Anxiety Disorders: Shalev AY

Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Foa EB, Kessler RC, McFarlane AC, Shalev AY. · Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Charleston 29425-0742, USA. · J Clin Psychiatry. · Pubmed #10761680 No free full text.

Abstract: OBJECTIVE: To provide primary care clinicians with a better understanding of management issues in posttraumatic stress disorder (PTSD) and guide clinical practice with recommendations on the appropriate management strategy. PARTICIPANTS: The 4 members of the International Consensus Group on Depression and Anxiety were James C. Ballenger (chair), Jonathan R. T. Davidson, Yves Lecrubier, and David J. Nutt. Other faculty invited by the chair were Edna B. Foa, Ronald C. Kessler, Alexander C. McFarlane, and Arieh Y. Shalev. EVIDENCE: The consensus statement is based on the 6 review articles that are published in this supplement and the scientific literature relevant to the issues reviewed in these articles. CONSENSUS PROCESS: Group meetings were held over a 2-day period. On day 1, the group discussed the review articles and the chair identified key issues for further debate. On day 2, the group discussed these issues to arrive at a consensus view. After the group meetings, the consensus statement was drafted by the chair and approved by all attendees. CONCLUSION: PTSD is often a chronic and recurring condition associated with an increased risk of developing secondary comorbid disorders, such as depression. Selective serotonin reuptake inhibitors are generally the most appropriate choice of first-line medication for PTSD, and effective therapy should be continued for 12 months or longer. The most appropriate psychotherapy is exposure therapy, and it should be continued for 6 months, with follow-up therapy as needed.

Hobfoll SE, Watson P, Bell CC, Bryant RA, Brymer MJ, Friedman MJ, Friedman M, Gersons BP, de Jong JT, Layne CM, Maguen S, Neria Y, Norwood AE, Pynoos RS, Reissman D, Ruzek JI, Shalev AY, Solomon Z, Steinberg AM, Ursano RJ. · Summa-Kent State University, Center for the Treatment and Study of Traumatic Stress, Akron, OH 44310, USA. · Psychiatry. · Pubmed #18181708 No free full text.

Abstract: Given the devastation caused by disasters and mass violence, it is critical that intervention policy be based on the most updated research findings. However, to date, no evidence-based consensus has been reached supporting a clear set of recommendations for intervention during the immediate and the mid-term post mass trauma phases. Because it is unlikely that there will be evidence in the near or mid-term future from clinical trials that cover the diversity of disaster and mass violence circumstances, we assembled a worldwide panel of experts on the study and treatment of those exposed to disaster and mass violence to extrapolate from related fields of research, and to gain consensus on intervention principles. We identified five empirically supported intervention principles that should be used to guide and inform intervention and prevention efforts at the early to mid-term stages. These are promoting: 1) a sense of safety, 2) calming, 3) a sense of self- and community efficacy, 4) connectedness, and 5) hope.

Shalev AY, Segman RH. · Department of Psychiatry, Hadassah University Hospital, Jerusalem, Israel. · Prog Brain Res. · Pubmed #18037015 No free full text.

Abstract: Summarizing the contributions in this section of the book, this chapter addresses questions regarding the complex etiology of PTSD, and the relative strength of discernable biological indicators of the disorder. It outlines two major approaches to exploring the biology of the disorder and discusses the reason for the many non-replications of findings. It defines the constructs of multicausality, equifinality, and multifinality, and evaluates their main implication for studies of PTSD, namely that no biological signal can be properly appraised without taking into account its context. Such context, in PTSD, includes both concurring biological systems and regulatory mechanisms, and environmental-psychosocial input. Studies of gene expression of PTSD exemplify one way of studying the context of putative biological signals. The role of biological alterations as templates for responding to psychosocial challenges is discussed.

