Combat stress reactions, posttraumatic stress disorder, cumulative life stress, and physical health among Israeli veterans twenty years after exposure to combat

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Social Science & Medicine 61 (2005) 1267–1277 www.elsevier.com/locate/socscimed

Combat stress reactions, posttraumatic stress disorder, cumulative life stress, and physical health among Israeli veterans twenty years after exposure to combat Yael Benyamini, Zahava Solomon Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv 69978, Israel Available online 2 March 2005

Abstract This study examined the association of initial combat stress reaction (CSR), chronic post-traumatic stress disorder (PTSD) and cumulative life stress on physical health 20 years after the 1982 war with Lebanon, in a sample of 504 Israeli veterans of the war. Two groups were assessed: male veterans who fought and suffered from CSR and a matched group of male veterans from the same units who did not exhibit such reactions. Twenty years following the war, participants were asked to rate their general physical health status, report health complaints and risk behaviors, and were screened for PTSD. CSR and, to a greater extent, PTSD, were found to be associated with general self-rated health, chronic diseases and physical symptoms, and greater engagement in risk behaviors. CSR and PTSD were also related to greater cumulative life stress since the war. Both negative and positive life events were independently related to most of the physical health measures but did not account for the associations of CSR and PTSD with poorer health. Tests of the interactions between CSR, PTSD and life stress in their association with physical health and risk behaviors showed that PTSD suppressed the effects of additional life stress (negative life events had a weaker effect on health among participants with PTSD). r 2005 Elsevier Ltd. All rights reserved. Keywords: Combat stress reaction; Post-traumatic stress disorder; Cumulative life stress; Veterans; Israel

Introduction There is ample evidence indicating that exposure to stress affects both physical and mental health (Christopher, 2004). While not all stressful events are traumatic, one of the most extreme forms of traumatic stress, which is clearly out of the normal range of human experience, is combat. Exposure to combat has often been linked with both psychological and somatic pathology Corresponding author. Tel.: +972 3 6409075;

fax: +972 3 6409182. E-mail addresses: [email protected] (Y. Benyamini), [email protected] (Z. Solomon).

(Schnurr & Jankowski, 1999; Wolfe et al., 1999). The two most common and conspicuous expressions of combat-induced psychological disorders are combat stress reaction (CSR) and post-traumatic stress disorder (PTSD). CSR refers to psychological breakdown on the battlefield, which is expressed in cognitive, affective, and behavioral symptoms. Its definition is first and foremost functional: the soldier ceases to function as a combatant or his functioning is severely impaired. The second type of combat-induced reaction is PTSD, which is defined according to DSM-IV as a reaction following the experience of an unusually traumatic event that involved the threat of death or serious injury to the person or to others and in which the person felt intense fear, horror,

0277-9536/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2005.01.023

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and helplessness. It is characterized by three main types of symptoms that cause clinical distress or impair functioning: (a) intrusion—re-experiencing the traumatic event after battles have ended; (b) avoidance— numbing of responsiveness to, or reduced involvement with, the external world; and, (c) signs of hyperarousal (American Psychiatric Association, 1994). Most studies of the impact of combat exposure focused on the extent to which this experience led to psychological problems. Research on the somatic effects of combat exposure and the reactions to it has received less attention even though it is likely that the distress caused by CSR and PTSD could also render the soldier vulnerable to somatic illnesses (Green & Schnurr, 2004). The current study examined self-reports of physical health, risk behaviors, and PTSD symptoms in Israeli soldiers 20 years after their combat experience in the 1982 Lebanon War. It included a comparison between two matched groups of veterans, those who had shown CSR and those who had not. Information about initial CSR status and current PTSD status enabled us to test the extent to which poorer health is related to the initial CSR and/or to chronic war-related PTSD. Additionally, cumulative life stress during the 20-year period was examined in order to assess the extent to which health problems were related to non-combat-related stress since the war. CSR, PTSD and physical health The two reactions, CSR and PTSD, are separate but related: veterans who have experienced CSR are more likely to develop PTSD. CSR alone increases vulnerability to physical and psychological problems in the short term: a substantial portion of veterans with CSR exhibits both PTSD and increased somatic complaints and additional psychological disorders (Solomon, 1993). However, most of the research on the psychological and physical sequelae of combat exposure did not deal with CSR but rather focused on the effects of PTSD (in many cases, due to lack of valid information about CSR in the samples studied). Numerous studies have provided evidence of associations between war-related PTSD and physical symptoms among veterans of World War II and the Korean War (Schnurr, Spiro, & Paris, 2000), Vietnam War (Beckham et al., 2003), and the Gulf War (Wolfe et al., 1999). Most of these studies focused on self-reports of specific physical symptoms. Similar associations between PTSD and physical health 5 years after the Gulf War were also reported for ratings of global health and of healthrelated quality of life (Barrett et al., 2002) and for greater use of services in clinics providing mostly nonmental health services (Calhoun, Bosworth, Grambow, Dudley, & Beckham, 2002). Moreover, another study reported that this association was mediated by the

