A longitudinal study of changes in psychological responses to continuous terrorism.

OBJECTIVE: The impact of ongoing terror over time has received little attention. This study assesses longitudinally prevalence and predictors of posttraumatic stress symptoms' trajectories, namely resistance, resilience, late-onset and chronicity in the course of intensive and ongoing terror. METHOD: Two surveys were performed at a two-year interval among 153 Jewish Israeli adults. RESULTS: Results show probable PTSD prevalence, number of traumatic stress related symptoms (TSRS), and rate of severe posttraumatic symptomatology (PTSS) to increase over time (from 18.2% to 31.2%). With this, many (66.7% of those with PTSD and 39.3% of those with PTSS at wave 1) recovered. Late-onset of severe PTSS (19.6% of the sample) was predicted by income reduction, a major lifetime traumatic event, sense of threat, dissociation, coping via disengagement and low mood. Chronicity was predicted by sense of threat, pessimism, dissociation and disengagement. CONCLUSIONS: Continuous exposure to terror has a strong negative impact on mental health. Secondly, even within a chronic situation of terror, a large proportion of individuals with elevated levels of posttraumatic symptomatology recover over time; third, prolonged exposure to terror may also exacerbate symptomatology, but not per-se trigger new PTSD cases.

Protective factors and predictors of vulnerability to chronic stress: a comparative study of 4 communities after 7 years of continuous rocket fire.

Many communities across the world are chronically exposed to extreme violence. Responses of residents from a city and rural community in Southern Israel, both exposed to 7 years of daily mortar fire, were compared to residents from demographically, socio-economically and geographically comparable non-exposed control samples to examine protective factors and predictors of vulnerability to chronic war-related attacks. Samples from a highly exposed city (Sderot) and a highly exposed rural community region (Otef Aza), along with a demographically comparable comparison non-exposed city (Ofakim) and non-exposed rural community region (Hevel Lachish), were obtained in 2007 using Random Digit Dialing. In total, 740 individuals (81.8% participation rate) were interviewed about trauma exposure, mental health, functioning and health care utilization. In the highly exposed city of Sderot, 97.8% of residents had been in close proximity to falling rockets; in the highly exposed rural community region of Otef Aza, 95.5% were similarly exposed. Despite exposure to chronic rocket attacks, residents of Otef Aza evidenced little symptomatology: only one person (1.5%) reported symptoms consistent with probable posttraumatic stress disorder (PTSD) and functioning levels did not differ from those of non-exposed communities. In contrast, posttraumatic stress (PTS), distress, functional impairment and health care utilization were substantially higher in the highly exposed city of Sderot than the other three communities. Lack of resources was associated with increased vulnerability among city residents; predictors of PTS across all samples included being female, older, directly exposed to rockets, history of trauma, suffering economic loss, and lacking social support. Increased community solidarity, sense of belonging and confidence in authorities may have served a protective function for residents of rural communities, despite the chronic attacks to which they were exposed.

Attitudes, opinions, behaviors, and emotions of the nursing staff toward patient restraint.

Physical restraints are used as a psychiatric intervention to protect psychiatric inpatients from self-harm or harm to others, by securing a safe environment for the patients and staff. We examined nurses' attitudes, environmental concerns, and emotional responses to physical restraint of psychiatric inpatients, using a questionnaire we constructed expressly for this study. Nurses reported that the main criteria for restraint were endangerment of the patient's self or surroundings. Bothersome actions and environmental conditions also significantly impacted nurses' decisions to physically restrain patients. Emotional reactions to restraining procedures as experienced by staff and as perceived for patients were generally negative. Nurses should be trained to deal with violent patients, establish limits, and recognize the therapeutic aspect of restraints in order to respond assertively.

Feeling the real world: limbic response to music depends on related content.

Emotions are often object related--they are about someone or something in the world. It is yet an open question whether emotions and the associated perceptual contents that they refer to are processed by different parts of the brain or whether the brain regions that mediate emotions are also involved in the processing of the associated content they refer to. Using functional magnetic resonance imaging, we showed that simply combining music (rich in emotion but poor in information about the concrete world) with neutral films (poor in emotionality but rich in real-world details) yields increased activity in the amygdala, hippocampus, and lateral prefrontal regions. In contrast, emotional music on its own did not elicit a differential response in these regions. The finding that the amygdala, the heart of the emotional brain, responds increasingly to an emotional stimulus when it is associated with realistic scenes supports a fundamental role for concrete real-world content in emotional processing.

