Yafit Levin

Depression and PTSD Co-Morbidity: What are We Missing?

Background: Posttraumatic stress disorder (PTSD) and depression comorbidity is highly common. Many hypotheses concerning this relation have been raised but the pertinent issues, including the wide clinical picture of this comorbidity, are still not clear. The current study aims to bridge these gaps. Method: We assessed PTSD, depression and comorbid indicators including dissociation, somatization, selfdestructive behavior and suicidality among Israeli Yom Kippur war veterans at three time points (N = 349, 287, 301). Results: Dissociation, somatization, self-destructive behavior and suicidality were predicted separately by group (PTSD, depression and comorbidity) and time of measurement using ANOVA and Chi squared analyses. The ‘comorbidity’ group expressed significantly higher dissociation, somatization, self-destructive behavior and suicidality, revealing high vulnerability of this group. Somatization presented a curvilinear-like development, increasing between T1 and T2 and slightly declining at T3, especially among the ‘comorbidity’ group. Suicidality showed a constant increase along the three measurements, especially among the comorbidity group. Conclusions: A PTSD/depression comorbidity is both highly prevalent and long lasting and is often expressed concurrently with other related symptomatology, which causes further suffering and makes it more complicated for treatment. Implications for policy makers are briefly discussed.

The implications of war captivity and long-term psychopathology trajectories for telomere length

BACKGROUND Previous findings have demonstrated the link between trauma, its psychopathological aftermath and cellular aging, as reflected in telomere length. However, as long-term examinations of psychopathology following trauma are scarce, very little is known regarding the repercussions of depression and PTSD trajectories of psychopathology for telomeres. The current study examined the implications of war captivity and depression/PTSD trajectories on telomere length. METHODS Ninety-nine former prisoners of war (ex-POWs) from the 1973 Yom Kippur War were evaluated for depression and PTSD at 18, 30, 35 and 42 years after the war. Data on leukocyte telomere length of ex-POWs and 79 controls was collected 42 years after the war. RESULTS Ex-POWs had shorter telomeres compared to controls (Cohens d=.5 indicating intermediate effect). Ex-POWs with chronic depression had shorter telomeres compared to those with delayed onset of depression (Cohens d=4.89), and resilient ex-POWs (Cohens d= 3.87), indicating high effect sizes. PTSD trajectories were not implicated in telomere length (Partial eta2=.16 and p=.11). CONCLUSION The findings suggest that the detrimental ramifications of war captivity are extensive, involving premature cellular senesces. These findings further point to the wear-and-tear effect of long-term depression, but not PTSD, on telomere length. Explanations for the findings are discussed.

World Assumptions Among Wives of Former Prisoners of War

This study examines (a) secondary trauma by evaluating World Assumptions (World Assumptions Scale scores) among spouses of Israeli ex-prisoners of war (ex-POWs) and (b) the relationship between the husbands’ current posttraumatic stress disorder (PTSD) symptoms and PTSD trajectory and the wives’ world assumptions. Data were prospectively collected thrice for ex-POWs and comparable veterans, and twice for their spouses. This study extends current research as it links trauma, beyond PTSD symptoms, to more negative world assumptions among spouses of traumatized ex-POWs. Spouses of ex-POWs with PTSD symptoms reported lower benevolence of the people and self-worth and higher randomness compared with spouses of ex-POWs without PTSD symptoms. Spouses of ex-POWs who endorsed chronic PTSD symptoms also reported greater levels of self-control compared with the delayed PTSD symptoms group. Results suggest that the relationship between husbands’ PTSD symptoms and wives’ world assumptions may be mediated by wives’ PTSD symptoms. The implications of the findings are discussed.

The Implication of Combat Stress and PTSD Trajectories in Metabolic Syndrome and Elevated C-Reactive Protein Levels: A Longitudinal Study