number of physician-diagnosed health conditions, suggesting that greater utilization was due to more illness and not to a bias due to distress-motivated misuse of services (Deykin et al., 2001). PTSD was also related to ‘‘hard’’ health measures, such as heart rate and blood pressure (Buckley, Holohan, Grief, Bedard, & Suvak, 2004). Substance abuse has been explored as a possible path from PTSD to physical health. Individuals who suffered from post-traumatic stress reported increased smoking and alcohol abuse (Pfefferbaum et al., 2002). Combat exposure was associated with increased risk for alcohol and cannabis dependence even after adjusting for PTSD, and PTSD mediated the association between combat exposure and tobacco dependence (Koenen et al., 2003). Even when no difference in the occurrence of smoking was found among veterans with and without PTSD, those with PTSD reported higher rates of heavy smoking (Beckham et al., 1997). In that study, combat exposure was directly related to smoking, in addition to an indirect effect through PTSD, and, as could be expected, smoking was also related to health complaints. However, other reports showed that the association between smoking and PTSD explains only a small part of the link between PTSD and poor physical health (Schnurr & Spiro, 1999; Weisberg et al., 2002). This link remains even after controlling for smoking and alcohol consumption (Beckham et al., 1998). Research has shown that it is not combat exposure in itself but the reactions to it, CSR (Solomon & Mikulincer, 1987) and PTSD (Wagner, Wolfe, Rotnitsky, Proctor, & Erickson, 2000) that underlie the association with poorer physical health. In a follow-up of Israeli veterans 18 years after the Yom Kippur War of 1973, present PTSD was a much more powerful predictor of physical symptoms than initial CSR (Neria & Koenen, 2003). Other findings also support the unique impact of PTSD: while many types of anxiety disorders were found to be associated with elevated levels of psychological symptoms, PTSD seems to have a unique role regarding physical health (Weisberg et al., 2002; Zayfert, Dums, Ferguson, & Hegel, 2002). These findings underscore the importance of following-up on the physical health of individuals who have been exposed to severe trauma and suffer from PTSD. The existing studies provide a wealth of evidence on this topic but many also suffer from several limitations. First, most studies had no information about participants’ initial reactions to the stressful event, i.e., about the extent to which they exhibited acute stress reaction at the battlefield. Second, many studies used unrepresentative samples that were biased by the recruitment procedures: participants were often recruited at veterans’ hospitals and clinics, so that the study population consisted of veterans who had turned for help in dealing with physical or mental health problems. Third, studies

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often failed to control for potential intervening variables such as stressful life events that have occurred since the focal trauma. The main aim of the present study was to assess the long-term impact of war on physical health and to find out to what extent initial CSR and chronic PTSD are related to long-term poor physical health among soldiers who had similar combat exposure. We examined both general perceptions of health and reports of specific problems and risk behaviors (smoking and drinking alcohol). Our first hypothesis was: Both CSR and PTSD are independently related to poorer general health, more chronic diseases and somatic symptoms, and greater engagement in risky health behaviors 20 years post-war. CSR, PTSD and cumulative life stress When examining the effects of a traumatic event that happened 20 years ago we must take into account that many other stressful events could have taken place in the meantime. Such events could have adverse effects on physical or psychological health, independent of the effects of CSR or PTSD, as some studies have found (Barakat, Kazak, Gallagher, Meeske, & Stuber, 2000). Other findings suggest more complex relations between PTSD and life events: pre-trauma (Solomon & Flum, 1988) and post-trauma life events increase the likelihood of developing PTSD (Brewin, Andrews, & Valentine, 2000) and exacerbate symptoms of existing PTSD (Kaup, Ruskin, & Nyman, 1994). PTSD increases the likelihood of reporting life events and their perceived severity (Maes, Mylle, Delmeire, & Janca, 2001) and decreases the ability to cope effectively with subsequent negative experiences (Fairbank, Hansen, & Fitterling, 1991). PTSD often impairs social functioning (Lopes Cardozo, Vergara, Agani, & Gotway, 2000), and can thus lead to stressful events in the family, social and work domains, such as divorce or being laid off. PTSD is also characterized by biased processing of potentially threatening information (Buckley, Blanchard, & Neill, 2000) and thus could bias memory and attention for negative life events, resulting in more frequent reports of more severe events. In sum, both CSR/PTSD and additional life stresses could adversely affect health, and, since they could exacerbate one another, they might also interact in their effects on health. Therefore, we will also assess the contribution of cumulative life stress in the 20 years since the war to the participants’ physical health and test whether this factor interacts with CSR and/or PTSD. Our second hypothesis is that (a) individuals with CSR and/or PTSD will report greater life stress over the 20year period since the war; (b) cumulative life stress will be related to poorer health, more chronic diseases and

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somatic symptoms, and greater engagement in risky health behavior since the war; and, (c) CSR and PTSD will interact with life stress in their relationship with worse health.

Method Participants The sample included 504 male veterans who took part in active combat in the Lebanon War in 1982. Two groups participated in the study: (a) The combat stress reaction group (CSR, n ¼ 286) were sampled from the population of soldiers who fought on the front line during the Lebanon War (1982) and were referred for psychiatric intervention by their battalion physicians during the 1982 Lebanon War. Diagnosis and treatment of CSR was made on or near the battlefield by Israel Defense Forces mental health personnel who were trained and experienced in the diagnosis and treatment of combat reactions (for details see Solomon, Shklar, & Mikulincer, in press). (b) The combat control group with no CSR (NCSR, n ¼ 218) included veterans who had participated in the same frontline combat units as the CSR group but had not shown symptoms of CSR. For each CSR casualty, a matched control participant was randomly selected from among eligible soldiers who had similar socio-demographic characteristics (age, education, and military rank and assignment). The difference in the number of subjects between the CSR and NCSR groups is due to the differential rate of participation in each group. There were no significant differences between the two groups in age, level of education and marital status. Mean age was 47.6 (75.43) for the CSR and 46.7 (75.78) for the controls. The level of education was also similar: 20.8% of the CSR group and 17.4% of the controls had elementary school education, 55.3% of the CSR and 51.8% of the controls had high school education, and the remainder had higher education. Most participants were married and this was their first marriage (84.6% of the CSR and 89.9% of the controls). Recruitment and procedure Participants were recruited from a pool of participants of a previous study conducted in 1983 on the basis of the population of CSR casualties from 1982. The former study included 360 CSR and 307 controls. After updating addresses and phone numbers, potential participants were contacted by telephone and the aim of the current study was explained. In the CSR group, 323 veterans were located and 286 of them agreed to participate in the current study (88.5%). In the control group, 258 veterans were located and 218 of them agreed