Does psychiatric comorbidity affect drug abuse treatment outcome? A prospective assessment of drug abuse, treatment tenure and infectious diseases in an Israeli methadone maintenance clinic.

OBJECTIVE: The influence of psychiatric comorbidity in drug addicts on therapeutic outcome is an important unresolved issue. We studied the links between patterns of psychiatric comorbidity and psychological distress with treatment outcome variables. METHOD: 151 methadone maintenance patients underwent a structured clinical interview, twice-weekly urinalysis for traces of drugs of abuse, and completed psychological distress and risk-taking questionnaires for periods of up to three years. Treatment tenure, demographics and hepatitis C status were recorded. RESULTS: High levels of lifetime (82.8%) and current (66.2%) Axis I psychiatric comorbidity were mostly anxiety and affective disorders many of which were substance induced. Patients with current psychiatric comorbidity had significantly more current substance use disorders, although they did not abuse more drugs or remain in treatment less time than patients with no current psychiatric comorbidity. Patients with a lifetime Axis 1 disorder remained in treatment longer. Severity of psychological distress was related to current substance-related diagnoses, benzodiazepine abuse, higher methadone dosage, risk-taking behavior and the presence of hepatitis C. CONCLUSIONS: Severity of psychological distress, but not comorbid psychiatric disorders, has a major negative association with treatment outcome of patients receiving methadone maintenance treatment (MMT). Surprisingly patients with comorbid mental illness seem to remain in treatment longer than those without. Therapeutic efforts should also focus on treating subjective distress and its possible influence upon drug use behavior.

Is terror gender-blind? Gender differences in reaction to terror events.

OBJECTIVE: This study examines gender differences in posttraumatic vulnerability in the face of the terror attacks that occurred during the Al-Aqsa Intifada. In addition, the contribution of level of exposure, sense of safety, self-efficacy, and coping strategies is assessed. METHOD: Participants were 250 men and 262 women, who constitute a representative sample of Israel's adult population. Data were collected via a structured questionnaire consisting of 51 items that were drawn from several questionnaires widely used in the study of trauma. RESULTS: The findings indicate that women endorsed posttraumatic and depressive symptoms more than men and that, generally, their odds of developing posttraumatic stress symptoms are six times higher than those of men. Results also revealed that women's sense of safety and self-efficacy are lower than men's and that there are gender differences in coping strategies in the face of terror. CONCLUSIONS: Gender differences in vulnerability to terror may be attributable to a number of factors, among these are women's higher sense of threat and lower self-efficacy, as well as their tendency to use less effective coping strategies than men. Level of exposure to terror was ruled out as a possible explanation for the gender differences in vulnerability.

Video testimony of long-term hospitalized psychiatrically ill Holocaust survivors.

OBJECTIVE: Many Holocaust survivors who have both psychotic disorders and residual symptoms of posttraumatic stress disorder (PTSD) remain chronically hospitalized in psychiatric institutions. This study investigated the clinical benefits of a therapeutic process facilitating a detailed videotaped account of traumatic experience (testimony method) in elderly long-term hospitalized Holocaust survivors. METHOD: Twenty-four schizophrenia patients (mean age=72.2 years) who were chronically hospitalized in Israeli state psychiatric hospitals underwent assessment by blind rating with a battery of psychiatric rating scales before and 4 months after extensive videotaped interview. The rating scales included the Positive and Negative Syndrome Scale; Clinical Global Impression (CGI); Mini-Mental State Examination (MMSE); Clinician-Administered PTSD Scale, Form 2; and Structured Interview for Disorders of Extreme Stress. Full pre- and postinterview data were available for 21 patients. RESULTS: Thirty-eight percent of the patients met the criteria for PTSD at the first interview, compared with only 19% at the second interview. The patients had significant reductions in functional impairment and in the severity and intensity of all posttraumatic symptom clusters (intrusion, avoidance, hyperarousal); the avoidance cluster showed the most reduction. Eleven subjects had an improvement of 30% or more in total posttraumatic severity score. No differences in Positive and Negative Syndrome Scale, MMSE, Structured Interview for Disorders of Extreme Stress, and CGI total scores were noted postinterview or between the two preinterview evaluation batteries in the comparison group. Female patients had a higher prevalence of PTSD symptoms. Total Clinician-Administered PTSD Scale, Form 2, scores and total Positive and Negative Syndrome Scale scores were inversely correlated both at baseline and at follow-up. CONCLUSIONS: Study observations suggest clinical benefits of the testimony method in the alleviation of many posttraumatic symptoms, but not psychosis, in a cohort of psychiatrically ill Holocaust survivors, despite an interval of as many as 60 years since the traumatic events. The findings have implications for care and rehabilitation of patients many years after acute traumatic events.