Peleg T, Shalev AY. · Department of Psychiatry, Center for Traumatic Stress Studies, Hadassah University Hospital, Ein Kerem Campus, Jerusalem 91120, Israel. · CNS Spectr. · Pubmed #16871125 links to  free full text

Abstract: Posttraumatic stress disorder (PTSD) has a discernible starting point and typical course, hence the particular appropriateness of longitudinal research in this disorder. This review outlines the salient findings of longitudinal studies published between 1988 and 2004. Studies have evaluated risk factors and risk indicators of PTSD, the disorder's trajectory, comorbid disorders and the predictive role of acute stress disorder. More recent studies used advanced data analytic methods to explore the sequence of causation that leads to chronic PTSD. Advantages and limitations of longitudinal methods are discussed.

Davidson JR, Stein DJ, Shalev AY, Yehuda R. · Department of Psychiatry and Behavioral Sciences, Duke University Medical Center Durham, NC 27710, USA. · J Neuropsychiatry Clin Neurosci. · Pubmed #15260364 links to  free full text

Abstract: Following exposure to trauma, a large number of survivors will develop acute symptoms of posttraumatic stress disorder (PTSD), which mostly dissipate within a short time. In a minority, however, these symptoms will evolve into chronic and persistent PTSD. A number of factors increase the likelihood of this occurring, including characteristic autonomic and hypothalamic-pituitary-adrenal axis responses. PTSD often presents with comorbid depression, or in the form of somatization, both of which significantly reduce the possibilities of a correct diagnosis and appropriate treatment. Mainstay treatments include exposure-based psychosocial therapy and selective serotonin reuptake inhibitors, such as paroxetine and sertraline, both of which have been found to be effective in PTSD. This paper looks at the course of PTSD, its disabling effect, its recognition and treatment, and considers possible new research directions.

Segman RH, Shalev AY. · Department of Psychiatry, Hadassah Hebrew University Medical Center, Jerusalem, Israel. · CNS Spectr. · Pubmed #15079143 No free full text.

Abstract: Posttraumatic stress disorder (PTSD) is a prevalent anxiety disorder marked by behavioral, physiologic, and hormonal alterations. PTSD is disabling and commonly follows a chronic course. The etiology of PTSD is unknown, although exposure to a traumatic event constitutes a necessary, but not sufficient, factor. A twin study of Vietnam veterans has shown significant genetic contribution to PTSD. The fact that PTSD's underlying genotypic vulnerability is only expressed following trauma exposure limits the usefulness of family-based linkage approaches. In contrast to the other major psychiatric disorders, large studies for the search of underlying genes have not been described in PTSD to date. Complementary approaches for locating involved genes include association-based studies employing case-control or parental genotypes for transmission dysequilibrium analysis and quantitative trait loci studies in animal models. Identification of susceptibility genes will increase our understanding of traumatic stress disorders and help to elucidate their molecular basis. The current review provides an up-to-date outline of progress in the field of PTSD.

King LA, King DW, Salgado DM, Shalev AY. · National Center for Posttraumatic Stress Disorder, Boston, MA, USA. · CNS Spectr. · Pubmed #15079142 No free full text.

Abstract: Traditional methods for analyzing trends in longitudinal data have typically emphasized average group change over time. In this article, we propose multilevel, regression-based methods for examining inter-individual differences in intra-individual change and apply these methods to research in trauma and posttraumatic stress disorder (PTSD). The outcome or dependent variable of interest is reconceptualized as an index of dynamic change reflecting the trend or trajectory of an individual's PTSD symptom severity scores across time. A basic statistical model is presented, and analyses and findings are demonstrated with an existing database used in previously published studies. The methods offer promise for future study of the natural course of PTSD chronicity or recovery, risk and resilience factors that influence individual growth or decline, and critical timepoints for intervention.

Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Marshall RD, Nemeroff CB, Shalev AY, Yehuda R. · Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA. · J Clin Psychiatry. · Pubmed #14728098 No free full text.