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to participate (84.5%). Those who agreed to participate in the study were offered to meet in their homes or in another preferred location to complete the questionnaire. Participants signed an informed consent form before they filled in the questionnaires. Data were collected in 2002. Measures CSR diagnosis during the 1982 Lebanon War was obtained from official military records. Post-traumatic stress disorder and somatic complaints 20 years after the war were obtained from self-report questionnaires in the current study. Post-traumatic stress disorder (PTSD) inventory. The PTSD Inventory (Solomon, Neria, Ohry, Waysman, & Ginzburg, 1994), a 17-item self-report scale based on DSM criteria, was used to assess posttraumatic symptomatology. The questionnaire consists of statements tapping both DSM-III and DSM-IV symptom criteria. Participants were asked to indicate, on a 4-point scale ranging from ‘‘never’’ to ‘‘often’’, the frequency in which they experienced the described symptom. Cronbach alpha for symptom intensity in the current study was 0.96. Concurrent validity of the scale is also high, compared to other self-report measures and to a clinical diagnosis of PTSD (Solomon et al., 1993). Health status A self-report questionnaire was designed to evaluate physical health and included the following sections: (1) General physical health status was assessed with the following two questions: (a) Self-rated health—‘‘How would you define your physical health status at the present? Very good, good, not so good, bad, very bad’’ (rated on a 5-point scale from 5 ¼ very good to 1 ¼ very bad). This question is commonly used in health surveys and was consistently found to have an independent contribution to the prediction of mortality and future health outcomes (Idler & Benyamini, 1997; Benyamini & Idler, 1999); (b) Perceived changes in health—‘‘Since the Lebanon War (summer of 1982), were there any changes in your physical health status?’’ Response options were ‘‘my health remained as it was’’, ‘‘my health is better than it was’’, and ‘‘I have health problems that I did not have before’’. Since only 8 people reported better health than before the war, the responses were recoded so that ‘‘0’’ indicated having health problems that were not present before the war and ‘‘1’’ indicated that the person’s health was the same or better than it was before the war. Note that a higher score in both general health measures indicates better health. (2) Diseases and symptoms—participants were presented with a checklist of 14 health problems and requested to indicate for each problem from which they

suffer whether it began before or after the Lebanon War. The list included allergies, hypertension, ulcer, other digestive problems, heart disease, chest pains, diabetes, malignant disease, weight gain, weight loss, back pain, head aches, joint pain, and fatigue or weakness. The number of health problems that had begun after the war was counted and served as an index of the number of illnesses. (3) Risk behaviors—participants were asked about changes since the war in alcohol consumption and cigarette smoking. Response options included: never engaged in these behaviors, engaged less, the same, a little more, or a lot more than before the war. For smoking they could also indicate that they had begun or stopped smoking after the war. Those who increased their usage were combined into one category. This resulted in a four-point scale for alcohol consumption (0 ¼ never drank, 1 ¼ less than before the war, 2 ¼ the same, 3 ¼ more) and a five-point scale for smoking (0 ¼ never smoked, 1 ¼ stopped smoking after the war, 2 ¼ smokes less than before the war, 3 ¼ the same, 4 ¼ smokes more than before the war or has begun smoking after the war). Cumulative life stress was assessed with a checklist of 20 life events in several domains: family (6 events; e.g., bereavement), work (4 items; e.g. fired), and personal (e.g., lost money). Three additional events in the health area were excluded to avoid confounding with the health measures. Participants were asked to indicate for each event whether they had experienced it since the war, and, if so, whether they appraised it as positive or negative. Two indicators were created by separate counts of the positive and negative events.

Results First, we examined the participants’ reports of their medical history before the War. The groups did not differ significantly in these reports: only 9.8% of the CSR group and 12.8% of the NCSR group endorsed at least one pre-war condition from among the 14 diseases and symptoms. Thus, any post-war differences between the groups are unlikely to be due to pre-existing differences in their health status, to the extent that one can rely on their recall of these conditions 20 years later. Next, we examined their ratings of PTSD symptoms. About a fourth of the participants fulfilled the DSM-IV criteria for post-traumatic stress disorder: 36.7% of the CSR group and 13.8% of the NCSR group. Participants’ PTSD diagnosis according to their score on the PTSD inventory served to split the sample into two subgroups: PTSD (n ¼ 135) and non-PTSD (NPTSD; n ¼ 369). Together with the division to CSR and NCSR, this enabled us to assess the independent contributions of past CSR and current PTSD status to the variations

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in health. Splitting the sample on both the CSR and the PTSD variables resulted in four groups: no initial CSR and no chronic PTSD (n ¼ 188), no CSR with chronic PTSD (n ¼ 30), initial CSR with no chronic PTSD (n ¼ 181), and initial CSR and chronic PTSD (n ¼ 105). General physical health status We now turn to the tests of our first hypothesis regarding the relationships between CSR/PTSD and poorer health. First, we examined general self-rated health: participants who initially exhibited CSR reported significantly poorer physical health. Similarly, those who reported current PTSD also reported poorer health. Within the CSR group, the mean level of selfrated health was 3.86 (7.91) among the NPTSD and 3.00 (7.85) among the PTSD subgroup. Within the NCSR group, the mean level of self-rated health was higher: 4.17 (7.77) among the NPTSD and 3.30 (7.84) among the PTSD subgroup. Both of the main effects (CSR and PTSD) were significant according to a twoway analysis of variance and there was no interaction of CSR and PTSD in their associations with self-rated health (CSR effect F ð1; 494Þ ¼ 15:09; po.001, partial eta squared ¼ :03; PTSD effect F ð1; 494Þ ¼ 96:94; po.001, partial eta squared ¼ :16; in all analyses in which the interaction effects were not significant, the main effects we report are from analyses in which the interaction was excluded). Regarding perceived changes in health, the CSR were less likely to report that their health was the same or better than it was before the war, compared with the NCSR, and similarly, the PTSD were less likely than the NPTSD to report same/better health. In a multiple logistic regression model that included both CSR and PTSD, both main effects, but not their interaction, were significant (OR ¼ :61 for the CSR effect, po.05, OR ¼ :20 for the PTSD effect, po.001). Specific health problems Participants in the CSR group reported an average of 2.38 health problems that had begun after the war, compared with 1.63 in the NCSR group. Differences related to current PTSD were much larger: an average of 3.81 health problems in the PTSD group compared with 1.42 in the NPTSD group. ANOVA showed a significant effect only for PTSD ðF ð1; 501Þ ¼ 160:84; po.001, partial eta squared ¼ :24) and not for CSR or for their interaction. Reports of six of the fourteen problems were significantly more frequent among the CSR, compared with the NCSR (as determined by chi square, not shown): digestive problems, weight loss, chest pains, headaches, joint aches, and fatigue. The PTSD reported significantly greater frequency of all problems, com-

