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Do previous experience and geographic proximity matter? Possible predictors for diagnosing Adjustment disorder vs. PTSD
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Do previous experience and geographic proximity matter? Possible predictors for diagnosing Adjustment disorder vs. PTSD ⁎
Michal Mahat-Shamir , Lia Ring, Yaira Hamama-Raz, Menachem Ben-Ezra, Shani Pitcho-Prelorentzos, Udi Y. David, Adi Zaken, Osnat Lavenda School of Social Work, Ariel University, Israel
A R T I C L E I N F O
A B S T R A C T
Keywords: ICD-11 Terror attack Adjustment disorder PTSD
The minority of people who have experienced a traumatic event and were diagnosed as either suffering from PTSD or from Adjustment disorder, may suggest that victims of a traumatic event vary in risk factors for the disorders. The current research aimed at examining the association between reports of Adjustment disorder and PTSD symptoms (In accordance with the proposed revisions of the ICD-11) and several vulnerability variables: previous traumatic event, previous stressful event and physical proximity to the terror attack. Using an online survey, 379 adult participants were recruited, and filled out Adjustment disorder, PTSD symptomatology scales, as well as a previous exposure, magnitude of exposure and death anxiety scales. Findings revealed that previous experience of traumatic events was a significant predictor associated with both PTSD and Adjustment disorder symptoms. Previous experience of stressful events was a significant predictor associated with Adjustment disorder alone. Physical proximity to the site of the attack was a significant predictor associated with PTSD symptoms but not Adjustment disorder symptoms. The importance of previous traumatic events, previous stressful events and physical proximity to the terror attack as factors which are associated with Adjustment disorder and PTSD symptomatology is discussed.
1. Introduction
Related Health Problems (ICD-11), scheduled for presentation to the World Health Assembly for approval in 2017, has provided an opportunity for the World Health Organization (WHO) to revisit these issues and devise a classification whose aim is to improve clinical utility and global applicability (International Advisory Group for the Revision of ICD-10 Mental and Behavioral Disorders, 2011; Reed, 2010; First et al., 2015). The working group of the ICD-11 has recommended a separate grouping of disorders specifically associated with stress for ICD-11, rather than combining them with anxiety disorders as in ICD-10 or DSM-5. Disorders specifically associated with stress have two key characteristics: they are identifiable on the basis of different psychopathology that is distinct from other mental disorders; and they arise in specific association with a stressful event or series of events. For each disorder in the grouping, the stressor is a necessary, although not sufficient, causal factor. The stressor could range from negative life events within the normal range of experience (in the case of Adjustment disorder) to traumatic stressors of exceptional severity (in the case of PTSD) (Maercker et al., 2013). As the ICD-11 provides new specific diagnostic criteria for both PTSD and Adjustment disorder, the current research aims at contributing to the understanding of the distinct
Threatening and stressful events, such as terror attacks, may be risk factors for many mental disorders. Disorders specifically associated with stress used to be the only diagnoses that included a direct exposure to a stressful event in their etiology as a qualifying diagnostic requirement. These diagnoses were also the subject of continuing controversy (Bracken et al., 1995; Stein et al., 2007). When the Diagnostic and Statistical Manual of Mental Disorders (DSM) -5 broadened the eligibility for the diagnosis of PTSD to include those people whose exposure was indirect (for example, hearing about a stressful event happening to others, or seeing it on television), some pointed out that such diagnostic expansion both diluted the value of the original construct and medicalized normal stress reactions (Stein et al., 2007; McNally, 2003). Significant controversy is also associated with the diagnosis of Adjustment disorder, in spite of its frequent use by clinicians (Reed et al., 2011; Evans et al., 2013). Adjustment disorder is one of the most ill-defined mental disorders, often described as the “wastebasket” of the psychiatric classification scheme (Casey and Bailey, 2011). The revision of the International Classification of Diseases and
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Corresponding author. E-mail address: [email protected] (M. Mahat-Shamir).
http://dx.doi.org/10.1016/j.psychres.2017.08.085 Received 30 January 2017; Received in revised form 6 August 2017; Accepted 29 August 2017 0165-1781/ © 2017 Elsevier B.V. All rights reserved.
Please cite this article as: Mahat-Shamir, M., Psychiatry Research (2017), http://dx.doi.org/10.1016/j.psychres.2017.08.085
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prior traumas, especially during childhood (Resnick et al., 1995; Breslau et al., 1999; Galea et al., 2002; Berntsen et al., 2012), compared with adult trauma victims who have not succumbed to PTSD. Notably, these findings also indicate the important role of the time since the traumatic event (De Bellis, 2001). These previous research findings may be interpreted as supporting a possible “sensitization” process, that is, early stressors producing greater responsiveness to subsequent stressors. To our best knowledge, there is no evidence in the literature indicating that previous trauma is a predictor of Adjustment disorder. Nevertheless, according to the ICD11, Adjustment disorder may be a maladaptive reaction to a combination of stressful life situations (Maercker et al., 2013). Therefore it is possible to assume the "sensitization" process is also valid for Adjustment disorder, namely that the experience of previous traumatic event will be a predictor of Adjustment disorder.
variables between Adjustment disorder and PTSD symptoms (in accordance with the revision of the ICD-11). According to ICD-11, Adjustment disorder is a maladaptive reaction to a stressful event, to ongoing psychosocial difficulties or to a combination of stressful life situations that usually emerges within a month of the stressor and tends to resolve in 6 months unless the stressor persists for a longer duration. The reaction to the stressor is characterized by symptoms of preoccupation like excessive worry, recurrent and distressing thoughts about the stressor or constant rumination about its implications. There is failure to adapt, i.e., the symptoms interfere with everyday functioning, like difficulties concentrating or sleep disturbance resulting in performance problems. The symptoms can also be associated with loss of interest in work, social life, caring for others, leisure activities resulting in impairment in social or occupational functioning (restriction of social network, conflicts in family, absenteeism and so on). If the definitional requirements are met for another disorder, that disorder should be diagnosed instead of Adjustment disorder (Maercker et al., 2013). PTSD according to the ICD-11 is a disorder that develops following exposure to an extremely threatening or horrific event or series of events characterized by: 1) re-experiencing the traumatic event(s) in the present in the form of vivid intrusive memories accompanied by fear or horror, flashbacks, or nightmares; 2) avoidance of thoughts and memories of the event(s), or avoidance of activities or situations reminiscent of the event(s); and 3) a state of perceived current threat in the form of excessive hyper-vigilance or enhanced startle reactions. The symptoms must last for at least several weeks and cause significant impairment in functioning (Maercker et al., 2013). Notably, Contrary to the DSM-5 which requires a time frame for the diagnosis of PTSD, this is not a requirement in the proposed ICD-11. As noted above, a stressor is a necessary for both Adjustment disorder and PTSD and it could range from negative life events within the normal range of experience (in the case of Adjustment disorder) to traumatic stressors of exceptional severity (in the case of PTSD) (Maercker et al., 2013). In that matter, it is important to note that the vast majority of community residents have experienced traumatic events (Breslau et al., 1999). Nevertheless, only a small minority of victims (< 10%), developed post-traumatic stress disorder (PTSD) (Breslau et al., 1998, 2004) and a diagnosis of Adjustment disorder may be much less of a common diagnosis in light of the ICD-11 revision. The minority of people, who have experienced a traumatic event and were diagnosed as either suffering from PTSD or from Adjustment disorder, may suggest that victims of a traumatic event vary in risk factors for the disorders (Breslau et al., 1999). The current research aim is at examining the association between reports of Adjustment disorder and PTSD symptoms (in accordance with the revision of the ICD-11) and several vulnerability variables: experience of previous traumatic events, experience of previous stressful events and physical proximity to the site of event.
