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Zahava Solomon, PhDTel Aviv University
I-Core for Mass Trauma ResearchVeterans' Mental Health Conference: Evidence Innovation and Practice London
March 14, 2019
From the Front Line to the Home Front: Three decades of veterans research
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…and that was the war in Her Majesty's Armed Forces. Really exciting, don’t you think?
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RESEARCH AIMS
•Does the war end when the shooting stops?
• Is CSR a normal and short-lived reaction to an abnormal situation?
•Are ex-POWs ever really free from captivity?
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STUDY: 1
Traced the 20-year longitudinal course of CSR casualties and matched controls and their spouses. Four assessments were conducted 1, 2, 3 and 20 years after the 1982 Lebanon War.
STUDY 2:
Ex-POWs, decorated heroes and controls of the 1973 Yom Kippur War, with four assessments 18, 30, 35 and 42 years after captivity.
Spouses assessed at 3 time points.
Adult offspring assessed once.
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CSR STUDY
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COMBAT STRESS REACTION
• CSR is a labile, polymorphic phenomenon marked by a wide variety of somatic and affective manifestations (e.g., restlessness, dissociation, withdrawal, startle reactions)
• Diagnosis based on functional impairment
Solomon, Z. (1993). Combat stress reaction: The enduring toll of war. New York: Plenum.
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COURSE OF PTSD BY STUDY GROUP AND TIME
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PTSD RATES BY TIME AND GROUP
CSR Group Non-CSR Group
CSR odds: 8.6 : 11.6 : 9.6 : 4.7
PTSD in one measurement point PTSD in two measurement points
PTSD in three measurement points PTSD in four measurement points
No PTSD
(Solomon & Mikulencer, 2006, AJP)
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PTSD TRAJECTORIES AND SEVERITY
Chronic – (3 months or more)
Delayed onset – 23.8% non-CSR (20 years), less severe than chronic
Recovered
Resilient
Reactivated
(Solomon & Mikulincer, 2006, AJP)
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Trauma is likened to cancer:
It metastasizes, and often has co-morbidities
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CO-MORBIDITY
The CSR group had significantly higher rates ofcomorbidity (PTSD with depression and anxiety) thanthe non-CSR group
PTSD accompanied by very high rates of comorbiddepression (81% vs 15.5%) and anxiety (69.7% vs 29.5%)
CSR/PTSD increased risk for comorbidity
(Ginzburg et al., 2010, Journal of Affective Disorders)
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SOCIAL FUNCTIONING
Across all 4 points of measurement, CSR veterans
reported more problems in social functioning than
non-CSR veterans (e.g., work, social relationships)
CSR casualties with PTSD reported particularly
impaired functioning
(Solomon & Mikulincer, 2007, JCCP)
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PHYSICAL HEALTH
20 years after the war, both CSR and PTSD were associated with:
Self-rated health
Chronic diseases
Physical symptoms
Health related risk behaviors (e.g., smoking)
(Solomon et al., 2006, J. Nerv. & Ment. Disease)
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CSR AND MORTALITY
(Solomon, Levin, Crompton, & Ginzburg, Health Psychology, In press)
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IS CSR SHORT-LIVED?
• CSR is a precursor for a profound, prolonged, and deeply entrenched psychiatric and somatic impairment
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WAR CAPTIVITY STUDY
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STRESSORS OF CAPTIVITY
Solitary confinement
Harsh physical conditions
Brutal torture
Oppression and humiliation
Interrogations
Total control by perpetrator
Issues of failure, betrayal
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PTSD RATES
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TRAJECTORIES OF PTSD
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PSYCHIATRIC CO-MORBIDITY
As in the CSR study, PTSD was the most common and conspicuous disorder, but not the sole psychiatric manifestation
High rates of co-morbidity – particularly depression, OCD, and anxiety
Higher co-morbidity implicated in greater impairment and distress
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HEALTH RISK BEHAVIORS
0
5
10
15
20
25
30
35
Alcohol Smoking Drugs
14.1
33.7
5.5
9.8
28.3
3.5
exPOWs
Controls
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SOMATIC MORBIDITY IN EX-POWS
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Sense of foreshortened future
Expect that their health will deteriorate in the future
Subjective age: feel/look/act older than chronological age
ACCELERATED/PREMATURE AGING
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SUICIDAL IDEATION
Ex-POWs’ unconditional LTMs fit the data adequately [χ² (1) = 3.08, p =.07, CFI = .93, NFI = .91, RMSEA = .13].
Controls’ unconditional LTMs fit the data adequately [χ² (1) = .61, p= .43, CFI = 1, NFI = .98, RMSEA = 0].
Ex-POWs’ rate of change in SI significantly differed from those for controls by virtue of increasing over time (2 = 36.80, df = 1, p < .001).