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pared with the NPTSD, with the exception of allergies and malignant diseases. Next, logistic regression analyses served to compute the adjusted odds ratio (OR) of having reported the disease in the CSR compared with the NCSR group and in the PTSD compared with the NPTSD group (in models which included both CSR and PTSD) and the adjusted OR for the interaction between CSR and PTSD in their relationship with the incidence of health problems (in models which included CSR, PTSD, and their interaction). Table 1 shows the results of these analyses for each health problem along with the percentage of participants in each group who reported that they suffer from this problem and that it had begun after the war. Reports of allergies and malignant disease were omitted because very few participants reported these diseases. Adjusted ORs for PTSD ranged from around 2.0 for diseases such as hypertension, ulcer, and diabetes, to around 5.0 or more for problems such as heart disease, chest pains, and headaches. After adjusting for PTSD, participants in the CSR group differed significantly from those in the NCSR in their reports of three health problems. Interaction effects of CSR by PTSD were apparent for only two of the health problems: within the NCSR group, chest pains and headaches were significantly more prevalent in the PTSD compared with the NPTSD group, whereas the difference related to PTSD was much smaller in the CSR group. Risk behaviors CSR and PTSD participants reported more changes for the worse in smoking and drinking since the war compared with the NCSR and NPTSD, respectively. Figs. 1 and 2 show the distributions of the participants in the four groups according to the changes they reported in smoking and drinking behavior since the war. Multiple logistic regression was used to test the effects of CSR, PTSD and their interaction on the odds of increased smoking/drinking versus all other responses. Both CSR and PTSD, but not their interaction, were related to more smoking (or having begun smoking) after the war (the OR for each one of them was 3.08, po.001). Only PTSD was related to increased alcohol consumption after the war (OR ¼ 4:89; po.001). Note also that pre-war drinking seems to be related to subsequent PTSD (compare the bars for ‘‘never drank’’ among the groups in Fig. 2). This relation is significant in the NCSR but not the CSR group. In sum, for initial CSR the data support our first hypothesis in part: it had a significant association with general self-rated health and perceived changes in health, with about half of the health problems, and with heavier smoking and drinking since the war.

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Table 1 Frequencies and odds ratiosa (OR) based on logistic regressions of self-reported diseases and somatic symptoms reported by participants with or without combat stress reaction (CSR), with and without current post-traumatic stress disorder (PTSD) Non CSR CSR

OR

Non

PTSD

OR

Non CSR

CSR

OR

CSR

PTSD PTSD (n ¼ 369) (n ¼ 135)

Non PTSD PTSD Non PTSD PTSD Group (n ¼ 188) (n ¼ 30) (n ¼ 181) (n ¼ 105) X PTSD

(n ¼ 218)

(n ¼ 286)

Hypertension

13.8% n ¼ 30

15.0% n ¼ 43

.96

12.5% n ¼ 46

20.0% n ¼ 27

1.78*

11.7% n ¼ 22

26.7% n¼8

13.3% n ¼ 24

18.1% n ¼ 19

.53

Ulcer

7.3% n ¼ 16

8.0% n ¼ 23

.91

6.2% n ¼ 23

11.9% n ¼ 16

2.08*

6.4% n ¼ 12

13.3% n¼4

6.1% n ¼ 11

11.4% n ¼ 12

.88

Other digestive problems 7.8% n ¼ 17

17.1% n ¼ 49

1.74

7.9% n ¼ 29

27.4% n ¼ 37

3.52*** 6.4% n ¼ 12

16.7% n¼5

9.4% n ¼ 17

30.5% n ¼ 32

1.44

Heart disease

6.0% n ¼ 13

4.5% n ¼ 13

.46

3.0% n ¼ 11

11.1% n ¼ 15

.23*** 3.7% n¼7

20.0% n¼6

2.2% n¼4

8.6% n¼9

.64

Chest pains

10.6% n ¼ 23

25.2% n ¼ 72

1.95*

10.6% n ¼ 39

41.5% n ¼ 56

.13*** 4.3% n¼8

50.0% n ¼ 15

17.1% n ¼ 31

39.0% n ¼ 41

.14**

Diabetes

5.0% n ¼ 11

6.3% n ¼ 18

1.01

4.3% n ¼ 16

9.6% n ¼ 13

2.35*

10.0% n¼3

4.4% n¼8

9.5% n ¼ 10

.91

Weight gain

24.8% n ¼ 54

21.3% n ¼ 61

17.3% n ¼ 64

37.8% n ¼ 51

3.44*** 19.7% n ¼ 37

56.7% n ¼ 17

14.9% n ¼ 27

32.4% n ¼ 34

.51

Weight loss

1.4% n¼3

9.4% n ¼ 27

5.50** 3.3% n ¼ 12

13.3% n ¼ 18

3.29**

3.3% n¼1

5.5% n ¼ 10

16.2% n ¼ 17

1.03

Back pains

34.4% n ¼ 75

38.5% n ¼ 110

.95

30.6% n ¼ 113

53.3% n ¼ 72

2.63*** 31.9% n ¼ 60

50.0% n ¼ 15

29.3% n ¼ 53

54.3% n ¼ 57

1.34

Headaches

16.1% n ¼ 35

30.1% n ¼ 86

1.50

14.1% n ¼ 52

51.1% n ¼ 69

5.76*** 9.6% n ¼ 18

56.7% n ¼ 17

18.8% n ¼ 34

49.5% n ¼ 52

Joint pains

8.7% n ¼ 19

16.8% n ¼ 48

1.56

8.7% n ¼ 32

25.9% n ¼ 35

3.28*** 7.4% n ¼ 14

16.7% n¼5

9.9% n ¼ 18

28.6% n ¼ 30

1.46

Fatigue or weakness

20.6% n ¼ 45

38.8% n ¼ 111

1.55

17.3% n ¼ 64

68.1% n ¼ 92

9.18*** 14.4% n ¼ 27

60.0% n ¼ 18

20.4% n ¼ 37

70.5% n ¼ 74

1.04

.58*

4.3% n¼8

1.1% n¼2

.34*

*po.05, **po.01, ***po.001. a The logistic regression analyses were conducted in two steps: in the first step only CSR and PTSD were entered and in the second step the interaction between them was added. Since most of the interaction effects were non-significant, the ORs presented for the main effects of CSR and of PTSD are based on the first step. The ORs for the interaction were taken from the results of the second step. For the two variables where a significant interaction was found, the ORs for CSR and PTSD at the second step do not differ substantially from those presented from the first step.