1.2. Previous stressful event Stressors are decisive life changes that occur following a stressful critical event (e.g. separations, emigration, chronic or severe acute illness, unemployment, conflicts in the workplace) (Baumeister et al., 2009). According to the ICD-11, PTSD is a disorder that develops following exposure to an extremely threatening or horrific event or series of events (Maercker et al., 2013), therefore it is not expected to find previous stressful event (which is not extremely threatening or horrific) to be a predictor for PTSD. With regard to Adjustment disorder, since it was most often associated with acute stressful events (Dobricki et al., 2010; Maercker et al., 2012), it is possible to assume that a previous stressful event will be a predictor for Adjustment disorder. Moreover and based on conservation of resource theory (COR) (Hobfoll, 1989), it is possible to assume that a previous stressful event is associated with psychosocial resource loss that begets mental health problems such as Adjustment disorder. 1.3. Physical proximity to the site of the attack There is some evidence that proximity to a terror scene may increase the risk of PTSD symptoms (Grieger et al., 2005; Schlenger et al., 2002) and that the closer one is to the terror scene, the greater is the PTSD symptoms level. For example, a population-based survey conducted 1 month after September 11 found that 7.5% of residents of Manhattan living south of 110th Street had symptoms consistent with a diagnosis of probable PTSD related to the attacks (Galea et al., 2002). Another post-disaster study of PTSD among employees of a hotel that was hit by a plane showed that employees who were onsite, and thus more directly affected by the event, had a higher prevalence and more prolonged duration of PTSD than offsite employees (Smith et al., 1990). These research findings meet the ICD-11 criteria for diagnosing PTSD, as the physical proximity to a terror attack site may be experienced as an extremely threatening or horrific event. As the physical proximity to a terror attack site may be experienced as an extremely threatening or horrific event and is neither a mere stressful event nor does it constitute an ongoing psychosocial difficulty or a combination of stressful life situations; the physical proximity to a terror attack does not meet the ICD-11 criteria for diagnosing Adjustment disorder.
1.1. Previous traumatic event One of the risk factors which modifies the probability of PTSD and of Adjustment disorder, may be a previous traumatic event experienced by the individual. Studies have indicated the association between previous trauma and the prevalence of PTSD. For an example, Galea et al. (2003) examined trends in probable PTSD prevalence in the general population of New York City in the first 6 months after the September 11 terrorist attack. The authors found that highest PTSD was reported among persons who had experienced 4 or more previous traumatic events (15.1%) vs. persons who had never experienced traumatic events (2.5%). Palgi et al. (2014) found that exposure to Hurricane Sandy was related to PTSD symptoms among those with high level of recollections of the WTC terror attack and past hurricanes. Moreover, Epidemiologic surveys have documented that adults with PTSD report elevated rates of
1.4. The current research The current study was conducted in Israel, a state that has known many wars and battles since its establishment, in 1948 (Bleich, 2017). In light of the ongoing Israeli-Palestine conflict, the population in Israel has always been the target of terror attacks, until this very day. The current study was conducted last June (June 8th, 2016 at 21:04), immediately after two Palestinian gunmen opened fire on civilians dining in a restaurant in “Sarona Market” in Tel Aviv, killing four people and 2
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2.2.2. Adjustment disorder Adjustment Disorder was assessed based on the Adjustment disorder New Module originally developed by Einsle et al. (2010) and later shortened to 20 items (Glaesmer et al., 2015; Maercker et al., 2012). The ADMN-20 is a measure based on the proposed ICD 11 adjustment disorder criteria. Core symptom clusters assessed were: preoccupation (four items) and failure to adapt (three items). Subtypes assessed were: avoidance (four items); depressed (three items); anxiety (two items); and impulse disturbance (three items). These subtypes are associated features that allow clinicians to identify the precise type of syndrome (Bachem et al., 2016). Finally, a criterion of impairment, indicating that the symptoms cause clinically significant impairment in social, occupational or other important area of functioning, was assessed. Participants were asked to indicate the frequency of items on the shortened version of the measure, on a 4-point Likert scale (1 = never; 2 = rarely; 3 = sometimes; 4 = often). Cronbach's alpha calculated for the present study was 0.960.
injuring 16 others (http://mfa.gov.il/MFA/ForeignPolicy/Terrorism/ Palestinian/Pages/Wave-of-terror-October-2015.aspx). Accordingly, Israel - a place experiencing terror/war may have a relatively higher level of death anxiety due to this relative large terror exposure. As death anxiety is known to be associated with various stress disorders (Hamama-Raz et al., 2016), we examined death anxiety in order to covariate it out and obtain results that were not driven by such anxiety. Below, prior to summarizing our hypotheses, we address death anxiety in greater detail. It is important to note that exposure to threatening life events can heighten death anxiety and psychiatric morbidity (Hoelterhoff and Chung, 2013). Moreover, exposure to terror attacks and violence, especially when the exposure is continuous, may have significant repercussions that may result in emotional stress, posttraumatic stress disorder, depression and risk-taking behaviors (Silver et al., 2002; Vizek‐Vidović et al., 2000), some of which have been linked with death anxiety. For example, death anxiety has been recently associated with post-traumatic symptom severity during ongoing terror attacks (Hamama-Raz et al., 2016). In addition, the importance of death anxiety as a precursor of well-being in older adults has been established (see review by Fortner and Neimeyer, 1999), and has been shown to affect individuals across the life cycle (Russac et al., 2007). The reoccurrence of such events that may heighten death anxiety, in Israel, allows for a better examination of the impact of previous exposure on the psychological responses of the population. Therefore, the current study aims at examining the psychological impact of the exposure to the terror attack in "Sarona Market" and its related risk factors. In particular, the study focuses on the association between reports of Adjustment disorder and PTSD (in accordance with the proposed revision of the ICD-11) and the experience of previous traumatic events, the experience of previous stressful events, and the physical proximity to the site of the attack. Based on the above, we have hypothesized the following:
2.2.3. PTSD PTSD was measured using the Post-traumatic Stress Disorder Checklist – Civilian Version, which is the ICD-11 proposed PTSD criteria based on the 6-items tapping to each cluster (avoidance, hyperarousal, re-experiencing) (Knefel and Lueger-Schuster, 2013). Notably, the proposed ICD 11 criteria for PTSD is different from the DSM-5 PTSD criteria. The proposed ICD 11 PTSD criteria refers only to core PTSD symptoms (Knefel and Lueger-Schuster, 2013). Participants were asked to rate on a five point Likert scale ranging from 1 = ‘‘none’’ to 5 = ‘‘very’’, the symptoms experienced in the past 4 weeks. A symptom was classified as present if participants rated it with 3 (‘‘moderately’’) or higher. The final PTSD score was comprised of the sum of all present symptoms. Cronbach's alpha calculated for the present symptoms was 0.807. 2.2.4. Previous exposure Participants were asked to report their previous exposure to stressful and traumatic life events. They were asked to refer to the occurrence of stressful life events (such as divorce, marriage, sickness of a close person, difficulties at work, material hardship, retirement, a move to a new apartment, crime victimization etc.) and to traumatic life events (such as life threatening event for the participant himself/herself or his/ her close ones, or witnessing a life threatening event) in the past month, on a free recall basis. In particular, the participants were asked two separate questions: a) were you exposed to stressful life events, in the past month? And b) were you exposed to traumatic life events, in the past month? Participants responded to each question with 1 = ’no’ or 2 = ‘yes’.
a) Previous exposure to stressful or traumatic events in the past will be positively associated with Adjustment disorder symptoms. b) Based on the previous studies, previous exposure to traumatic events in the past, but not previous exposure to stressful events, will be positively associated with PTSD symptoms. c) Based on previous studies, physical proximity to the site of the attack will be positively associated with PTSD symptoms.
2. Method 2.1. Procedure and sample
2.2.5. Magnitude of exposure Magnitude of exposure was indicated by the physical proximity of the participants to the site of the attack. Participants were asked to report whether they were present in the “Sarona Market” area during the shooting attack. Responses were 1 = ’no’; 2 = ’yes’.
The study was conducted immediately after the occurrence of the shooting attack in “Sarona Market” in Tel Aviv. A convenience sample of adult Jewish Israelis was collected using an online survey, advertised through various means such as social media (mainly Facebook) and smartphone applications (e.g., Whatsapp). The link led to a dedicated site where participants provided informed consent. The survey was anonymous and no personal information could be identified. The sample consisted of 379 participants living in different areas in Israel, ranging in age from 18 to 69 (M = 34.4; SD = 10.67). It included 240 women (63.3%). The study was approved by the ethics committee in faculty of social sciences at the authors' university.