Abstract: OBJECTIVE: To provide an update to the "Consensus Statement on Posttraumatic Stress Disorder From the International Consensus Group on Depression and Anxiety" that was published in a supplement to The Journal of Clinical Psychiatry (2000) by presenting important developments in the field, the latest recommendations for patient care, and suggestions for future research. PARTICIPANTS: The 4 members of the International Consensus Group on Depression and Anxiety were James C. Ballenger (chair), Jonathan R. T. Davidson, Yves Lecrubier, and David J. Nutt. Other faculty who were invited by the chair were Randall D. Marshall, Charles B. Nemeroff, Arieh Y. Shalev, and Rachel Yehuda. EVIDENCE: The consensus statement is based on the 7 review articles in this supplement and the related scientific literature. CONSENSUS PROCESS: Group meetings were held over a 2-day period. On day 1, the group discussed topics to be represented by the 7 review articles in this supplement, and the chair identified key issues for further debate. On day 2, the group discussed these issues to arrive at a consensus view. After the group meetings, the consensus statement was drafted by the chair and approved by all faculty. CONCLUSION: There have been advancements in the science and treatment of posttraumatic stress disorder. Attention to this disorder has increased with recent world events; however, continued efforts are needed to improve diagnosis, treatment, and prevention of posttraumatic stress disorder.

Shalev AY, Tuval-Mashiach R, Hadar H. · Center for Traumatic Stress, Kiryat Hadassah, Israel. · J Clin Psychiatry. · Pubmed #14728091 No free full text.

Abstract: There is a large body of literature on the psychological consequences of trauma experienced by individuals, but there are few studies of the acute and long-term effects of mass trauma on victimized communities. Acute stress reactions are expected, and overall resilience in the aftermath of major disasters is the rule rather than the exception. However, the available literature on mass trauma suggests that certain factors may provide clues to identifying persons at greater risk for posttraumatic stress disorder (PTSD). The severity of the trauma and the accessibility of support systems may affect long-term outcome. In industrialized countries, mass violence caused by malicious human intent may be a more virulent precursor to PTSD than other types of mass trauma, such as technological or natural disasters. School-aged children, women, persons with existing psychiatric illness, those who experienced significant losses or threat to life, those who have insufficient psychological and social support systems, and persons who exhibit symptoms of functional impairment may be at greater risk for PTSD. The findings of a population study of 2 traumatized communities are discussed. Early intervention in communities suffering mass trauma should consist of general support and bolstering of the recovery environment rather than psychological treatment; some forms of early psychological interventions may worsen outcome. There is a great unmet need for treatment and intervention guidelines for victims of mass trauma, and well-designed studies are warranted.

Shalev AY. · Department of Psychiatry, Hadassah University Hospital, PO Box 12000, Jerusalem 91120, Israel. · Biol Psychiatry. · Pubmed #11950455 No free full text.

Abstract: This article summarizes the literature on acute reactions to traumatic stress in adults. It describes their morphology, natural course, long-term outcome, and underlying biological factors, and outlines directions for management and research. It assumes two categories of responses: those that mediate survival and those related to learning and adaptation. The complementary roles of fear conditioning, processing novelty, and adjusting to change are discussed.

Shalev AY. · Hebrew University of Jerusalem Medical School and Department of Psychiatry, Hadassah University Hospital, Israel. · J Clin Psychiatry. · Pubmed #11495095 No free full text.

Abstract: Our understanding of posttraumatic stress disorder (PTSD) has increased significantly over the last 2 decades. Although the cause of the condition is usually easy to determine in individual patients, the symptoms of PTSD are diverse and a mixture of psychological processes are involved. This article presents a broad overview of PTSD, including its definition according to DSM-IV and ICD-10 diagnostic criteria, and its clinical course with reference to its association with depression and other mental disorders. The article also briefly reviews the assessment of patients and considers physiologic features such as responses to startle stimuli that appear to be useful in diagnosing PTSD and in differentiating it from other anxiety disorders and depression. Finally, a brief overview of the treatment of PTSD is given, including psychological and biological treatment options.