However, some of these effects were weak and nonsignificant after adjusting for PTSD. For chronic PTSD, the hypothesis was supported in full: it was significantly and independently related to each of the different indicators of poorer health and greater engagement in risk behaviors measured 20 years after the war. Cumulative life stress Our second hypothesis involved the possibility that life stress experienced over the 20-year period since the war contributed to the deterioration in health or interacted with CSR and/or PTSD in their effects on poorer health. First, we examined the association between CSR/PTSD and life events. Participants in the

CSR group reported significantly more negative life events (NLE) since the war than the NCSR (2.5472.47 compared with 1.3571.69) and significantly less positive life events (PLE; 1.7171.64 compared with 2.3171.54). Participants with PTSD reported significantly more NLE since the war than NPTSD (3.9572.51 compared with 1.3271.65) and significantly less PLE (1.2871.44 compared with 2.2271.61; in all four comparisons the difference according to t-tests was significant, po.001). When the associations of CSR and PTSD to NLE were tested together using two-way ANOVA, the effects of CSR and PTSD, but not their interaction, were significant (for CSR, Fð1; 501Þ ¼ 12:48; p ¼ .001, partial eta squared ¼ :02; for PTSD, F ð1; 501Þ ¼ 154:18; po.001, partial eta squared ¼ :24). For PLE the main

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Percentage of Participants

Y. Benyamini, Z. Solomon / Social Science & Medicine 61 (2005) 1267–1277

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

7.0 30.0

23.0 9.1

13.3

20.3

6.7 23.3

40.6

NPTSD

23.2 43.8 33.9

more or began after the war the same as before the war less than before the war

2.3

10.5 4.8

11.9

19.0

stopped after the war

21.9

never smoked

26.7

28.8

PTSD

NPTSD

NCSR

1273

PTSD

CSR

Percentage of Participants

Fig. 1. Smoking behavior after the war among soldiers who did or did not exhibit initial combat stress reaction (CSR and NCSR) in the Lebanon War and those who do or do not fulfill the criteria for post-traumatic stress disorder (PTSD and NPTSD) twenty years after the war.

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

4.8

10.2 26.7

32.4

35.6

more after the war

36.7 26.7

8.5

23.8 5.1 4.8

16.7 51.1

never drank

48.0

39.0

30.0

NPTSD

PTSD

NPTSD

NCSR

the same as before the war less than before the war

PTSD

CSR

Fig. 2. Drinking behavior after the war among soldiers who did or did not exhibit initial combat stress reaction (CSR and NCSR) in the Lebanon War and those who do or do not fulfill the criteria for post-traumatic stress disorder (PTSD and NPTSD) twenty years after the war.

effects were significant but the effect of PTSD was weaker. Next, life events and all interactions between life events, CSR, and PTSD were added as covariates to the analyses of variance and logistic regression models reported in the previous sections. Due to the large number of interactions, these analyses were first conducted separately for the NLE and the PLE. The only significant interaction was between PTSD and negative life events. A final model for each summary health variable was computed, entering CSR, PTSD, NLE and their interaction with PTSD, and PLE. In these models, PTSD retained a significant independent effect on SRH, health changes, and number of illnesses. CSR retained a significant independent effect only on

SRH. In addition, NLE and its interaction with PTSD had a significant effect in all analyses whereas PLE had a significant effect in the analyses for SRH and perceived change in health but not for the number of illnesses. NLE were related to poorer health and PLE were related to better health. In order to understand the PTSD by NLE interaction, we examined the correlations of NLE with SRH and with the total number of illnesses separately for the NPTSD and the PTSD groups. These correlations were higher in the NPTSD group compared with the PTSD. For example, for the total number of health conditions, the correlation with negative life events was .35 (po.001) for the NPTSD and only .15 (p ¼ :09) for the PTSD. Thus, there was a pervasive effect of PTSD

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Percentage of participants

1274

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

11.2 33.1 6.6

22.1

Few NLE

7.4

9.3 4.6

14.8

21.3

more or began after the war the same as before the war less than before the war

25.9

22.2

stopped after the war

Few NLE

Many NLE

42.6

18.9 4.1 14.8

16.9

32.2

33.3

18.5

40.2

Many NLE

NPTSD

never smoked

PTSD

Fig. 3. Smoking behavior after the war among soldiers who did or did not exhibit initial combat stress reaction (CSR and NCSR) in the Lebanon War and those who reported few (none or one) or many (two or more) negative life events (NLE) in the twenty years after the war.

on health status, and, within the PTSD group, other negative life events seemed to have a weaker impact on health, compared with the NPTSD group. The analyses for risk behaviors were also repeated in a similar fashion. CSR and PTSD retained their significant independent associations with increased smoking after controlling for NLE, PLE, and the NLE by PTSD interaction. In order to facilitate the interpretation of this interaction, we present the distribution of the participants’ smoking history according to the PTSD by life events groups in Fig. 3. Note the large number of participants with PTSD and greater life stress who smoked more after the war but also the greater impact of NLE on smoking history in the NPTSD group. For alcohol consumption, CSR and PTSD similarly retained their significant independent effects. In addition, NLE and a 3-way interaction between CSR, PTSD, and PLE had significant effects. This interaction is difficult to interpret since attempts to chart the data resulted in many small cells. In sum, our second hypothesis was mostly supported: (a) individuals with CSR and/or PTSD reported greater cumulative life stress, which was related to poorer health. Life stress interacted with PTSD status for most measures, but did not exacerbate its effect but rather showed a weaker effect in the presence of PTSD.