2.2.6. Death anxiety A single item measure was used to indicate death anxiety (AbdelKhalek, 1998). Participants were asked to what extent they agree with the statement: “I am afraid of death”. Responses were on a 7 point Likert scale ranging from 1 = ’strongly disagree’ to 7 = ’strongly agree’.
2.2. Measures
2.3. Data analysis
2.2.1. Demographics Participants were asked to report their age by providing year of birth, their gender (1 = male; 2 = female) and their current marital status (1 = single; 2 = married or living in partnership).
In order to test the study's hypotheses two-step hierarchical regression analyses were conducted using SPSS 23 software (IBM Corp.). The first step included control variables that were demographic variables: participants' age, gender, marital status and death anxiety 3
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Table 1 Mean scores, standard deviations and frequencies of the study's variables (n = 379). Variables
Dependent variables Adjustment disorder PTSD (positive symptoms) Independent variables Age (years) Gender (Male) Marital status (Single) Death anxiety Strongly disagree Disagree Disagree somewhat Neither Disagree nor agree Agree somewhat Agree Strongly agree Were in “Sarona Market” during the attack (Yes) Exposure to stressful event in the past month (Yes) Exposure to traumatic event in the past month (Yes)
Table 2 Factors associated with Adjustment disorder following shooting attack (n = 379).
Statistics
Variables
Mean
S.D
39.7 1.1
14.42 1.57
34.4
10.67
N (%) Adjustment disorder Step 1 Age (years) Gender Marital status Step 2 Age (years) Gender Marital status Death anxiety Were in “Sarona Market” during the attack Exposure to stressful event in the past month Exposure to traumatic event in the past month Model summary Step 1
139 (36.7) 165 (43.5) 12 (3.2) 32 (8.4) 29 (7.7) 77 (20.3) 69 (18.2) 106 (28.0) 54 (14.2) 18 (4.7) 137 (36.1) 35 (9.2)
which is known to be associated with various stress disorders. The second step included participants’ reports of being present in the “Sarona Market” area during the shooting attack and the two independent variables indicating participants’ exposure to previous stressful and/or traumatic life events, in the past month. Regression analysis was conducted once with Adjustment disorder as the dependent variable and again with PTSD symptoms as the dependent variable. Additionally, potential multicollinearity was examined between the study variables. No indication of multicollinearity was found, as tolerance levels ranged from 0.830 to 0.969 and variation inflation factor levels ranged from 1.032 to 1.204, indicating low levels of multicollinearity which are considered in line with literature requirements (O'Brien, 2007).
Step 2
Statistics B
S.E
t
P value
0.287 2.384 − 3.518
0.073 1.502 1.562
3.923 1.887 − 2.253
P < 0.001 0.113 0.025
0.188 2.722 − 1.758 1.949 4.513
0.072 1.444 1.533 0.434 3.449
2.615 1.884 − 1.146 4.490 1.308
0.009 0.060 0.252 P < 0.001 0.192
3.571
1.521
2.348
0.019
9.919
2.723
3.642
P < 0.001
R = 0.325; R2 = 0.106; R2 change = 0.106; F (4,374) = 11.054; p < 0.001 R = 0.431; R2 = 0.186; R2 change = 0.080; F (3,371) = 12.115; p < 0.001
Table 3 Factors associated with PTSD following shooting attack (n = 379). Variables
PTSD Step 1 Age (years) Gender Marital status Step 2 Age (years) Gender Marital status Death anxiety Were in “Sarona Market” during the attack Exposure to stressful event in the past month Exposure to traumatic event in the past month Model summary Step 1
3. Results Table 1 summarizes the mean scores, standard deviations and frequencies of the study's variable. Table 2 summarizes the results of the regression analysis conducted to test the predicting power of the independent variables (previous exposure to stressful, traumatic events and physical proximity to the site of the attack) on Adjustment disorder. As indicated in Table 2, the model explains 18.6% of the variance in Adjustment disorder. The control variables contributed significantly to the explained variance (F [4,374] = 11.054, p < 0.001) and accounted for 10.6% of the variation in Adjustment disorder. Introducing the independent variables contributed above and beyond the control variables and explained an additional 8.0% of variation in Adjustment disorder. The change in R2 was significant (F [3,371] = 12.115, p < 0.001). In line with the study's hypothesis, the physical proximity to the site of the attack was found to be non-significant predictor of Adjustment disorder, while previous exposure to stressful or traumatic events in the past month were positively and significantly associated with Adjustment disorder (B = 3.571; t = 2.348; p = 0.019; B = 9.919; t = 3.642; p < 0.001, in accordance). Table 3 summarizes the results of the regression analysis conducted to test the predicting power of the independent variables (previous exposure to stressful, traumatic events and physical proximity to the site of the attack) on PTSD. As indicated in the table, the model explains 23.2% of the variance in PTSD. The control variables contributed significantly to the explained variance (F [4,374] = 10.311, p < 0.001) and accounted for 9.9% of the variation in PTSD. Introducing the
Step 2
Statistics B
S.E
t
P value
0.007 0.294 − 0.704
0.008 0.165 0.171
0.912 1.784 − 4.113
0.362 0.075 P < 0.001
− 0.006 0.373 − 0.425 0.171 1.686
0.008 0.153 0.163 0.046 0.366
− 0.765 2.433 − 2.612 3.718 4.605
0.445 0.015 0.009 P < 0.001 P < 0.001
0.311
0.161
1.929
0.055
1.036
0.289
3.584
P < 0.001
R = 0.315; R2 = 0.099; R2 change = 0.099; F (4,374) = 10.311; p < 0.001 R = 0.482; R2 = 0.232; R2 change = 0.133; F (3,371) = 12.994; p < 0.001
independent variables contributed above and beyond the control variables and explained an additional 13.3% of variation in PTSD. The change in R2 was significant (F [3,371] = 21.367, p < 0.001). As opposed to the Adjustment disorder model, in the PTSD model, the physical proximity to the site of the attack was found to be a positively significant predictor (B = 1.686; t = 4.605; p < 0.001). In regard to previous exposure to stressful or traumatic events, only previous exposure to traumatic events in the past month was significantly associated with PTSD (B = 1.036; t = 3.584; p < 0.001). Previous exposure to stressful events in the past month was found to be nonsignificant predictor. 4
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4. Discussion
differences such as age, gender and marital status and beyond individual differences in regard to death anxiety. Moreover, as found in earlier studies, the present findings further support the positive association found between age and higher level of PTSD (Hoffman et al., 2015; Lavenda et al., 2017), as well as between gender and levels of PTSD (Cao et al., 2017), in the context of terror or conflict disaster. The current research findings indicate upon the far-reaching impact of disasters, such as a terror attack, that can engender a range of psychological consequences (Raphael and Maguire, 2009). The major question remains as for the severity of the consequences of terror attacks. This question is even more relevant when examining a geographic location, such as Israel, where terror attacks occur with predictable frequency. Within the context of our study, while the average number of positive symptoms of PTSD was low (1.1), 46% of the sample had presented at least one positive symptom of PTSD. Meaning, almost half of the sample present some level of PTSD symptomatology. Regarding the severity question, it is important to note that until relatively recently, the focus on PTSD has nearly engulfed all other considerations about the consequences and implications of terror attacks, while Adjustment disorder was mostly used as a diagnosis when the symptoms of the patient did not fully meet the criteria for other mental health disorders (PTSD, mood disorder or other anxiety disorders) (Maercker et al., 2013). It is important to differentiate between the two disorders when looking at the impact of a terror attack in order to accurate treatment. For example, there is evidence for the usefulness of cognitive behavioral approach for treating Adjustment disorder while both prolonged exposure procedures and stress inoculation training were found effective in reducing symptoms of PTSD. The current study's results emphasize the distinct definitions of Adjustment disorder and PTSD according to the new diagnostic concept of the ICD‐11 (Maercker et al., 2007, 2013), showing the different risk factors for the disorders. Our research should be interpreted in light of several