Brunello N, Davidson JR, Deahl M, Kessler RC, Mendlewicz J, Racagni G, Shalev AY, Zohar J. · Department of Pharmaceutical Sciences, University of Modena and Reggio Emilia, Modena, Italy. · Neuropsychobiology. · Pubmed #11287794 No free full text.

Abstract: Epidemiological studies clearly indicate that posttraumatic stress disorder (PTSD) is becoming a major health concern worldwide even if still poorly recognized and not well treated. PTSD commonly co-occurs with other psychiatric disorders, and several symptoms overlap with major depressive disorders, anxiety disorders and substance abuse; this may contribute to diagnostic confusion and underdiagnosis. This anxiety disorder provokes significant occupational, psychiatric, medical and psychosocial disability, and its consequences are enormously costly, not only to the survivors and their families, but also to the health care system and society. Work impairment associated with PTSD is very similar to the amount of work impairment associated with major depression. The pathophysiology of PTSD is multifactorial and involves dysregulation of the serotonergic as well as the noradrenergic system. A rational therapeutic approach should normalize the specific psychobiological alterations associated with PTSD. This can be achieved through the use of antidepressant drugs, mainly of those that potentiate serotonergic mechanisms. Recent double-blind placebo-controlled studies report the efficacy of selective serotonin reuptake inhibitors. Several cognitive-behavioral and psychosocial treatments have also been reported to be efficacious and could be considered when treating PTSD patients.

Shalev AY. · Department of Psychiatry, Hadassah University Hospital, Jerusalem, Israel. · Psychiatr Q. · Pubmed #10934750 No free full text.

Abstract: The pathogenic effect of extreme events has been equated with their immediate stressfulness, and thereby with the biology of stress. This article extends this classical view to include, among other pathogenic factors the biological dimensions of learning, social interaction, territorial behavior, and a top-down brain process that links personal and cultural meanings with emotional and bodily responses. The paper depicts the way in which mechanisms related to stress and aversive learning trigger an initial response and those related to separation, loss and sensitization shape its long-term consequences. Traumatic events are followed by a critical period of increased brain plasticity, during which irreversible neuronal changes may occur in those who develop traumatic stress disorders.

Shalev AY. · Department of Psychiatry, Hadassah University Hospital, Center for Traumatic Stress, Jerusalem, Israel. · J Clin Psychiatry. · Pubmed #10761677 No free full text.

Abstract: This article summarizes the features of posttraumatic stress disorder (PTSD) that may affect treatment outcome and discusses the areas in which treatment outcome can be productively evaluated. PTSD is a complex psychiatric condition that tends to run a chronic course. Measurement of treatment outcome in PTSD is confounded by multiple factors, including a high prevalence of comorbid disorders, reactivation of the syndrome by ongoing environmental stressors, spontaneous recovery of the early disorder, and a fluctuating course of the chronic disorder. Four principal domains of treatment outcome may be evaluated in PTSD: core symptom severity, comorbid conditions (particularly depression), adverse practices (e.g., violence or alcohol consumption), and social/vocational disability. To gain an accurate assessment of these domains, a comprehensive assessment battery is needed. The relevant instruments and their yield in studies of PTSD are reviewed.

Pitman RK, Orr SP, Shalev AY, Metzger LJ, Mellman TA. · VA Medical Center, Manchester, NH, USA. · Semin Clin Neuropsychiatry. · Pubmed #10553028 No free full text.