OBJECTIVE This study sheds light on the importance of long-term follow-up of trauma survivors, posttraumatic stress disorder (PTSD) trajectories, and early detection of health risk factors in trauma survivors. The present study prospectively assessed the following over 23 years: (1) the association of psychological and physiologic stress during captivity with elevated C-reactive protein (CRP) levels and metabolic syndrome (MetS), which includes hypertension; elevated levels of insulin, triglycerides, and fasting glucose; decreased levels of high-density lipoprotein cholesterol; and obesity and (2) the implication of PTSD trajectories in elevated CRP levels and MetS. METHODS Measurements were taken in 1991, 2003, 2008, and 2015. Participants were 116 Israeli combat veterans of the 1973 Yom Kippur War (of these, 101 were former prisoners of war [ex-POWs] and 15 were comparable controls). The medical assessments relevant for this study were body mass index, fasting blood glucose levels, and diabetes, blood pressure or a diagnosis of hypertension, high-density lipoprotein cholesterol and triglyceride levels, and medication intake. In addition, the PTSD Inventory was used to assess PTSD symptoms and trajectories over time according to DSM-IV-TR PTSD criteria. RESULTS Captivity-in particular, the captivity stressors of weight loss, physical suffering, psychological suffering, and humiliation-was implicated in both elevated CRP levels and MetS, significantly so with elevated CRP levels (P = .01, R² = 0.33). Captivity-induced PTSD, in particular chronic and delayed PTSD trajectories, was associated with elevated CRP levels and MetS, significantly so for MetS (P = .05). CONCLUSIONS Monitoring inflammation using markers like CRP level in trauma survivors can be beneficial, particularly if PTSD is chronic or delayed. Clinicians treating trauma survivors should raise awareness of the importance of such measures in light of long-term health vulnerabilities.

Intergenerational transmission of captivity trauma and posttraumatic stress symptoms: A twenty three-year longitudinal triadic study.

Objectives: The aversive, long-term toll of war captivity and fathers’ combat-induced posttraumatic stress disorder symptoms (PTSS) on adult offspring’s mental health has been recently exemplified. However, studies that have examined the implication of PTSS of both fathers and mothers in the intergenerational transmission of trauma to offspring are still lacking. This prospective study assessed the unique and combined effects of former prisoners of war (ex-POWs) fathers’ and mothers’ PTSS in adult offspring’s PTSS. Method: A sample of 123 Israeli father–mother–offspring triads (79 ex-POW triads and a comparable group of 44 veteran triads) completed self-report measures. Following the 1973 Yom Kippur War, fathers participated in 3 waves of measurements (1991, 2003, 2008), mothers participated in 2 waves of measurements (2004, 2011), while offspring took part in 2014. Results: Both fathers’ and mothers’ PTSS were positively related to offspring’s PTSS. Among ex-POW triads, fathers’ PTSS in 2003 and 2008 and mothers’ PTSS in 2004 predicted offspring’s PTSS in 2014. Interestingly, serial multiple mediation model results showed that mothers’ PTSS in 2004 mediated the link between fathers’ PTSS in 1991 and offspring’s PTSS in 2014. Furthermore, fathers’ PTSS in 2008 mediated the link between mothers’ PTSS in 2004 and offspring’s PTSS in 2014. Conclusions: Over time, both ex-POWs fathers’ and mothers’ PTSS are implicated in their offspring’s PTSS. However, both direct and indirect effects of both parents’ posttraumatic reactions contribute to the intergenerational transmission of captivity related trauma.

Posttraumatic stress symptoms and marital adjustment among Israeli combat veterans: The role of loneliness and attachment.

Objective: War trauma may foster ramifications for marital relationships. Veterans may feel that no one can understand them and thus impact their relationships. The current study aims to shed light on the role that posttraumatic stress symptoms (PTSS), loneliness, and attachment orientations may play in marital adjustment among combat veterans. Method: Participants were 504 veterans who served in the Lebanon War in 1982. Results: Analysis revealed that higher PTSS levels were related to lower marital adjustment and that the indirect path of this relation through loneliness was significant. Furthermore, attachment orientations moderated the direct link between PTSS and marital adjustment, but failed to moderate the indirect effect through loneliness. Conclusions: A sense of isolation should be addressed in therapy, as well as the interpersonal expectations of the veteran.

Posttraumatic growth among spouses of combat veterans: Adaptive or maladaptive for adjustment?

We examined the relationship between posttraumatic growth (PTG) and distress in spouses of trauma survivors. A sample of spouses of combat veterans of the 1973 Yom Kippur War were assessed using questionnaires pertaining to PTG, depression, anxiety, and posttraumatic stress, in 2004 and 2011. Applying cross-lagged modeling strategy, higher PTG levels predicted higher depression and anxiety levels above and beyond initial distress. Thus, psychological growth in spouses of survivors appears to signify subsequent distress.