limitations. First, it should be noted that this study was based on self- reported measures, and was collected using a cross-sectional design. Accordingly, there was no information regarding participants' psychiatric condition prior to data gathering. Moreover, as data was collected through an online survey, the issue of a self-selection bias may be a potential limitation in the current study, and future studies may choose to employ alternative data gathering methods. Additionally, our study assessed the association between Adjustment disorder and PTSD and previous trauma, pervious stressful events and proximity to the terror attack in a population which is under a threat of ongoing terror. Geographic locations where terrorist attacks occur with regularity are also typically encumbered by other terrorist-related stressors, such as frequent reminders of the attack, likelihood of losing a loved one, personal injury, disruption in routine, and post-disaster stress in the community (Shalev et al., 2006). Therefore, it is important to examine whether the association between the variables varies among different populations and situations. Lastly, participants were asked to report PTSD symptoms in the past 4 weeks, even though the report of time duration is not required according to ICD-11. Despite this difference, it is assumed that the present findings were not affected by it. Despite these limitations, to the best of our knowledge, the current study is one of the very few research efforts to examine previous trauma, previous stressful events and proximity to the terror attack as predictors of Adjustment disorder and PTSD as defined in the revision of the ICD-11. In light of these risk factors, we aim for delineating the difference between adjustment disorders and PTSD by using a risk/ protective factors profiles. Albeit, this is a very preliminary step, evidently these conditions share a common denominator such as death anxiety that according to the TMT is one to common denominators of stress syndromes (Iverach et al., 2014). However, other risk factors such as proximity and exposure to stressful event in the last month help to differentiate between adjustment disorders and PTSD. More studies are needed to further explore this suggestion and to gather more findings in
The current study focused on risk factors predicting PTSD and Adjustment disorder symptoms in light of the proposed ICD-11 criteria. In particular, the present study examined the association between previous exposure to traumatic events, previous exposure to stressful events, physical proximity to the terror attack site and the reported symptoms of PTSD and Adjustment disorder following a terror attack. Due to the ongoing Israeli-Palestinian conflict, Israel is a living lab for stress syndromes as Israeli citizens are continuously exposed to terror attacks that may heighten death anxiety and psychiatric morbidity (Hoelterhoff and Chung, 2013). It is important to note that death anxiety was found to be significantly associated with both PTSD and Adjustment disorder. Therefore, following previous studies (HamamaRaz et al., 2016) and TMT (Meni: What is TMT, no all the readers know that you mean Terror Management Theory; you should explain a bit)., it was important to control for death anxiety un the current study. Moreover, and as terror attacks may heighten death anxiety and psychiatric morbidity (Hoelterhoff and Chung, 2013), the presentation of stress symptoms in the aftermath of a stressful or a traumatic event in the short term, is well known. Nevertheless, in line with the study's hypotheses, previous experience of traumatic events in the past month was found to be a significant predictor of both PTSD and Adjustment disorder symptoms, while previous experience of stressful events in the past month was found to be a significant predictor of Adjustment disorder alone. These findings support the existence of a “sensitization” process that puts individuals that have recently experienced trauma, at risk of developing either PTSD or Adjustment disorder. Nevertheless, this sensitization process is somewhat diverse, based on the intensity of the previous experience. Individuals that have recently experienced a stressful event, which is considered to be a relatively low-scaled event in terms of the psychological distress it evokes (Brickman and Campbell, 1971; Clark et al., 2008; Lucas et al., 2003) are prone to developing Adjustment disorder but not PTSD; whereas individuals who have recently experienced a much more intense and disturbing event may be prone to develop either Adjustment disorder or PTSD. These findings align with the ICD-11 revision regarding the distinct definition of both disorders and the circumstances in which they are most probably evoked. Namely, PTSD is defined based on the occurrence of a life threatening event, i.e. traumatic event, whereas Adjustment disorder is diagnosed based on the exposure to a stressful event, ongoing psychosocial difficulties or to a combination of stressful life situations (Maercker et al., 2013). Regarding the study's hypothesis on physical proximity to the attack site, the findings indicate the power of proximity in predicting PTSD symptoms but not of Adjustment disorder symptoms. Here again, the physical proximity to the site of attack serves as a differentiating factor between these diagnoses. These findings align with previous findings indicating the significance of physical proximity cycles and its diverse impact on the extent to which individuals develop psychological distress (Galea et al., 2002). Moreover, the findings further differentiate the diagnosis of Adjustment disorder from that of PTSD. One way to explain these findings is by the fact that individuals who were physically close to the life threatening event are more likely to experience a sever sense of danger. Danger is a gradient gateway to PTSD exposure, whereas for AJD across all levels of proximity – whether far away or even further away – one may feel the same level of stress just by being exposed to the news, this is relevant to AJD – but that is separate from danger (PTSD). The fact that physical proximity to the site of event does not play a role in the reported symptoms of Adjustment disorder may thus, be attributed to the fact that the physical proximity to the terror site is an extremely threatening or horrific event that may cause a severe sense of danger, and not a stress. Therefore, it does not meet the ICD-11 criteria for diagnosing Adjustment disorder. It is important to note that the findings of the present study were found beyond possible demographic 5
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Not so close but still extremely loud: recollection of the world trade center terror attack and previous hurricanes moderates the association between exposure to hurricane sandy and posttraumatic stress symptoms. Compr. Psychiatry 55, 807–812. Raphael, B., Maguire, P., 2009. Disaster mental health research: past, present, and future. In: Neria, Y., Galea, S., Norris, F.H. (Eds.), Mental Health and Disasters. Cambridge University Press, New York, pp. 7–28. Reed, G.M., 2010. Toward ICD-11: improving the clinical utility of WHO's international classification of mental disorders. Prof. Psychol. Res. Pract. 41, 457–464. Reed, G.M., Correia, J.M., Esparza, P., Saxena, S., Maj, M., 2011. The WPA‐WHO global survey of psychiatrists' attitudes towards mental disorders classification. World Psychiatry 10, 118–131. Resnick, H.S., Yehuda, R., Pitman, R.K., Foy, D.W., 1995. Effect of previous trauma on acute plasma cortisol level following rape. Am. J. Psychiatry 152, 1675–1677. 