Abstract: Psychophysiological research in trauma-exposed populations has provided objective data supporting the validity of the post-traumatic stress disorder (PTSD) diagnostic concept. Consistent with a conditioning model, PTSD patients show specific increased peripheral physiological responding to audio-visually and imaginally presented stimuli symbolizing or resembling the etiologic traumatic event. PTSD patients respond to startling stimuli with larger autonomic and electromyographic responses, especially under threat conditions. Electroencephalographic event-related potential (ERP) response abnormalities in PTSD include reduced P2 amplitude at high stimulus intensities, impaired P1 habituation, and attenuated P3 amplitude to target auditory stimuli. However, larger P3 and N1 amplitude responses and shorter P3 and N1 latencies have been reported in PTSD subjects in response to trauma-related stimuli. These ERP findings suggest sensory, cognitive, and affective processing abnormalities in PTSD. Polysomnographic sleep studies have revealed increased awakenings, reduced sleep time, and increased motor activity, or in some cases, paradoxical deepening of sleep. There is also evidence for increased phasic eye movement activity during rapid eye movement (REM) sleep and disrupted REM continuity in PTSD. Psychophysiological studies are offering valuable insights into the pathophysiology of this important neuropsychiatric condition.

Bonne O, Shemer Y, Gorali Y, Katz M, Shalev AY. · Department of Psychiatry, Hadassah University Medical School and the Department of Psychiatry, Hadassah University Hospital, Jerusalem, Israel. · J Clin Psychiatry. · Pubmed #12716269 No free full text.

Abstract: BACKGROUND: Homeopathy is commonly used for the treatment of medical and psychological conditions. Such prevalent use, however, is not supported by robust, methodologically sound research. This study evaluates the effect of homeopathic treatment in generalized anxiety disorder, a prevalent mental disorder characterized by an enduring pattern of excessive apprehension and distress and by mental and bodily complaints. METHOD: Forty-four patients with DSM-IV generalized anxiety disorder participated in a randomized, double-blind, placebo-controlled 10-week trial of individually tailored homeopathic remedy. Homeopathic therapy was administered by an expert who followed the traditional routines of homeopathic diagnosis and prescription. Thirty-nine subjects completed the study (20 in the active treatment group and 19 in the placebo group). Subjects' symptoms were rated before treatment and after 5 and 10 weeks of treatment, with the Hamilton Rating Scale for Anxiety (HAM-A) as main outcome measure. Additional measures of outcome included the Brief Symptom Inventory, the Psychological General Well-Being Index, the Hamilton Rating Scale for Depression, the Beck Depression Inventory, Spielberger's State-Trait Anxiety Inventory, and a Visual Analogue Scale of subjective distress. RESULTS: Significant (p <.05) improvement in most measures, including the HAM-A, was observed in both the active treatment and placebo groups, yet no group effect was observed. CONCLUSION: The effect of homeopathic treatment on mental symptoms of patients with generalized anxiety disorder did not differ from that of placebo. The improvement in both conditions was substantial. Improvement of such magnitude may account for the current belief in the efficacy of homeopathy and the current increase in the use of this practice.

Agid O, Shalev AY, Lerer B. · Department of Psychiatry, Hadassah-Hebrew University Medical Center, Jerusalem, Israel. · J Clin Psychiatry. · Pubmed #11305702 No free full text.

Abstract: BACKGROUND: There is considerable comorbidity of major depression and posttraumatic stress disorder (PTSD), and antidepressants have been reported to be effective in treating PTSD. Addition of triiodothyronine (T3) to ongoing antidepressant treatment is considered an effective augmentation strategy in refractory depression. We report the effect of T3 augmentation of antidepressants in patients with PTSD. METHOD: T3 (25 microg/day) was added to treatment with a selective serotonin reuptake inhibitor (SSRI) (paroxetine or fluoxetine, 20 mg/day for at least 4 weeks and 40 mg/day for a further 4 weeks) of 5 patients who fulfilled DSM-IV criteria for PTSD but not for major depressive disorder (although all patients had significant depressive symptoms). The Clinician-Administered PTSD Scale, the 21-item Hamilton Rating Scale for Depression, and the Clinical Global Impressions-Severity of Illness scale were administered every 2 weeks, and self-assessments were performed with a 100 mm visual analog mood scale. RESULTS: In 4 of the 5 patients, partial clinical improvement was observed with SSRI treatment at a daily dose of 20 mg with little further improvement when the dose was raised to 40 mg/day. This improvement was substantially enhanced by the addition of T3. Improvement was most striking on the Hamilton Rating Scale for Depression. CONCLUSION: T3 augmentation of SSRI treatment may be of therapeutic benefit in patients with PTSD, particularly those with depressive symptoms. Larger samples and controlled studies are needed in order to confirm this observation.