Discussion Veterans who had experienced CSR during the war and/or were diagnosed with combat-related PTSD 20 years after the war reported poorer physical health, more diseases and somatic symptoms, and greater engagement in risk behaviors, in line with our first hypothesis. Adjusting for PTSD, initial CSR had a weaker effect. Nevertheless, it is quite impressive that an

acute reaction that happened so long ago is associated with global self-rated health, with several symptoms and with smoking independent of the effect of PTSD. It is also worthwhile noting that CSR seems to be a precursor, though not a necessary condition, for the development of PTSD. These associations of CSR and PTSD with physical health are similar to those that were found at shorter intervals after combat exposure. The main difference from most previous studies is the length of the followup. For over a quarter of our sample, who meet the criteria for PTSD after such a long period of time— almost half their lives—the aftereffects of their combat experience have turned into a chronic problem, which is accompanied by pervasive effects on their physical health. Why do veterans with PTSD report more physical problems? One could argue that this reflects attention biases (Buckley et al., 2000) that led to greater reporting of indicators of poor health. Another explanation could be in terms of somatization, or the tendency to express psychological distress via somatic symptomatology (Waitzkin & Magan˜a, 1997), which was related to selfreported health among veterans with PTSD (Beckham et al., 1998). Our study relied only on self-reports and therefore there was no way to test to what extent these reports correlated with more objective measures of health. However, it is important to note that PTSD was associated not only with potentially distress-related symptoms (such as headaches or fatigue) but also with chronic diseases such as hypertension, diabetes and heart disease that are less likely to be biased. Moreover, studies that did include physician-reported diagnoses (Schnurr et al., 2000) or direct indications of biological alterations (such as changes in brain activation patterns, Liberzon & Phan, 2003), reported that these measures were related to PTSD. Therefore, though biased

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reporting or somatization probably do account for some of the increased physical complaints among the PTSD participants, attributing the difference solely to these factors seems to downplay the relationship of combat experience in general and long-term PTSD in particular to physical health. The findings are in line with the integrative model proposed by Schnurr and Green (2004), which relates trauma to physical health. In this model, trauma exposure has both direct and indirect effects on morbidity. PTSD is the key mechanism that leads from the trauma to poorer health, through a variety of biological, psychological, cognitive, and behavioral pathways. The question is not which of these pathways is most influential in its effect on physical health but rather how do they interact to impair health. Individual differences in the immediate reaction to the war experience may have coupled with other characteristics that have led some of the participants to exhibit chronic stress reactions. These reactions may have direct effects on physiological responses as well as on behavioral responses (e.g., risk behaviors), together leading to a greater disease burden at middle age. Schnurr and Jankowski (1999) suggested summarizing the additive and interactive effects of such factors with the concept of allostatic load: ‘‘the cost of chronic exposure to fluctuating or heightened neural or neuroendocrine response resulting from repeated or chronic environmental challenge that an individual reacts to as being particularly stressful’’ (McEwen & Stellar, 1993, p. 2093; see also Friedman & McEwen, 2004). Thus, PTSD turns an initial acute stressful event into a chronic stressor with multiple negative effects. Our findings suggest that these processes do not subside over 20 years and may accelerate age-related decline in physical health. In addition to the combat-related stress that is still manifested in PTSD and to the cumulative stress of life events, health problems are not only a possible outcome but also a stressor in itself. Traumas and posttraumatic reactions can add to and interact with chronic diseases to produce an accumulated burden of adversity that negatively affects both acute disease events and ways of coping with them (Alonzo, 2000). One could view the lives of our participants along a continuum of cumulative adversity, created by the initial combat exposure and CSR, the long-lingering PTSD, and additional health co-morbidities. Another aim of our study was to test the role of cumulative life stress in relation to physical health. Though it was also related to poorer health, it did not account for the associations of CSR and PTSD with physical health, in line with our second hypothesis. PTSD also interacted with NLE in their effects on physical health: NLE were more strongly related to poor health among the NPTSD. This pattern of results fits the ‘‘suppressor model’’, one of four possible models for the

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effects of NLE, proposed by Ruch, Chandler and Harter (1980). According to this model, a traumatizing experience could modify or even eliminate the effects of other life changes. The effect of PTSD seemed to be so profound among those experiencing it, that other NLE could not add much to this negative influence. Only among the NPTSD, the typical pattern of a strong association between NLE and poor health was found. Another finding is also in line with this model: pre-war drinking was related to PTSD in the NCSR but not in the CSR group, suggesting that once CSR had occurred, it was the dominant factor that rendered the person vulnerable for PTSD, more than, in this case, a previous history of drinking (or the dispositions that it reflects). Should we also look at the full half of the cup? Bonnano (2004) suggested in a recent review of the literature that resilience in the face of trauma is more common than is often believed. Almost three-fourths of our participants were quite resilient: they were exposed to the extreme conditions of combat, many have even exhibited CSR, and yet have not developed chronic PTSD and have reported better health. However, though there clearly is a full half to the cup, it’s important not to downplay the empty half, of those who still carry the mental and physical scars of an acute traumatic event that happened 20 years ago. It is essential that the long-term suffering of trauma victims will be recognized and legitimized by society and by health care professionals (Sayer, Spoont, & Nelson, 2004; Solomon, 1996). Strengths and limitations of the study Our study showed that PTSD is related to reports of poorer health, as has been reported numerous times before (Green & Schnurr, 2004). The unique strengths of this study are the identification of initial CSR in addition to chronic PTSD, the control for combat experience achieved by matching soldiers from the same combat units, and the long follow-up period. To the best of our knowledge, there is only one study, also of Israeli veterans (of the 1973 war) that included all these characteristics (Neria & Koenen, 2003). Another study reported more health complaints among ex-prisoners of war after 18 years and a correlation between PTSD and these complaints (Ohry et al., 1994). Both studies reported similar findings to our own. The current study added the adjustment for cumulative life stress, which enabled us to test an alternative explanation of poor health in terms of non-combat-related stress. The main limitation of the current study is the lack of objective health measures such as physician examinations and physiological measures. The measures we used consisted mainly of checklists, with no indication of the severity of each health condition. Therefore, the excess in health problems found here might be an underestimate of