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order to expand our knowledge. References Abdel-Khalek, A.M., 1998. Single-versus multi-item scales in measuring death anxiety. Death Stud. 22, 763–772. Baumeister, H., Maercker, A., Casey, P., 2009. Adjustment disorder with depressed mood: a critique of its DSM-IV and ICD-10 conceptualizations and recommendations for the future. Psychopathology 42, 139–147. Bachem, R., Perkonigg, A., Stein, D.J., Maercher, A., 2016. Measuring the ICD-11 Adjustment disorder concept: validity and sensitivity to change of the Adjustment disorder – New Module questionnaire in a clinical intervention study. Int. J. Method Psychiatr. Res. http://dx.doi.org/10.1002/mpr.1545. Berntsen, D., Johannessen, K.B., Thomsen, Y.D., Bertelsen, M., Hoyle, R.H., Rubin, D.C., 2012. Peace and war trajectories of PTSD symptoms before, during, and after military deployment in Afghanistan. Psychol. Sci. 23, 1557–1565. Bleich, A., 2017. Trauma, resilience, and being Israeli. Traumatology 23 (1), 23–26. http://dx.doi.org/10.1037/trm0000079. Bracken, P.J., Giller, J.E., Summerfield, D., 1995. Psychological responses to war and atrocity: the limitations of current concepts. Soc. Sci. Med. 40, 1073–1082. Breslau, N., Kessler, R.C., Chilcoat, H.D., Schultz, L.R., Davis, G.C., Andreski, P., 1998. Trauma and posttraumatic stress disorder in the community. Arch. Gen. Psychiatry 55, 626–632. Breslau, N., Chilcoat, H.D., Kessler, R.C., Davis, G.C., 1999. Previous exposure to trauma and PTSD effects of subsequent trauma: results from the Detroit Area Survey of Trauma. Am. J. Psychiatry 156, 902–907. Breslau, N., Wilcox, H.C., Storr, C.L., Lucia, V.C., Anthony, J.C., 2004. Trauma exposure and posttraumatic stress disorder: a study of youth in urban America. J. Urban Health 81, 530–544. Brickman, P., Campbell, D.T., 1971. Hedonic relativism and planning the good society. In: Appley, M.H. (Ed.), Adaptation Level Theory: A Symposium. Academic Press, New York, pp. 287–302. Cao, X., Wang, L., Cao, C., Zhang, J., Elhai, J.D., 2017. DSM-5 posttraumatic stress disorder symptoms structure in disaster-exposure adolescents: stability across gender and relation to behavioral problems. J. Abnorm. Child Psychol. 45, 803. http://dx. doi.org/10.1007/s10802-016-0193-1. Casey, P., Bailey, S., 2011. Adjustment disorders: the state of the art. World Psychiatry 10, 11–18. Clark, A.E., Diener, E., Georgellis, Y., Lucas, R.E., 2008. Lags and leads in life satisfaction: a test of the baseline hypothesis. Econ. J. 118, F222–F243. De Bellis, M.D., 2001. Developmental traumatology: the psychobiological development of maltreated children and its implications for research, treatment, and policy. Dev. Psychopathol. 13, 539–564. Dobricki, M., Komproe, I.H., deJong, T.V.M., Maercker, A., 2010. Adjustment disorders after severe life-events in four post conflict settings. Soc. Psychiatry Psychiatr. Epidemiol. 45, 39–2046. Einsle, F., Köllner, V., Dannemann, S., Maercker, A., 2010. Development and validation of a self-report for the assessment of adjustment disorders. Psychol. Health Med. 15 (5), 584–595. Evans, S.C., Reed, G.M., Roberts, M.C., Esparza, P., Watts, A.D., Correia, J.M., et al., 2013. Psychologists' perspectives on the diagnostic classification of mental disorders: results from the WHO-IUPsyS Global Survey. Int. J. Psychol. 48, 177–193. First, M.B., Reed, G.M., Hyman, S.E., Saxena, S., 2015. The development of the ICD‐11 clinical descriptions and diagnostic guidelines for mental and behavioral disorders. World Psychiatry 14, 82–90. Fortner, B.V., Neimeyer, R.A., 1999. Death anxiety in older adults: a quantitative review. Death Stud. 23, 387–411. http://dx.doi.org/10.1007/s10802-016-0193-110.1080/ 074811899200920. Galea, S., Ahern, J., Resnick, H., Kilpatrick, D., Bucuvalas, M., Gold, J., Vlahov, D., 2002. Psychological sequelae of the September 11 terrorist attacks in New York City. NEJM 346, 982–987. Galea, S., Vlahov, D., Resnick, H., Ahern, J., Susser, E., Gold, J., et al., 2003. Trends of probable post-traumatic stress disorder in New York City after the September 11 terrorist attacks. Am. J. Epidemiol. 158, 514–524. Glaesmer, H., Romppel, M., Brähler, E., Hinz, A., Maercker, A., 2015. Adjustment disorder as proposed for ICD-11: dimensionality and symptom differentiation. Psychiatry Res. 229, 940–948. Grieger, T.A., Waldrep, D.A., Lovasz, M.M., Ursano, R.J., 2005. Follow-up of Pentagon employees two years after the terrorist attack of September 11, 2001. Psychiatr. Serv. 1378–1374 ,56. Hamama-Raz, Y., Mahat-Shamir, M., Pitcho-Prelorentzos, S., Zaken, A., David, U.Y., BenEzra, M., Bergman, Y.S., 2016. The link between death anxiety and post-traumatic symptomatology during terror: direct links and possible moderators. Psychiatry Res.
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Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Do previous experience and geographic proximity matter? Possible predictors for diagnosing Adjustment disorder vs. PTSD ⁎
Michal Mahat-Shamir , Lia Ring, Yaira Hamama-Raz, Menachem Ben-Ezra, Shani Pitcho-Prelorentzos, Udi Y. David, Adi Zaken, Osnat Lavenda School of Social Work, Ariel University, Israel
A R T I C L E I N F O
A B S T R A C T
Keywords: ICD-11 Terror attack Adjustment disorder PTSD
The minority of people who have experienced a traumatic event and were diagnosed as either suffering from PTSD or from Adjustment disorder, may suggest that victims of a traumatic event vary in risk factors for the disorders. The current research aimed at examining the association between reports of Adjustment disorder and PTSD symptoms (In accordance with the proposed revisions of the ICD-11) and several vulnerability variables: previous traumatic event, previous stressful event and physical proximity to the terror attack. Using an online survey, 379 adult participants were recruited, and filled out Adjustment disorder, PTSD symptomatology scales, as well as a previous exposure, magnitude of exposure and death anxiety scales. Findings revealed that previous experience of traumatic events was a significant predictor associated with both PTSD and Adjustment disorder symptoms. Previous experience of stressful events was a significant predictor associated with Adjustment disorder alone. Physical proximity to the site of the attack was a significant predictor associated with PTSD symptoms but not Adjustment disorder symptoms. The importance of previous traumatic events, previous stressful events and physical proximity to the terror attack as factors which are associated with Adjustment disorder and PTSD symptomatology is discussed.
1. Introduction
Related Health Problems (ICD-11), scheduled for presentation to the World Health Assembly for approval in 2017, has provided an opportunity for the World Health Organization (WHO) to revisit these issues and devise a classification whose aim is to improve clinical utility and global applicability (International Advisory Group for the Revision of ICD-10 Mental and Behavioral Disorders, 2011; Reed, 2010; First et al., 2015). The working group of the ICD-11 has recommended a separate grouping of disorders specifically associated with stress for ICD-11, rather than combining them with anxiety disorders as in ICD-10 or DSM-5. Disorders specifically associated with stress have two key characteristics: they are identifiable on the basis of different psychopathology that is distinct from other mental disorders; and they arise in specific association with a stressful event or series of events. For each disorder in the grouping, the stressor is a necessary, although not sufficient, causal factor. The stressor could range from negative life events within the normal range of experience (in the case of Adjustment disorder) to traumatic stressors of exceptional severity (in the case of PTSD) (Maercker et al., 2013). As the ICD-11 provides new specific diagnostic criteria for both PTSD and Adjustment disorder, the current research aims at contributing to the understanding of the distinct
Threatening and stressful events, such as terror attacks, may be risk factors for many mental disorders. Disorders specifically associated with stress used to be the only diagnoses that included a direct exposure to a stressful event in their etiology as a qualifying diagnostic requirement. These diagnoses were also the subject of continuing controversy (Bracken et al., 1995; Stein et al., 2007). When the Diagnostic and Statistical Manual of Mental Disorders (DSM) -5 broadened the eligibility for the diagnosis of PTSD to include those people whose exposure was indirect (for example, hearing about a stressful event happening to others, or seeing it on television), some pointed out that such diagnostic expansion both diluted the value of the original construct and medicalized normal stress reactions (Stein et al., 2007; McNally, 2003). Significant controversy is also associated with the diagnosis of Adjustment disorder, in spite of its frequent use by clinicians (Reed et al., 2011; Evans et al., 2013). Adjustment disorder is one of the most ill-defined mental disorders, often described as the “wastebasket” of the psychiatric classification scheme (Casey and Bailey, 2011). The revision of the International Classification of Diseases and
⁎
Corresponding author. E-mail address: [email protected] (M. Mahat-Shamir).
http://dx.doi.org/10.1016/j.psychres.2017.08.085 Received 30 January 2017; Received in revised form 6 August 2017; Accepted 29 August 2017 0165-1781/ © 2017 Elsevier B.V. All rights reserved.