Emotional impact of exposure to terrorism among young-old and old-old Israeli citizens.

OBJECTIVE: Since September 2000, continuous terrorist attacks have exposed Israeli society to trauma, and the impact of these events on the mental health of the elderly Israeli population remains unclear. The authors sought to assess the prevalence of posttraumatic stress-related symptoms of distress, depression, optimism, self-efficacy, and sense of safety of the young-old and old-old Jewish population after 19 months of intense terrorism in Israel, in order to identify correlates of the psychological sequelae and compare symptoms and coping methods of these populations with those of younger adults. METHODS: Authors did a telephone survey using stratified sampling with a national sample of young-old (65-74 years old), old-old (>74 years old) and a comparison group of younger adults (18-64 years old). RESULTS: No difference was found in the level of exposure, traumatic stress symptoms, including probable PTSD, except for a nonsignificant tendency toward more depersonalization and emotional numbness in the elderly group, a tendency toward more sleeplessness, more re-experiencing of unwanted thoughts, hyperarousal, fewer avoidance symptoms, and less disengagement-coping in the old-old group. Younger adults were found to be significantly more optimistic. Young-old and old-old people used cigarettes/alcohol and tranquilizers more often to cope with the situation, and old-old people who used disengagement-coping felt less helped by it. CONCLUSIONS: Young-old and old-old people do not differ significantly from the younger adult population with regard to their response to 19 months of intense and recurrent terrorism.

Cannabis abuse is not a risk factor for treatment outcome in methadone maintenance treatment: a 1-year prospective study in an Israeli clinic.

OBJECTIVE: We addressed the following questions. What are the current and lifetime prevalence of cannabis abuse in an Israeli methadone maintenance treatment (MMT) clinic? Does cannabis abuse change over time during MMT? Is cannabis abuse related to treatment outcome measures such as retention rate and the abuse of drugs? Is the abuse of cannabis related to psychopathology, HIV/HCV risk-taking and infectious diseases? Do cannabis abusers (CAs) have a different psychosocial and demographic profile than nonabusers (NCAs)? Is cannabis abuse part of a polydrug abuse tendency or a distinct substance of abuse? METHOD: Overlapping samples of either the entire clinic population (n = 283) or all the patients who had completed 1 year of MMT treatment (n = 196 of which 20 were re-entering) underwent random and twice-weekly observed urine analysis for various drugs of abuse, responded to self-report questionnaires (SCL-90-R; HIV/HCV risk-taking behaviours; n = 164), interviews (ASI, n = 176; SCID, n = 151) and hepatitis C and HIV testing (n = 149). RESULTS: Lifetime abuse prevalence was found in 75% and current abuse at MMT intake in 25%. Abuse did not increase significantly over a 1-year period. Cannabis abusers were found to be more often polydrug abusers than NCAs. Cannabis abusers did not suffer from more psychological distress, infectious diseases, and did not engage in more HCV/HIV risk-taking behaviour, nor did they leave treatment earlier than NCAs. CONCLUSIONS: Cannabis abuse MMT patients should be treated as polydrug abusers, although no specific influences of cannabis abuse on psychological and medical conditions of MMT patients have been observed. Treatment policy should take these results into consideration.

Exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in Israel.