Stein DJ, Cloitre M, Nemeroff CB, Nutt DJ, Seedat S, Shalev AY, Wittchen HU, Zohar J. · · CNS Spectr. · Pubmed #19169194 links to  free full text

Abstract: The association between traumatic events and psychopathology has long been recognized, and the literature on posttraumatic stress disorder (PTSD) has burgeoned since this entity was introduced into the diagnostic nomenclature. This literature has been characterized by a range of clinical controversies about the optimal diagnosis and treatment of PTSD. In response, several systematic reviews of treatment, clinical guidelines, and consensus statements about PTSD have been generated, but their conclusions are not always consistent. Our aim here is to provide a concise overview of the literature on PTSD, focusing in particular on recent investigations and publications, with the objective of summarizing practical clinical implications and suggesting future research opportunities. We consider, in turn, the diagnosis and evaluation, psychobiology, pharmacotherapy, psychotherapy, and prevention of PTSD.

Einav S, Shalev AY, Ofek H, Freedman S, Matot I, Weiniger CF. · Department of Anesthesia, Hadassah Hebrew University Medical Center, Jerusalem, Israel. · Br J Psychiatry. · Pubmed #18670006 links to  free full text

Abstract: Post-traumatic stress disorder (PTSD) can reduce performance. The association between PTSD and other psychopathologies among hospital doctors was examined using self-report questionnaires during a wave of suicide bombing in Jerusalem. Thirty-three doctors with PTSD symptoms and 155 without were compared on coping, burnout and acceptance of treatment. Doctors with PTSD symptoms demonstrated significantly more anxiety, depression, negative coping strategies and burnout. Hospital doctors who develop PTSD symptoms suffer greater burnout and manifest negative coping strategies but are reluctant to receive treatment.

Shalev AY, Videlock EJ, Peleg T, Segman R, Pitman RK, Yehuda R. · Department of Psychiatry, Hadassah University Hospital, Jerusalem, Israel. · Int J Neuropsychopharmacol. · Pubmed #17971262 No free full text.

Abstract: The aim of the study was to evaluate the association between post-traumatic disorder (PTSD) and hypothalamic-pituitary-adrenal (HPA) axis responses to the triggering trauma. A companion paper evaluates the adrenergic response and interactions between the two. We measured plasma and saliva cortisol, hourly urinary excretion of cortisol, plasma levels of adrenocorticotropin (ACTH), and the leukocyte glucocorticoid receptor (GR) density of 155 non-injured survivors of traumatic events (91 males and 64 females; 125 road traffic accidents, 19 terrorist attacks, 11 others). Measurements were taken during survivors' admissions to an emergency room (ER) of a general hospital, and in the mornings, 10 d, 1 month, and 5 months later. Symptoms of peri-traumatic dissociation, PTSD, and depression were assessed on each follow-up session. The clinician-administered PTSD scale (CAPS) conferred a diagnosis of PTSD at 5 months. Survivors with (n=31) and without (n=124) PTSD at 5 months had similar levels of hormones at all times. Plasma cortisol levels decreased with time in both groups. Female subjects had lower ACTH levels than males. PTSD in females was associated with higher levels of ACTH. In unselected cohorts of trauma survivors, PTSD is not preceded by a detectable abnormality of peripheral HPA axis hormones.

Videlock EJ, Peleg T, Segman R, Yehuda R, Pitman RK, Shalev AY. · Department of Psychiatry, Hadassah University Hospital, Jerusalem, Israel. · Int J Neuropsychopharmacol. · Pubmed #17971259 No free full text.