Please cite this article as: Mahat-Shamir, M., Psychiatry Research (2017), http://dx.doi.org/10.1016/j.psychres.2017.08.085
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prior traumas, especially during childhood (Resnick et al., 1995; Breslau et al., 1999; Galea et al., 2002; Berntsen et al., 2012), compared with adult trauma victims who have not succumbed to PTSD. Notably, these findings also indicate the important role of the time since the traumatic event (De Bellis, 2001). These previous research findings may be interpreted as supporting a possible “sensitization” process, that is, early stressors producing greater responsiveness to subsequent stressors. To our best knowledge, there is no evidence in the literature indicating that previous trauma is a predictor of Adjustment disorder. Nevertheless, according to the ICD11, Adjustment disorder may be a maladaptive reaction to a combination of stressful life situations (Maercker et al., 2013). Therefore it is possible to assume the "sensitization" process is also valid for Adjustment disorder, namely that the experience of previous traumatic event will be a predictor of Adjustment disorder.
variables between Adjustment disorder and PTSD symptoms (in accordance with the revision of the ICD-11). According to ICD-11, Adjustment disorder is a maladaptive reaction to a stressful event, to ongoing psychosocial difficulties or to a combination of stressful life situations that usually emerges within a month of the stressor and tends to resolve in 6 months unless the stressor persists for a longer duration. The reaction to the stressor is characterized by symptoms of preoccupation like excessive worry, recurrent and distressing thoughts about the stressor or constant rumination about its implications. There is failure to adapt, i.e., the symptoms interfere with everyday functioning, like difficulties concentrating or sleep disturbance resulting in performance problems. The symptoms can also be associated with loss of interest in work, social life, caring for others, leisure activities resulting in impairment in social or occupational functioning (restriction of social network, conflicts in family, absenteeism and so on). If the definitional requirements are met for another disorder, that disorder should be diagnosed instead of Adjustment disorder (Maercker et al., 2013). PTSD according to the ICD-11 is a disorder that develops following exposure to an extremely threatening or horrific event or series of events characterized by: 1) re-experiencing the traumatic event(s) in the present in the form of vivid intrusive memories accompanied by fear or horror, flashbacks, or nightmares; 2) avoidance of thoughts and memories of the event(s), or avoidance of activities or situations reminiscent of the event(s); and 3) a state of perceived current threat in the form of excessive hyper-vigilance or enhanced startle reactions. The symptoms must last for at least several weeks and cause significant impairment in functioning (Maercker et al., 2013). Notably, Contrary to the DSM-5 which requires a time frame for the diagnosis of PTSD, this is not a requirement in the proposed ICD-11. As noted above, a stressor is a necessary for both Adjustment disorder and PTSD and it could range from negative life events within the normal range of experience (in the case of Adjustment disorder) to traumatic stressors of exceptional severity (in the case of PTSD) (Maercker et al., 2013). In that matter, it is important to note that the vast majority of community residents have experienced traumatic events (Breslau et al., 1999). Nevertheless, only a small minority of victims (< 10%), developed post-traumatic stress disorder (PTSD) (Breslau et al., 1998, 2004) and a diagnosis of Adjustment disorder may be much less of a common diagnosis in light of the ICD-11 revision. The minority of people, who have experienced a traumatic event and were diagnosed as either suffering from PTSD or from Adjustment disorder, may suggest that victims of a traumatic event vary in risk factors for the disorders (Breslau et al., 1999). The current research aim is at examining the association between reports of Adjustment disorder and PTSD symptoms (in accordance with the revision of the ICD-11) and several vulnerability variables: experience of previous traumatic events, experience of previous stressful events and physical proximity to the site of event.
1.2. Previous stressful event Stressors are decisive life changes that occur following a stressful critical event (e.g. separations, emigration, chronic or severe acute illness, unemployment, conflicts in the workplace) (Baumeister et al., 2009). According to the ICD-11, PTSD is a disorder that develops following exposure to an extremely threatening or horrific event or series of events (Maercker et al., 2013), therefore it is not expected to find previous stressful event (which is not extremely threatening or horrific) to be a predictor for PTSD. With regard to Adjustment disorder, since it was most often associated with acute stressful events (Dobricki et al., 2010; Maercker et al., 2012), it is possible to assume that a previous stressful event will be a predictor for Adjustment disorder. Moreover and based on conservation of resource theory (COR) (Hobfoll, 1989), it is possible to assume that a previous stressful event is associated with psychosocial resource loss that begets mental health problems such as Adjustment disorder. 1.3. Physical proximity to the site of the attack There is some evidence that proximity to a terror scene may increase the risk of PTSD symptoms (Grieger et al., 2005; Schlenger et al., 2002) and that the closer one is to the terror scene, the greater is the PTSD symptoms level. For example, a population-based survey conducted 1 month after September 11 found that 7.5% of residents of Manhattan living south of 110th Street had symptoms consistent with a diagnosis of probable PTSD related to the attacks (Galea et al., 2002). Another post-disaster study of PTSD among employees of a hotel that was hit by a plane showed that employees who were onsite, and thus more directly affected by the event, had a higher prevalence and more prolonged duration of PTSD than offsite employees (Smith et al., 1990). These research findings meet the ICD-11 criteria for diagnosing PTSD, as the physical proximity to a terror attack site may be experienced as an extremely threatening or horrific event. As the physical proximity to a terror attack site may be experienced as an extremely threatening or horrific event and is neither a mere stressful event nor does it constitute an ongoing psychosocial difficulty or a combination of stressful life situations; the physical proximity to a terror attack does not meet the ICD-11 criteria for diagnosing Adjustment disorder.
1.1. Previous traumatic event One of the risk factors which modifies the probability of PTSD and of Adjustment disorder, may be a previous traumatic event experienced by the individual. Studies have indicated the association between previous trauma and the prevalence of PTSD. For an example, Galea et al. (2003) examined trends in probable PTSD prevalence in the general population of New York City in the first 6 months after the September 11 terrorist attack. The authors found that highest PTSD was reported among persons who had experienced 4 or more previous traumatic events (15.1%) vs. persons who had never experienced traumatic events (2.5%). Palgi et al. (2014) found that exposure to Hurricane Sandy was related to PTSD symptoms among those with high level of recollections of the WTC terror attack and past hurricanes. Moreover, Epidemiologic surveys have documented that adults with PTSD report elevated rates of
1.4. The current research The current study was conducted in Israel, a state that has known many wars and battles since its establishment, in 1948 (Bleich, 2017). In light of the ongoing Israeli-Palestine conflict, the population in Israel has always been the target of terror attacks, until this very day. The current study was conducted last June (June 8th, 2016 at 21:04), immediately after two Palestinian gunmen opened fire on civilians dining in a restaurant in “Sarona Market” in Tel Aviv, killing four people and 2
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2.2.2. Adjustment disorder Adjustment Disorder was assessed based on the Adjustment disorder New Module originally developed by Einsle et al. (2010) and later shortened to 20 items (Glaesmer et al., 2015; Maercker et al., 2012). The ADMN-20 is a measure based on the proposed ICD 11 adjustment disorder criteria. Core symptom clusters assessed were: preoccupation (four items) and failure to adapt (three items). Subtypes assessed were: avoidance (four items); depressed (three items); anxiety (two items); and impulse disturbance (three items). These subtypes are associated features that allow clinicians to identify the precise type of syndrome (Bachem et al., 2016). Finally, a criterion of impairment, indicating that the symptoms cause clinically significant impairment in social, occupational or other important area of functioning, was assessed. Participants were asked to indicate the frequency of items on the shortened version of the measure, on a 4-point Likert scale (1 = never; 2 = rarely; 3 = sometimes; 4 = often). Cronbach's alpha calculated for the present study was 0.960.