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the full impact of PTSD on physical health. Even with the same health problems, individuals with PTSD may actually experience poorer physical health. Similarly, our data included only risk behaviors but other studies showed that individuals with PTSD are also less likely to engage in preventive health behaviors (Buckley, Mozley, Bedard, Dewulf, & Greif, 2004), which could further contribute to poorer health over time. The findings should also be viewed within their cultural context. In Israel, the threat to personal and national survival is ever present and very real. Therefore, as Leiblich (1978) summarized, Israeli men are under intense cultural pressure to be strong. On the one hand, breakdown in combat is in direct opposition to the cultural mandate, which may exacerbate the trauma. The cultural mandate has also caused many casualties to go to great lengths to hide their stress reactions and subsequent PTSD (Solomon, 1993). On the other hand, combatants in Israel are held in high esteem and consequently the State goes to great lengths to ensure their physical and mental well-being and provide treatment for any problem encountered during active service. Thus, one cannot negate the possibility that this latter tendency increased rates of reporting mental problems.

References Alonzo, A. A. (2000). The experience of chronic illness and post-traumatic stress disorder: The consequences of cumulative adversity. Social Science & Medicine, 50(10), 1475–1484. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. Barakat, L. P., Kazak, A. E., Gallagher, P. R., Meeske, K., & Stuber, M. (2000). Posttraumatic stress symptoms and stressful life events predict the long-term adjustment of survivors of childhood cancer and their mothers. Journal of Clinical Psychology in Medical Settings, 7(4), 189–196. Barrett, D. H., Doebbeling, C. C., Schwartz, D. A., Voelker, M. D., Falter, K. H., Woolson, R. F., & Doebbeling, B. N. (2002). Posttraumatic stress disorder and self-reported physical health status among U.S. Military personnel serving during the Gulf War period: A population-based study. Psychosomatics, 43(3), 195–205. Beckham, J. C., Kirby, A. C., Feldman, M. E., Hertzberg, M. A., Moore, S. D., Crawford, A. L., Davidson, J. R., & Fairbank, J. A. (1997). Prevalence and correlates of heavy smoking in Vietnam veterans with chronic posttraumatic stress disorder. Addictive Behaviors, 22(5), 637–647. Beckham, J. C., Moore, S. D., Feldman, M. E., Hertzberg, M. A., Kirby, A. C., & Fairbank, J. A. (1998). Health status, somatization, and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder. American Journal of Psychiatry, 155(11), 1565–1569.

Beckham, J. C., Taft, C. T., Vrana, S. R., Feldman, M. E., Barefoot, J. C., Moore, S. D., Mozley, S. L., Butterfield, M. I., & Calhoun, P. S. (2003). Ambulatory monitoring and physical health report in Vietnam veterans with and without chronic posttraumatic stress disorder. Journal of Traumatic Stress, 16(4), 329–335. Benyamini, Y., & Idler, E. L. (1999). Community studies reporting association between self-rated health and mortality: Additional studies, 1995–1998. Research on Aging, 21(3), 392–401. Bonnano, G. A. (2004). Loss, trauma and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59(1), 20–28. Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Metaanalysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting & Clinical Psychology, 68(5), 748–766. Buckley, T. C., Blanchard, E. B., & Neill, W. T. (2000). Information processing and PTSD: A review of the empirical literature. Clinical Psychology Review, 20(8), 1041–1065. Buckley, T. C., Holohan, D., Greif, J. L., Bedard, M., & Suvak, M. (2004). Twenty-four-hour ambulatory assessment of heart rate and blood pressure in chronic PTSD and non-PTSD veterans. Journal of Traumatic Stress, 17(2), 163–171. Buckley, T. C., Mozley, S. L., Bedard, M. A., Dewulf, A. C., & Greif, J. (2004). Preventive health behaviors, health-risk behaviors, physical morbidity, and health-related role functioning impairment in veterans with post-traumatic stress disorder. Military Medicine, 169(7), 536–540. Calhoun, P. S., Bosworth, H. B., Grambow, S. C., Dudley, T. K., & Beckham, J. C. (2002). Medical service utilization by veterans seeking help for posttraumatic stress disorder. American Journal of Psychiatry, 159(12), 2081–2086. Christopher, M. (2004). A broader view of trauma: A biopsychosocial–evolutionary view of the role of the traumatic stress response in the emergence of pathology and/or growth. Clinical Psychology Review, 24, 75–98. Deykin, E. Y., Keane, T. M., Kaloupek, D., Fincke, G., Rothendler, J., Siegfried, M., & Creamer, K. (2001). Posttraumatic stress disorder and the use of health services. Psychosomatic Medicine, 63(5), 835–841. Fairbank, J. A., Hansen, D. J., & Fitterling, J. M. (1991). Patterns of appraisal and coping across different stressor conditions among former prisoners of war with and without posttraumatic stress disorder. Journal of Consulting & Clinical Psychology, 59(2), 274–281. Friedman, M. J., & McEwen, B. S. (2004). Posttraumatic stress disorder, allostatic load, and medical illness. In B. L. Green, & P. P. Schnurr (Eds.), Trauma and health: Physical health consequences of exposure to extreme stress (pp. 157–188). Washington, DC: American Psychological Association. Green, B. L., & Schnurr, P. P. (Eds.). (2004). Trauma and health: Physical health consequences of exposure to extreme stress. Washington, DC: American Psychological Association. Idler, E. L., & Benyamini, Y. (1997). Self-rated health and mortality: A review of 27 community studies. Journal of Health and Social Behavior, 38(1), 21–37.