Abstract: The aim of the study was to prospectively evaluate the association between the occurrence of post-traumatic stress disorder (PTSD) and the adrenergic response to the traumatic event, and additionally, to explore the link between PTSD and the initial norepinephrine:cortisol ratio. Plasma levels and urinary excretion of norepinephrine (NE) were measured in 155 survivors of traumatic events during their admission to a general hospital emergency room (ER) and at 10 d, 1 month and 5 months later. Symptoms of peri-traumatic dissociation, PTSD and depression were assessed in each follow-up session. The Clinician-Administered PTSD Scale (CAPS) conferred a diagnosis of PTSD at 5 months. Trauma survivors with (n=31) and without (n=124) PTSD had similar levels of plasma NE, urinary NE excretion, and NE:cortisol ratio in the ER. Plasma NE levels were lower in subjects with PTSD at 10 d, 1 month, and 5 months. There was a weak but significant positive correlation between plasma levels of NE in the ER and concurrent heart rate, and a negative correlation between NE in the ER and dissociation symptoms. Peripheral levels of NE, shortly after traumatic events, are poor risk indicators of subsequent PTSD among civilian trauma victims. Simplified biological models may not properly capture the complex aetiology of PTSD.

Weiniger CF, Shalev AY, Ofek H, Freedman S, Weissman C, Einav S. · Department of Anesthesiology and Critical Care, the Hadassah Hebrew University Medical Center, Jerusalem, Israel. · J Clin Psychiatry. · Pubmed #16848648 No free full text.

Abstract: BACKGROUND AND OBJECTIVE: Surgical physicians often treat victims of terror-related multiple-casualty incidents. This may cause secondary posttraumatic stress disorder (PTSD), impairing their ability to care for patients. The objective of this study was to determine whether professional exposure to victims of terror caused PTSD in Israeli physicians from surgical disciplines. METHOD: This was a validated questionnaire survey of physicians (November 2002 through March 2003) from 2 Jerusalem hospitals (a tertiary trauma center and a secondary regional hospital) divided into study (physicians from surgical disciplines regularly exposed to victims of terror) and control (physicians not regularly exposed) groups. Questionnaires included the PTSD Symptom Scale-Self-Report to diagnose PTSD (DSM-IV criteria) and allowed exclusion of other causes of similar symptoms. The main outcome measure was the difference in the prevalence of PTSD between groups. RESULTS: Included were 212 (102 study, 110 control) participants. The study group experienced a significantly higher level of exposure to terror victims at work, validating prospective group definitions. The prevalence of PTSD was similar in both groups (study group = 16%, control group = 15%; p = 1.00). The study and control groups were similar in all predicting variables except for number of years in medical practice, occupational status, and workplace. The groups had similar levels of exposure to terror outside work (p = .24). The probability that a physician would have PTSD was related to use of nonadaptive coping strategies (OR = 5.1; p = .009) and a higher level of exposure to terror out of work (OR = 3.5; p = .013). CONCLUSION: Hospital physicians from surgical disciplines who were professionally exposed to victims of terror did not demonstrate a higher incidence of PTSD than their less exposed counterparts.

Shalev AY, Tuval R, Frenkiel-Fishman S, Hadar H, Eth S. · Department of Psychiatry, Hadassah University Hospital, P.O. Box 12000, Jerusalem 91120, Israel. · Am J Psychiatry. · Pubmed #16585442 links to  free full text