injuring 16 others (http://mfa.gov.il/MFA/ForeignPolicy/Terrorism/ Palestinian/Pages/Wave-of-terror-October-2015.aspx). Accordingly, Israel - a place experiencing terror/war may have a relatively higher level of death anxiety due to this relative large terror exposure. As death anxiety is known to be associated with various stress disorders (Hamama-Raz et al., 2016), we examined death anxiety in order to covariate it out and obtain results that were not driven by such anxiety. Below, prior to summarizing our hypotheses, we address death anxiety in greater detail. It is important to note that exposure to threatening life events can heighten death anxiety and psychiatric morbidity (Hoelterhoff and Chung, 2013). Moreover, exposure to terror attacks and violence, especially when the exposure is continuous, may have significant repercussions that may result in emotional stress, posttraumatic stress disorder, depression and risk-taking behaviors (Silver et al., 2002; Vizek‐Vidović et al., 2000), some of which have been linked with death anxiety. For example, death anxiety has been recently associated with post-traumatic symptom severity during ongoing terror attacks (Hamama-Raz et al., 2016). In addition, the importance of death anxiety as a precursor of well-being in older adults has been established (see review by Fortner and Neimeyer, 1999), and has been shown to affect individuals across the life cycle (Russac et al., 2007). The reoccurrence of such events that may heighten death anxiety, in Israel, allows for a better examination of the impact of previous exposure on the psychological responses of the population. Therefore, the current study aims at examining the psychological impact of the exposure to the terror attack in "Sarona Market" and its related risk factors. In particular, the study focuses on the association between reports of Adjustment disorder and PTSD (in accordance with the proposed revision of the ICD-11) and the experience of previous traumatic events, the experience of previous stressful events, and the physical proximity to the site of the attack. Based on the above, we have hypothesized the following:
2.2.3. PTSD PTSD was measured using the Post-traumatic Stress Disorder Checklist – Civilian Version, which is the ICD-11 proposed PTSD criteria based on the 6-items tapping to each cluster (avoidance, hyperarousal, re-experiencing) (Knefel and Lueger-Schuster, 2013). Notably, the proposed ICD 11 criteria for PTSD is different from the DSM-5 PTSD criteria. The proposed ICD 11 PTSD criteria refers only to core PTSD symptoms (Knefel and Lueger-Schuster, 2013). Participants were asked to rate on a five point Likert scale ranging from 1 = ‘‘none’’ to 5 = ‘‘very’’, the symptoms experienced in the past 4 weeks. A symptom was classified as present if participants rated it with 3 (‘‘moderately’’) or higher. The final PTSD score was comprised of the sum of all present symptoms. Cronbach's alpha calculated for the present symptoms was 0.807. 2.2.4. Previous exposure Participants were asked to report their previous exposure to stressful and traumatic life events. They were asked to refer to the occurrence of stressful life events (such as divorce, marriage, sickness of a close person, difficulties at work, material hardship, retirement, a move to a new apartment, crime victimization etc.) and to traumatic life events (such as life threatening event for the participant himself/herself or his/ her close ones, or witnessing a life threatening event) in the past month, on a free recall basis. In particular, the participants were asked two separate questions: a) were you exposed to stressful life events, in the past month? And b) were you exposed to traumatic life events, in the past month? Participants responded to each question with 1 = ’no’ or 2 = ‘yes’.
a) Previous exposure to stressful or traumatic events in the past will be positively associated with Adjustment disorder symptoms. b) Based on the previous studies, previous exposure to traumatic events in the past, but not previous exposure to stressful events, will be positively associated with PTSD symptoms. c) Based on previous studies, physical proximity to the site of the attack will be positively associated with PTSD symptoms.
2. Method 2.1. Procedure and sample
2.2.5. Magnitude of exposure Magnitude of exposure was indicated by the physical proximity of the participants to the site of the attack. Participants were asked to report whether they were present in the “Sarona Market” area during the shooting attack. Responses were 1 = ’no’; 2 = ’yes’.
The study was conducted immediately after the occurrence of the shooting attack in “Sarona Market” in Tel Aviv. A convenience sample of adult Jewish Israelis was collected using an online survey, advertised through various means such as social media (mainly Facebook) and smartphone applications (e.g., Whatsapp). The link led to a dedicated site where participants provided informed consent. The survey was anonymous and no personal information could be identified. The sample consisted of 379 participants living in different areas in Israel, ranging in age from 18 to 69 (M = 34.4; SD = 10.67). It included 240 women (63.3%). The study was approved by the ethics committee in faculty of social sciences at the authors' university.
2.2.6. Death anxiety A single item measure was used to indicate death anxiety (AbdelKhalek, 1998). Participants were asked to what extent they agree with the statement: “I am afraid of death”. Responses were on a 7 point Likert scale ranging from 1 = ’strongly disagree’ to 7 = ’strongly agree’.
2.2. Measures
2.3. Data analysis
2.2.1. Demographics Participants were asked to report their age by providing year of birth, their gender (1 = male; 2 = female) and their current marital status (1 = single; 2 = married or living in partnership).
In order to test the study's hypotheses two-step hierarchical regression analyses were conducted using SPSS 23 software (IBM Corp.). The first step included control variables that were demographic variables: participants' age, gender, marital status and death anxiety 3
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Table 1 Mean scores, standard deviations and frequencies of the study's variables (n = 379). Variables
Dependent variables Adjustment disorder PTSD (positive symptoms) Independent variables Age (years) Gender (Male) Marital status (Single) Death anxiety Strongly disagree Disagree Disagree somewhat Neither Disagree nor agree Agree somewhat Agree Strongly agree Were in “Sarona Market” during the attack (Yes) Exposure to stressful event in the past month (Yes) Exposure to traumatic event in the past month (Yes)
Table 2 Factors associated with Adjustment disorder following shooting attack (n = 379).
Statistics
Variables
Mean
S.D
39.7 1.1
14.42 1.57
34.4
10.67
N (%) Adjustment disorder Step 1 Age (years) Gender Marital status Step 2 Age (years) Gender Marital status Death anxiety Were in “Sarona Market” during the attack Exposure to stressful event in the past month Exposure to traumatic event in the past month Model summary Step 1
139 (36.7) 165 (43.5) 12 (3.2) 32 (8.4) 29 (7.7) 77 (20.3) 69 (18.2) 106 (28.0) 54 (14.2) 18 (4.7) 137 (36.1) 35 (9.2)
which is known to be associated with various stress disorders. The second step included participants’ reports of being present in the “Sarona Market” area during the shooting attack and the two independent variables indicating participants’ exposure to previous stressful and/or traumatic life events, in the past month. Regression analysis was conducted once with Adjustment disorder as the dependent variable and again with PTSD symptoms as the dependent variable. Additionally, potential multicollinearity was examined between the study variables. No indication of multicollinearity was found, as tolerance levels ranged from 0.830 to 0.969 and variation inflation factor levels ranged from 1.032 to 1.204, indicating low levels of multicollinearity which are considered in line with literature requirements (O'Brien, 2007).
