת של לוחמים לשעבר‪ ,‬שלושים‬ ‫וחמש שנים לאחר סיום המלחמה‪.‬‬ ‫שיטה‪ :‬המדגם כלל שתי קבוצות של לוחמים לשעבר‬ ‫ממלחמת יום הכיפורים ‪ -‬פדויי שבי (‪ 176‬לוחמים) וקבוצת‬ ‫השוואה של לוחמים לשעבר שלא נפלו בשבי (‪ 118‬לוחמים)‪.‬‬ ‫תסמיני ‪ PTSD‬והד"ק‪ ,‬גורמי דחק הקשורים בקרב ובשבי וכן‬ ‫דרכי התמודדות בשבי הוערכו באמצעות שאלונים לדיווח‬ ‫עצמי בשנת ‪.2008‬‬ ‫תוצאות‪ :‬פדויי שבי דיווחו על מספר גדול יותר של תסמיני‬ ‫‪ PTSD‬ועל שיעורים גבוהים יותר של תסמיני ‪ PTSD‬שמילאו את‬ ‫הקריטריונים לאבחנת ההפרעה‪ ,‬לעומת לוחמים לשעבר‪ .‬כמו‬ ‫כן‪ ,‬פדויי שבי דיווחו על מספר גדול יותר של מקבצי תסמיני‬ ‫הד"ק ועל שיעורים גבוהים יותר של תסמיני הד"ק שמילאו‬ ‫את הקריטריונים לאבחנת הד"ק‪ .‬נוסף לכך נמצא קשר חיובי‬ ‫בין מקבצי תסמיני ‪ PTSD‬למקבצי תסמיני הד"ק‪ .‬לסיום‪ ,‬אבדן‬ ‫משקל וסבל נפשי בשבי‪ ,‬כמו גם אבדן שליטה רגשית ואומדן‬ ‫סכום תסמיני הד"ק ניבאו את אומדן סכום תסמיני ה־‪.PTSD‬‬ ‫יחד עם זאת‪ ,‬רק אומדן סכום תסמיני ‪ PTSD‬נמצא מנבא את‬ ‫אומדן סכום תסמיני הד"ק‪.‬‬ ‫מסקנות‪ :‬מחקר זה הדגים את המחיר הכבד והנרחב של‬ ‫שבי מלחמה שלושה עשורים לאחר שחרור פדויי השבי‪.‬‬ ‫לקראת פרסום המהדורה החמישית של המדריך האבחוני‬

‫‪israel journal of‬‬

‫‪psychiatry‬‬ ‫כרך ‪ ,50‬מס' ‪2013 ,3‬‬

‫והסטטיסטי להפרעות נפש‪ ,‬המחקר מצביע על מספר גדול‬ ‫של מקבצי תסמיני הד"ק במקביל לתסמיני ‪ PTSD‬בקרב פדויי‬ ‫שבי‪ ,‬ומודגשים בו יחסי הגומלין המורכבים בין שתי קטגוריות‬ ‫האבחון הללו‪ .‬ניתן לראות את תסמיני הד"ק כמאפיינים נלווים‬ ‫ל–‪ ,PTSD‬אך האחרונים הם גורם מרכזי בתסמיני הד"ק‪.‬‬ ‫ההשפעה של חשיפה מתמשכת לאירועי‬ ‫טרור על תפקוד אמהות וילדיהן‬

‫מ‪ .‬שחורי־ביטון‪ ,‬אריאל‬

‫מחקרים שונים מצביעים על ההשפעה הפתוגנית של חשיפה‬ ‫לאירועי טרור‪ .‬מרבית המחקרים התמקדו בהשפעה של חשיפה‬ ‫לאירועים טראומטיים ספציפיים‪ .‬מחקר זה התמקד בהשפעה‬ ‫של חשיפה מתמשכת לאירועי טרור (בעיקר חשיפה ממושכת‬ ‫לירי טילים)‪ .‬מטרת המחקר הייתה לבחון את ההשפעה של‬ ‫אופן ההתמודדות של אמהות עם החשיפה לאירועי טרור על‬ ‫ילדיהן‪ .‬נבחנו הקשרים בין סימפטומים פוסט–טראומטיים של‬ ‫אמהות לבין אלו של ילדיהן כמו גם הקשר של סימפטומים‬ ‫אלו לבעיות התנהגות של הילד ורמת הפחד הנחווית‪ .‬במחקר‬ ‫השתתפו ‪ 152‬אמהות ו–‪ 152‬ילדיהן‪ ,‬הגרים על הגבול הדרומי‬ ‫של ישראל‪ .‬מהממצאים עולה כי ככל שרמת החשיפה של‬ ‫הילד לאירועי טרור גבוהה יותר וככל שרמת הפחד שלו‬ ‫והסימפטומים הפוסט–טראומטיים של האם חמורים יותר‪,‬‬ ‫כך רמת המצוקה שלו (תסמינים פוסט–טראומטיים) גבוהה‬ ‫יותר‪ .‬נוסף לכך‪ ,‬נמצא כי בעיות בהתנהגות ובעיות חברתיות‬ ‫של הילדים קשורות אף הן לרמת הסימפטומים הפוסט–‬ ‫טראומטיים של האמהות‪ .‬תוצאות המחקר נדונו לאור‬ ‫החשיבות של הפרשנות הסובייקטיבית של הפרט לאירועים‬ ‫שהוא נחשף אליהם‪ .‬ממצאי המחקר מצביעים על הצורך‬ ‫במחקרים נוספים שיבחנו משתנים קוגניטיביים והקשרים‬ ‫חברתיים נוספים‪.‬‬ ‫תגובה פוסט־טראומטית של ילדים יהודים‬ ‫וערבים שנחשפו להתקפת טילים‪,‬‬ ‫לפני ואחרי התערבות של מורים‬

‫ל‪ .‬וולמר‪ ,‬ד‪ .‬חמיאל‪ ,‬מ‪ .‬סלואן‪ ,‬מ‪ .‬פייאנס‪ ,‬מ‪ .‬פיקר‪ ,‬ט‪ .‬אדיב‬ ‫ונ‪ .‬לאור‪ ,‬תל־אביב‬

‫רקע‪ :‬השתייכות למיעוט אתני היא גורם סיכון עבור ילדים‬ ‫שנחשפו לטראומה‪ .‬מחקר זה בדק כיצד הושפעו קבוצה של‬ ‫תלמידים יהודים ושתי קבוצות של תלמידים ערבים בישראל‬ ‫מחשיפה להתקפות טילים בזמן מלחמת לבנון בשנת ‪,2006‬‬ ‫‪222‬‬