Abstract: OBJECTIVE: The authors evaluated psychological responses to continuous terror. METHOD: Data were collected after 10 months of escalating hostilities against civilians in Israel. The study's participants were randomly selected adults living in two suburbs of Jerusalem, one frequently and directly exposed to acts of terrorism (N=167) and the other indirectly exposed (N=89). Participants provided information about exposure to terror-related incidents, disruption of daily living, symptoms of posttraumatic stress disorder (PTSD), and general distress (assessed with the Brief Symptom Inventory). RESULTS: Residents of the directly exposed community reported more frequent exposure to terror and deeper disruption of daily living. Notwithstanding, the directly and indirectly exposed groups reported comparable rates of PTSD and similar levels of symptoms: 26.95% of the directly exposed group and 21.35% of the indirectly exposed group met DSM-IV PTSD symptom criteria (criteria B through D), and about one-third of those with PTSD symptoms (35.7% in the directly exposed group and 31.5% in the indirectly exposed group) reported significant distress and dysfunction. Subjects who did not meet PTSD symptom criteria had very low levels of PTSD symptoms, and their Brief Symptom Inventory scores were within population norms. Exposure and disruption of daily living contributed to PTSD symptoms in the directly exposed group. Disruption of daily routines contributed to Brief Symptom Inventory scores in both groups. CONCLUSIONS: Continuous terror created similar distress in proximal and remote communities. Exposure to discrete events was not a necessary mediator of terror threat. A subgroup of those exposed developed serious symptoms, whereas others were surprisingly resilient. Disruption of daily routines was a major secondary stressor.

Bachar E, Hadar H, Shalev AY. · Department of Psychiatry, Hebrew University of Jerusalem, Jerusalem, Israel. · J Nerv Ment Dis. · Pubmed #16260935 No free full text.

Abstract: This study empirically examined the role of narcissistic traits and narcissistic vulnerability in the development of post-traumatic stress disorder (PTSD). One hundred forty-four survivors of a traumatic event were assessed 1 week, 1 month, and 4 months following the event. In the first-week assessment, patients were administered the Narcissistic Vulnerability Scale and self-reported rating scale to assess event severity and symptoms ensuing from the impact of the traumatic event: depression, intrusions, avoidance, and arousal. In the follow-up assessments, subjects were interviewed on the Clinician-Administered PTSD Scale and were readministered the self-rating symptoms scale. Survivors who developed acute (1 month) and chronic (4 months) PTSD had significantly higher levels of narcissistic vulnerability in the first-week assessment. Narcissistic Vulnerability Scale scores predicted PTSD status with sensitivity of 81.6% and 85.1% and specificity of 40.4% and 38.6% at the 1-month and 4-month assessments, respectively. Narcissistic vulnerabilities contribute to the occurrence of PTSD.

Shalev AY, Freedman S. · Department of Psychiatry, Hadassah University Hospital, P.O. Box 12000, Jerusalem, Israel. · Am J Psychiatry. · Pubmed #15930068 links to  free full text

Abstract: OBJECTIVE: This study evaluated the prevalence of posttraumatic stress disorder (PTSD) and the longitudinal course of early PTSD symptoms in survivors of terrorist attacks. It additionally assessed the effect of continuous terrorism on the course of early symptoms of PTSD. METHOD: Thirty-nine survivors of terrorist attacks and 354 survivors of motor vehicle accidents were evaluated upon admission to a general hospital emergency room and 1 week and 4 months later. Heart rate was measured upon admission to the emergency room. Peritraumatic dissociation was assessed at 1 week. PTSD symptoms, anxiety, and depression were measured at 1 week and 4 months. The Clinician-Administered PTSD Scale conferred a diagnosis of PTSD at 4 months. Additionally, the course of early PTSD symptoms during an era of frequent terrorist attacks (N=137) was compared with that seen during years of relative calm (N=256). RESULTS: Survivors of terrorist attacks had higher rates of PTSD than motor vehicle accident survivors (37.8% versus 18.7%). The type of traumatic event, however, did not add to the prediction of PTSD from the emergency room heart rate, peritraumatic dissociation symptoms, and early PTSD symptoms. The longitudinal course of early PTSD symptoms was not affected by the greater frequency of terrorist attacks. CONCLUSIONS: Early symptoms are reliable risk indicators of PTSD across events and circumstances. Converging effects of terror-induced fear, adjustment, and resiliency might explain the lack of effect of intense terrorism on the course of PTSD symptoms.