(Zerach, Levi-Belz, & Solomon, 2014, SPR)
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ALL CAUSE MORTALITY
35-years after the war, ex-POWs’ all cause mortality rate was 4 times higher than controls
42-years after the war mortality rate was 1.66 times higher than controls
ControlsEx-POWs
Cu
mu
lati
ve
Su
rviv
al
Age at Death (Solomon et al., 2014, J. Behav. Med.)
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TELOMERES
Telomeres are repetitive TTAGGG sequences located at the chromosomal ends, which confer genomic stability. In each cell division, telomeres progressively shorten, denoting an inverse correlation between telomere length and human age.
Apart from normal ageing, leukocyte telomere shortening is also correlated with life events, external stressors and lifestyle, such as chronic illness, disability, nutrition and smoking.
Augmented telomere erosion has emerged as a robust indicator of the human biological age, and a significant marker of cellular senescence.
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TELOMERE LENGTH
(Solomon et al., 2017, Psychoneuroendocrinology)
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PTSD TRAJECTORIES AND TELOMERE LENGTH
(Solomon et al, 2017, Psychoneuroendocrinology)
Late onset Recovered Chronic Resilient
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THE BODY KEEPS SCORE - PAIN
*p<0.05, **p<0.01
(Defrin, Ginzburg, Mikulincer Solomon, 2014, EJP)
*
**
0
20
40
60
80
100
Chronic pain
Pre
vale
nce
(%
)
*
**
*
**
0
5
10
15
20
25
30
PRI NWC Pain areasA
vera
ge v
alue
s exPOWs
Controls
*
**
**
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PTSD TRAJECTORIES AND PAIN
0
5
10
15
20
25
30
35
Group
Chro
nic
pai
n inte
nsi
ty (PR
I)
Controls
Resilient
Delayed
Chronic
*****
(Defrin, Lahav, Solomon 2017, J Pain)
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IMPAIRED FUNCTIONING
High rates are unemployed
80% report interpersonal difficulties at work
70% report severe difficulties that undermine social ties
Severe problems in family relationships
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“‘Secondary traumatization’ refers to the
traumatization of persons in close proximity to
victims of traumatic events, who suffer from a range
of emotional symptoms” (Figley, 1983)
SECONDARY TRAUMATIZATION
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SECONDARY TRAUMATIZATION IN VETERANS' WIVES IN BOTH STUDIES
1. PTSD-like symptoms
2. Somatic complaints and SRH
3. Comorbidity: Depression, GAD
4. Impaired social functioning
5. Impaired sexual satisfaction
(Zerach, Greene, & Solomon, 2015, Journal of Health Psychology; Bachem, Levin, &
Solomon, submitted; Greene, Lahav, Bronstein, & Solomon, 2014, Journal of Family
Psychology)
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RECIPROCITY OF TRAUMATIC STRESS
(Bachem, Levin, Zhou, Zerach, & Solomon, 2017, JMFT; Levin, Bachem, & Solomon, 2016, Family Process)
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SPILLOVER OR COMPENSATION?
In both husbands and wives, lower marital adjustment predicted lower parental functioning, supporting the spillover hypothesis
(Levin, Bachem, & Solomon, 2016, Family Process)
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AN INTEGRATIVE MODEL OF MUTUAL EFFECTS WITHIN FAMILIES OF TRAUMATIZED VETERANS
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OFFSPRING RAMIFICATIONS
• Offspring of traumatized veterans are at an increased risk for:
• Psychological distress
• Increased anxiety in the face of adversity
• Survivor guilt
• Difficulties in regulating and coping with aggression
• Behavioral problems
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OFFSPRING PTSD SYMPTOMS ACCORDING TO FATHERS' CAPTIVITY AND PTSD
0
1
2
3
4
5
6
Combatant father with noPTSD
Ex-POW father with no PTSDEx-POW father with PTSD
2.492.68
3.80
***
***
(Zerach, Kanat-Maymon, Aloni, & Solomon, 2016, JAD)
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WHY IS THEIR DISTRESS SO ENTRENCHED?
Accumulation of stressors
(Israeli security situation)
Failure and betrayal
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The effects of trauma are broad and long lasting: Decades after the wars end, traumatized veterans, their spouses, and offspring are at an increased risk for distress and illness
Intervention should target the family unit and account for societal acknowledgement
CONCLUSIONS
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PRACTICAL IMPLICATIONS
An establishment of a CSR unit that provides free of charge, life-long treatment for veterans
Recognition of Secondary Traumatization in spouses and offspring and the provision of treatment
Evaluation of treatment modalities: Front Line Treatment (Proximity-Immediacy-Expectancy)
Evaluation of Department of Defense procedures for treatment (e.g., front-line), rehabilitation and compensation
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PRACTICAL IMPLICATIONS
Formation of self-help organization – "Awake at
Night"
Department of Defense outreach to all ex-POWS
Advocacy for ex-POWS recognition and rights
(Knesset, Public committees, President of Israel)
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