The Impact of Captivity and Posttraumatic Stress Disorder on Cognitive Performance Among Former Prisoners of War: A Longitudinal Study

OBJECTIVE War captivity is a potent pathogen for various aspects of mental health, including cognitive impairments. However, little is known about the long-term impact of war captivity and posttraumatic stress disorder (PTSD) on cognitive functioning among former prisoners of war (ex-POWs). This study assesses the effect of captivity, PTSD trajectories, and the accumulating differential effect in the prediction of cognitive performance. METHODS This longitudinal research includes 4 assessments (1991 [T1], 2003 [T2], 2008 [T3], 2015 [T4]) of Israeli ex-POWs and comparable combatants from the 1973 Yom Kippur War. Accordingly, 95 ex-POWs and 26 comparable combatants were included in this study. PTSD was assessed according to the DSM-IV, and cognitive performance was assessed using the Montreal Cognitive Assessment (MoCA). RESULTS Ex-POWs reported higher levels of PTSD symptoms compared to controls (P = 0.007). No difference was found between the groups regarding MoCA total score. Ex-POWs with chronic PTSD were found to have more difficulty in overall cognitive functioning, compared to ex-POWs with delayed, recovery, and resilient trajectories (P = 0.03). Finally, physical and psychological suffering in captivity and intrusion symptoms predicted cognitive performance (P < .001, R² = 37.9%). These findings support the potent pathogenic effects of war captivity on cognitive abilities, more than 4 decades after the end of the traumatic event. CONCLUSIONS Our results showed captivity to be a unique and powerful traumatic experience, leading to PTSD and long-lasting and enduring neuropsychological implications. These findings highlight the importance of viewing ex-POWs, in particular those suffering from chronic PTSD, especially as they age, as a high-risk population for cognitive disorders. This requires the appropriate diagnosis and cognitive therapy as a way to preserve cognitive abilities among this population.

Long-Term Trajectories of Posttraumatic Stress Disorder: Categorical versus Continuous Assessment

Objective: Long-term trajectories of posttraumatic stress disorder (PTSD) may fluctuate over time and typically conform to four heterogeneous patterns: resilience, recovery, delayed-onset, and chronic symptomatology. However, such fluctuations are typically short ranged and have rarely been investigated over the course of decades after the trauma. Moreover, existing studies have used a variety of measurements, either employing a categorical Diagnostic and Statistical Manual of Mental Disorders (DSM)-oriented approach or a continuous measure of symptom severity. The aim of this study was to evaluate the two methods of analyzing trajectories of PTSD by examining the level of concordance between them, their sensitivity, and their validity. Method: A total of 349 Israeli veterans from the 1973 Yom Kippur War were examined at four time points over more than four decades since the war. A latent class growth analysis (LCGA) was conducted to identify different PTSD trajectories, using both categorical and continuous PTSD assessments. Results: Descriptive results revealed that the four commonly observed patterns of PTSD are insufficient for capturing the range of individual PTSD trajectories. Using a categorical measure in the explorative LCGA yielded three trajectories (resilient, chronic, and delayed onset). The continuous measure yielded five trajectories (resilient, chronic, recovered, and two delayed-onset trajectories), which provided a slightly more nuanced distinction of participants’ distress-induced psychosocial dysfunction as compared to the three-trajectory solution. Conclusion: These findings suggest that using a continuous PTSD trajectory measure provides a somewhat more sensitive estimation of PTSD trajectories. More specifically, taking into consideration symptom intensity and fluctuation over time may provide a more comprehensive picture of the survivors’ distress.

Perceived social support, loneliness, and later life telomere length following wartime captivity.

Objectives: Telomere length (TL) is a robust indicator of cellular aging. TL erosion has been associated with exposure to social and traumatic stressors. Loneliness and perceived social support are strongly linked to increased morbidity and mortality, but have yet to be investigated in relation to TL after extreme stress. The present study examined whether loneliness and lack of perceived social support following wartime captivity may be associated with TL as repatriated prisoners of war (ex-POWs) enter old age and contribute to its prediction. Method: A cohort of Israeli ex-POWs from the 1973 Yom Kippur War (n = 83) were assessed. Questionnaires were utilized to assess loneliness and perceived social support 18 years after the repatriation (T1), and Southern blotting was used to measure TL 24 years later (T2). A zero-order Pearson correlation test and a hierarchical regression analysis were utilized in order to examine the research questions. Results: Loneliness and lack of perceived social support each significantly predicted shorter TL in later life, and together added 25.8% to the overall explained variance. Conclusions: This is the first study to empirically demonstrate that loneliness and lack of perceived social support in early adulthood may be associated with shorter TL during transition to old age in a population that has endured extreme stress. Although the study design precludes causal inferences, several psychobiological mechanisms may explain the findings. The potential clinical significance of social deficits for longevity and heath in related populations is therefore addressed, and an agenda for future investigations is suggested.