ARTICLE IN PRESS Y. Benyamini, Z. Solomon / Social Science & Medicine 61 (2005) 1267–1277 Kaup, B. A., Ruskin, P. E., & Nyman, G. (1994). Significant life events and PTSD in elderly World War II veterans. American Journal of Geriatric Psychiatry, 2(3), 239–243. Koenen, K. C., Lyons, M. J., Goldberg, J., Simpson, J., Williams, W. M., Toorney, R., Eisen, S. A., True, W., & Tsuang, M. T. (2003). Co-twin control study of relationships among combat exposure, combat-related PTSD, and other mental disorders. Journal of Traumatic Stress, 16(5), 433–438. Leiblich, A. (1978). Tin soldiers on Jerusalem Beach. New York: Pantheon. Liberzon, I., & Phan, K. L. (2003). Brain-imaging studies of posttraumatic stress disorder. CNS Spectrums, 8(9), 641–650. Lopes Cardozo, B., Vergara, A., Agani, F., & Gotway, C. A. (2000). Mental health, social functioning, and attitudes of Kosovar Albanians following the war in Kosovo. Journal of the American Medical Association, 284(5), 569–577. Maes, M., Mylle, J., Delmeire, L., & Janca, A. (2001). Pre- and post-disaster negative life events in relation to the incidence and severity of post-traumatic stress disorder. Psychiatry Research, 105, 1–12. McEwen, B. S., & Stellar, E. (1993). Stress and the individual. Mechanisms leading to disease. Archives of Internal Medicine, 153(18), 2093–2101. Neria, Y., & Koenen, K. C. (2003). Do combat stress reaction and posttraumatic stress disorder relate to physical health and adverse health practices? An 18-year follow-up of Israeli war veterans. Anxiety, Stress, and Coping, 16(2), 227–239. Ohry, A., Solomon, Z., Neria, Y., Waysman, M., Bar-On, Z., & Levy, A. (1994). The aftermath of captivity: An 18-year follow-up of Israeli ex-POWs. Behavioral Medicine, 20(1), 27–33. Pfefferbaum, B., Vinekar, S. S., Trautman, R. P., Lensgraf, S. J., Reddy, C., Patel, N., & Ford, A. L. (2002). The effect of loss and trauma on substance use behavior in individuals seeking support services after the 1995 Oklahoma City bombing. Annals of Clinical Psychiatry, 14(2), 89–95. Ruch, L. O., Chandler, S. M., & Harter, R. A. (1980). Life change and rape impact. Journal of Health and Social Behavior, 21, 248–260. Sayer, N. A., Spoont, M., & Nelson, D. (2004). Veterans seeking disability benefits for posttraumatic stress disorder: Who applies and the self-reported meaning of disability compensation. Social Science & Medicine, 58(11), 2133–2143. Schnurr, P. P., & Green, B. L. (2004). Understanding relationships among trauma, posttraumatic stress disorder, and health outcomes. In B. L. Green, & P. P. Schnurr (Eds.), Trauma and health: Physical health consequences of exposure to extreme stress (pp. 247–275). Washington, DC: American Psychological Association. Schnurr, P. P., & Jankowski, M. K. (1999). Physical health and post-traumatic stress disorder: Review and synthesis. Seminars in Clinical Neuropsychiatry, 4, 295–303.

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Schnurr, P. P., & Spiro, A., 3rd. (1999). Combat exposure, posttraumatic stress disorder symptoms, and health behaviors as predictors of self-reported physical health in older veterans. Journal of Nervous & Mental Disease, 187(6), 353–359. Schnurr, P. P., Spiro, A., 3rd., & Paris, A. H. (2000). Physiciandiagnosed medical disorders in relation to PTSD symptoms in older male military veterans. Health Psychology, 19(1), 91–97. Solomon, Z. (1993). Combat stress reaction. New York: Plenum Press. Solomon, Z. (1996). Responses of mental health professionals to man-made trauma: The Israeli experience. Social Science & Medicine, 43(5), 769–774. Solomon, Z., Benbenishty, R., Neria, Y., Abramowitz, M., Ginsburg, K., & Ohry, A. (1993). Assessment of PTSD: Validations of the revised PTSD inventory. Israel Journal of Psychiatry and Related Sciences, 30, 110–115. Solomon, Z., & Flum, H. (1988). Life events, combat stress reaction and post-traumatic stress disorder. Social Science & Medicine, 26(3), 319–325. Solomon, Z., & Mikulincer, M. (1987). Combat stress reactions, post-traumatic stress disorder and somatic complaints among Israeli soldiers. Journal of Psychosomatic Research, 31, 131–137. Solomon, Z., Neria, Y., Ohry, A., Waysman, M., & Ginzburg, K. (1994). PTSD among Israeli former prisoners of war and soldiers with combat stress reaction: A longitudinal study. American Journal of Psychiatry, 151, 554–559. Solomon, Z., Shklar, R., & Mikulincer, M. (in press). Front line treatment of combat stress reaction: A 20-year longitudinal evaluation study. American Journal of Psychiatry. Wagner, A. W., Wolfe, J., Rotnitsky, A., Proctor, S. P., & Erickson, D. J. (2000). An investigation of the impact of posttraumatic stress disorder on physical health. Journal of Traumatic Stress, 13(1), 41–55. Waitzkin, H., & Magan˜a, H. (1997). The black box in somatization: Unexplained physical symptoms, culture, and narratives of trauma. Social Science & Medicine, 45(6), 811–825. Weisberg, R. B., Bruce, S. E., Machan, J. T., Kessler, R. C., Culpepper, L., & Keller, M. B. (2002). Nonpsychiatric illness among primary care patients with trauma histories and posttraumatic stress disorder. Psychiatric Services, 53(7), 848–854. Wolfe, J., Proctor, S. P., Erickson, D. J., Heeren, T., Friedman, M. J., Huang, M. T., Sutker, P. B., Vasterling, J. J., & White, R. F. (1999). Relationship of psychiatric status to Gulf War veterans’ health problems. Psychosomatic Medicine, 61(4), 532–540. Zayfert, C., Dums, A. R., Ferguson, R. J., & Hegel, M. T. (2002). Health functioning impairments associated with posttraumatic stress disorder, anxiety disorders, and depression. Journal of Nervous & Mental Disease, 190(4), 233–240.