Step 2
Statistics B
S.E
t
P value
0.287 2.384 − 3.518
0.073 1.502 1.562
3.923 1.887 − 2.253
P < 0.001 0.113 0.025
0.188 2.722 − 1.758 1.949 4.513
0.072 1.444 1.533 0.434 3.449
2.615 1.884 − 1.146 4.490 1.308
0.009 0.060 0.252 P < 0.001 0.192
3.571
1.521
2.348
0.019
9.919
2.723
3.642
P < 0.001
R = 0.325; R2 = 0.106; R2 change = 0.106; F (4,374) = 11.054; p < 0.001 R = 0.431; R2 = 0.186; R2 change = 0.080; F (3,371) = 12.115; p < 0.001
Table 3 Factors associated with PTSD following shooting attack (n = 379). Variables
PTSD Step 1 Age (years) Gender Marital status Step 2 Age (years) Gender Marital status Death anxiety Were in “Sarona Market” during the attack Exposure to stressful event in the past month Exposure to traumatic event in the past month Model summary Step 1
3. Results Table 1 summarizes the mean scores, standard deviations and frequencies of the study's variable. Table 2 summarizes the results of the regression analysis conducted to test the predicting power of the independent variables (previous exposure to stressful, traumatic events and physical proximity to the site of the attack) on Adjustment disorder. As indicated in Table 2, the model explains 18.6% of the variance in Adjustment disorder. The control variables contributed significantly to the explained variance (F [4,374] = 11.054, p < 0.001) and accounted for 10.6% of the variation in Adjustment disorder. Introducing the independent variables contributed above and beyond the control variables and explained an additional 8.0% of variation in Adjustment disorder. The change in R2 was significant (F [3,371] = 12.115, p < 0.001). In line with the study's hypothesis, the physical proximity to the site of the attack was found to be non-significant predictor of Adjustment disorder, while previous exposure to stressful or traumatic events in the past month were positively and significantly associated with Adjustment disorder (B = 3.571; t = 2.348; p = 0.019; B = 9.919; t = 3.642; p < 0.001, in accordance). Table 3 summarizes the results of the regression analysis conducted to test the predicting power of the independent variables (previous exposure to stressful, traumatic events and physical proximity to the site of the attack) on PTSD. As indicated in the table, the model explains 23.2% of the variance in PTSD. The control variables contributed significantly to the explained variance (F [4,374] = 10.311, p < 0.001) and accounted for 9.9% of the variation in PTSD. Introducing the
Step 2
Statistics B
S.E
t
P value
0.007 0.294 − 0.704
0.008 0.165 0.171
0.912 1.784 − 4.113
0.362 0.075 P < 0.001
− 0.006 0.373 − 0.425 0.171 1.686
0.008 0.153 0.163 0.046 0.366
− 0.765 2.433 − 2.612 3.718 4.605
0.445 0.015 0.009 P < 0.001 P < 0.001
0.311
0.161
1.929
0.055
1.036
0.289
3.584
P < 0.001
R = 0.315; R2 = 0.099; R2 change = 0.099; F (4,374) = 10.311; p < 0.001 R = 0.482; R2 = 0.232; R2 change = 0.133; F (3,371) = 12.994; p < 0.001
independent variables contributed above and beyond the control variables and explained an additional 13.3% of variation in PTSD. The change in R2 was significant (F [3,371] = 21.367, p < 0.001). As opposed to the Adjustment disorder model, in the PTSD model, the physical proximity to the site of the attack was found to be a positively significant predictor (B = 1.686; t = 4.605; p < 0.001). In regard to previous exposure to stressful or traumatic events, only previous exposure to traumatic events in the past month was significantly associated with PTSD (B = 1.036; t = 3.584; p < 0.001). Previous exposure to stressful events in the past month was found to be nonsignificant predictor. 4
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4. Discussion
differences such as age, gender and marital status and beyond individual differences in regard to death anxiety. Moreover, as found in earlier studies, the present findings further support the positive association found between age and higher level of PTSD (Hoffman et al., 2015; Lavenda et al., 2017), as well as between gender and levels of PTSD (Cao et al., 2017), in the context of terror or conflict disaster. The current research findings indicate upon the far-reaching impact of disasters, such as a terror attack, that can engender a range of psychological consequences (Raphael and Maguire, 2009). The major question remains as for the severity of the consequences of terror attacks. This question is even more relevant when examining a geographic location, such as Israel, where terror attacks occur with predictable frequency. Within the context of our study, while the average number of positive symptoms of PTSD was low (1.1), 46% of the sample had presented at least one positive symptom of PTSD. Meaning, almost half of the sample present some level of PTSD symptomatology. Regarding the severity question, it is important to note that until relatively recently, the focus on PTSD has nearly engulfed all other considerations about the consequences and implications of terror attacks, while Adjustment disorder was mostly used as a diagnosis when the symptoms of the patient did not fully meet the criteria for other mental health disorders (PTSD, mood disorder or other anxiety disorders) (Maercker et al., 2013). It is important to differentiate between the two disorders when looking at the impact of a terror attack in order to accurate treatment. For example, there is evidence for the usefulness of cognitive behavioral approach for treating Adjustment disorder while both prolonged exposure procedures and stress inoculation training were found effective in reducing symptoms of PTSD. The current study's results emphasize the distinct definitions of Adjustment disorder and PTSD according to the new diagnostic concept of the ICD‐11 (Maercker et al., 2007, 2013), showing the different risk factors for the disorders. Our research should be interpreted in light of several limitations. First, it should be noted that this study was based on self- reported measures, and was collected using a cross-sectional design. Accordingly, there was no information regarding participants' psychiatric condition prior to data gathering. Moreover, as data was collected through an online survey, the issue of a self-selection bias may be a potential limitation in the current study, and future studies may choose to employ alternative data gathering methods. Additionally, our study assessed the association between Adjustment disorder and PTSD and previous trauma, pervious stressful events and proximity to the terror attack in a population which is under a threat of ongoing terror. Geographic locations where terrorist attacks occur with regularity are also typically encumbered by other terrorist-related stressors, such as frequent reminders of the attack, likelihood of losing a loved one, personal injury, disruption in routine, and post-disaster stress in the community (Shalev et al., 2006). Therefore, it is important to examine whether the association between the variables varies among different populations and situations. Lastly, participants were asked to report PTSD symptoms in the past 4 weeks, even though the report of time duration is not required according to ICD-11. Despite this difference, it is assumed that the present findings were not affected by it. Despite these limitations, to the best of our knowledge, the current study is one of the very few research efforts to examine previous trauma, previous stressful events and proximity to the terror attack as predictors of Adjustment disorder and PTSD as defined in the revision of the ICD-11. In light of these risk factors, we aim for delineating the difference between adjustment disorders and PTSD by using a risk/ protective factors profiles. Albeit, this is a very preliminary step, evidently these conditions share a common denominator such as death anxiety that according to the TMT is one to common denominators of stress syndromes (Iverach et al., 2014). However, other risk factors such as proximity and exposure to stressful event in the last month help to differentiate between adjustment disorders and PTSD. More studies are needed to further explore this suggestion and to gather more findings in
The current study focused on risk factors predicting PTSD and Adjustment disorder symptoms in light of the proposed ICD-11 criteria. In particular, the present study examined the association between previous exposure to traumatic events, previous exposure to stressful events, physical proximity to the terror attack site and the reported symptoms of PTSD and Adjustment disorder following a terror attack. Due to the ongoing Israeli-Palestinian conflict, Israel is a living lab for stress syndromes as Israeli citizens are continuously exposed to terror attacks that may heighten death anxiety and psychiatric morbidity (Hoelterhoff and Chung, 2013). It is important to note that death anxiety was found to be significantly associated with both PTSD and Adjustment disorder. Therefore, following previous studies (HamamaRaz et al., 2016) and TMT (Meni: What is TMT, no all the readers know that you mean Terror Management Theory; you should explain a bit)., it was important to control for death anxiety un the current study. Moreover, and as terror attacks may heighten death anxiety and psychiatric morbidity (Hoelterhoff and Chung, 2013), the presentation of stress symptoms in the aftermath of a stressful or a traumatic event in the short term, is well known. Nevertheless, in line with the study's hypotheses, previous experience of traumatic events in the past month was found to be a significant predictor of both PTSD and Adjustment disorder symptoms, while previous experience of stressful events in the past month was found to be a significant predictor of Adjustment disorder alone. These findings support the existence of a “sensitization” process that puts individuals that have recently experienced trauma, at risk of developing either PTSD or Adjustment disorder. Nevertheless, this sensitization process is somewhat diverse, based on the intensity of the previous experience. Individuals that have recently experienced a stressful event, which is considered to be a relatively low-scaled event in terms of the psychological distress it evokes (Brickman and Campbell, 1971; Clark et al., 2008; Lucas et al., 2003) are prone to developing Adjustment disorder but not PTSD; whereas individuals who have recently experienced a much more intense and disturbing event may be prone to develop either Adjustment disorder or PTSD. These findings align with the ICD-11 revision regarding the distinct definition of both disorders and the circumstances in which they are most probably evoked. Namely, PTSD is defined based on the occurrence of a life threatening event, i.e. traumatic event, whereas Adjustment disorder is diagnosed based on the exposure to a stressful event, ongoing psychosocial difficulties or to a combination of stressful life situations (Maercker et al., 2013). Regarding the study's hypothesis on physical proximity to the attack site, the findings indicate the power of proximity in predicting PTSD symptoms but not of Adjustment disorder symptoms. Here again, the physical proximity to the site of attack serves as a differentiating factor between these diagnoses. These findings align with previous findings indicating the significance of physical proximity cycles and its diverse impact on the extent to which individuals develop psychological distress (Galea et al., 2002). Moreover, the findings further differentiate the diagnosis of Adjustment disorder from that of PTSD. One way to explain these findings is by the fact that individuals who were physically close to the life threatening event are more likely to experience a sever sense of danger. Danger is a gradient gateway to PTSD exposure, whereas for AJD across all levels of proximity – whether far away or even further away – one may feel the same level of stress just by being exposed to the news, this is relevant to AJD – but that is separate from danger (PTSD). The fact that physical proximity to the site of event does not play a role in the reported symptoms of Adjustment disorder may thus, be attributed to the fact that the physical proximity to the terror site is an extremely threatening or horrific event that may cause a severe sense of danger, and not a stress. Therefore, it does not meet the ICD-11 criteria for diagnosing Adjustment disorder. It is important to note that the findings of the present study were found beyond possible demographic 5
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