CONTEXT: The terrorist attacks on Israeli society have been ongoing since September 2000. However, few studies have examined the impact of terrorism on nationally representative population samples, and no study has examined the psychological impact of ongoing terrorism in Israel. OBJECTIVES: To determine the level of exposure to terrorist attacks and the prevalence of traumatic stress-related (TSR) symptoms, symptoms of posttraumatic stress disorder (PTSD), and sense of safety after 19 months of terrorism in Israel, and to identify correlates of the psychological sequelae and the modes of coping with the terrorism. DESIGN, SETTING, AND PARTICIPANTS: Telephone survey conducted April-May 2002, using a strata sampling method, of 902 eligible households and a representative sample of 742 Israeli residents older than 18 years (82% contact rate) and a final participation of 512 (57%). MAIN OUTCOME MEASURES: Number of TSR symptoms, rates of those with symptom criteria for PTSD and acute stress disorder assessed by the Stanford Acute Stress Reaction Questionnaire, self-reported feelings of depression, optimism, sense of safety, help-seeking, and modes of coping. RESULTS: Of 512 survey participants, 84 (16.4%) had been directly exposed to a terrorist attack and 191 (37.3%) had a family member or friend who had been exposed. Of 510 participants who responded to questions about TSR symptoms, 391 (76.7%) had at least 1 TSR symptom (mean, 4.0 [SD, 4.5]; range, 0-23; mean intensity, 0.8; range, 0-4). Symptom criteria for PTSD were met by 48 participants (9.4%) and criteria for acute stress disorder, by 1 participant; 299 (58.6%) reported feeling depressed. The majority of respondents expressed optimism about their personal future (421/512 [82.2%]) and the future of Israel (307/509 [66.8%]), and expressed self-efficacy with regard to their ability to function in a terrorist attack (322/431 [74.6%]). Most expressed a low sense of safety with respect to themselves (307/509 [60.4%]) and their relatives (345/507 [67.9%]). Few reported a need for professional help (27/506 [5.3%]). Female sex, sense of safety, and use of tranquilizers, alcohol, and cigarettes to cope were associated with TSR symptoms and symptom criteria for PTSD; level of exposure and objective risk were not. The most prevalent coping mechanisms were active information search about loved ones and social support. CONCLUSIONS: Considering the nature and length of the Israeli traumatic experience, the psychological impact may be considered moderate. Although the survey participants showed distress and lowered sense of safety, they did not develop high levels of psychiatric distress, which may be related to a habituation process and to coping mechanisms.

Treatment of benzodiazepine dependence in methadone maintenance treatment patients: a comparison of two therapeutic modalities and the role of psychiatric comorbidity.

OBJECTIVE: Therapeutic approaches for benzodiazepine (BZD) dependence in patients in methadone maintenance treatment (MMT) have met with limited success. Clonazepam detoxification (CDTX) and clonazepam maintenance treatment (CMT) were compared in an open, clinical naturalistic study on such patients. METHODS: Benzodiazepine dependent patients substituted their BZD of abuse for clonazepam and were then either detoxified (CDTX) or a maintenance dose was reached and maintained (CMT). Patients were considered as failing the trial if they either abused BZDs (CDTX group) or abused BZDs over the maintenance dose (CMT group). Treatment outcome was evaluated based upon self and staff reports over 1 year after beginning treatment. Axis I and II psychiatric diagnosis was assessed and methadone dosage and history of abuse was recorded. RESULTS: In the CDTX group, 9/33 (27.3%), were BZD-free after 2 months. In the CMT group, 26/33 (78.8%) refrained from abusing additional BZDs over the maintenance dose after 2 months. The same success rate remained over the entire year. Survival analysis showed CMT to be more successful than the CDTX. Axis I psychiatric comorbidity was found to be positively related to treatment success in the CMT group while axis II antisocial personality disorder was found to be negatively related to treatment success in that group. It had no impact in the CDTX group. CONCLUSIONS: Maintenance strategy with clonazepam is a useful BZD treatment modality for BZD-dependent MMT patients with a long-term history of abuse and previous attempts at detoxification. Psychiatric comorbidity may have an important role in choosing the adequate treatment modality and influencing treatment outcome.