Relationships of DSM-5 PTSD symptom clusters to suicidal ideation and death ideation in outpatient military veterans.

Veterans with PTSD are at higher risk for suicide. This study examined the specific associations of PTSD symptom clusters with suicidal ideation (SI) and death ideation (DI), independently from depressive symptom clusters. Participants included 695 Israeli male outpatient military veterans (M = 25.35 years, SD = 5.65), divided into subsamples of probable PTSD (PTSD Checklist for DSM-5 [PCL-5] ≥ 33) and subthreshold PTSD scores (PCL-5 < 33). Data were extracted from medical chartsand self-report questionnaires. The main analyses included logistic regression to evaluate the associations between SI and DI (Brief Symptom Inventory, items 9 and 39) and PTSD symptom clusters (PCL-5), controlling for depressive symptom clusters (Beck Depression Inventory; cognitive-affective and somatization) in each subsample. The results showed that, for veterans with probable PTSD, the negative alterations in cognition and mood symptom cluster was positively correlated with SI and DI, while avoidance was negatively correlated with SI, independently from depressive symptoms clusters. In those with sub-syndromal PTSD, the re-experiencing cluster was positively correlated with DI, independently from the depressive symptom clusters. These findings highlight the importance of targeting PTSD components, such as negative alterations in cognition and mood symptoms experienced by veterans with PTSD, as part of suicide prevention efforts.

The Link Between Somatization and Dissociation and PTSD Severity in Veterans Who Sought Help From the IDF Combat Stress Reaction Unit.

INTRODUCTION: This study aimed to examine the relationships between dissociative and somatic symptoms and how they might contribute to PTSD severity among ex-soldiers who sought help from the IDF Combat Stress Reaction Unit (CSRU). MATERIALS AND METHODS: This cross-sectional study included 1,305 former compulsory, career, and reserve soldiers, who filled out self-report questionnaires on admission for evaluation at the CSRU. The study's dependent variables included two posttraumatic stress disorder measures (CAPS and PCL-5). The independent variables were the Dissociative Experience Scale and Brief Symptom Inventory. Background and service-related variables were also examined. RESULTS: Spearman correlation revealed that the higher the level of somatization is, the higher the level of PTSD via PCL and CAPS. A significant positive association was found between somatization and dissociation (r = 0.544; P < 0.001). The higher the somatization level, the more severe the dissociation. A multivariate logistic regression analysis to predict severe PTSD revealed that the longer the time elapsed from the traumatic event (OR = 1.019, P = 0.015), the higher the risk for severe PTSD. The most prominent variables were dissociation (OR = 6.420, P < 0.001) and somatization (OR = 4.792, P < 0.001). The entire model reached 40.8% of the shared variance in the regression. CONCLUSIONS: While there is direct reference to dissociation in the clinical assessment by PCL or CAPS, there is no such reference to somatization. Highly functioning combatants sometimes express their distress somatically. Our findings suggest regarding severe somatic symptoms as diagnostic criteria for PTSD.

Factors associated with self-harm behaviors during military service in the Israel Defense Forces, rates of such behaviors and their outcomes.

The military environment involves stressful situations that may trigger or aggravate suicidal behaviors, such as suicide attempts (SAs), which significantly increase the likelihood of future suicide. This cross-sectional study aims to assess risk factors for severe SAs and non-suicidal self-injury (NSSI) among Israel Defense Forces (IDF) soldiers. Data were retrieved from an IDF computerized self-harm surveillance database and were based on the criteria of the Columbia Suicide Severity Rating Scale (C-SSRS) and the Suicide Attempt Self-Injury Interview (SASII). The cohort included all 1,238 occurrences of self-harm behavior, during 2017-2021. Other investigated variables included adjustment difficulty (AD, as per IDF definition) and psychiatric diagnosis (PD) as reported by mental health officers (MHOs) during recruitment. Higher rates of adjustment difficulties were found among soldiers who had conducted NSSIs. Higher rates of previous psychiatric diagnoses were found among individuals with SAs, and their risk of dying by suicide during military service was twice as high (OR = 2.356; p < .001). If the latter also served in a combat unit, the risk was almost fourfold (OR = .3.860; p < .001). The current study demonstrates a clear difference between IDF soldiers who conduct NSSI vs. those conducting SA with regard to adjustment difficulty (as per IDF definition) and PD.

The Psychological Impact of Exposure to Battle on Medics: A Cross-Sectional Study of Ex-Soldiers Who Sought Help From the IDF Combat Reaction Unit.

INTRODUCTION: The present study's central aim was to examine two questions: (1) Will there be differences in mental health outcomes between medics and non-medics who sought help at the Israeli Combat Reaction Unit (CRU)? (2) Will there be differences in mental health outcomes between combatants and non-combatants? MATERIALS AND METHODS: This cross-sectional study included files of 1,474 Israeli Defense Forces ex-service members (89% combatants, of whom 13% were medics; 11% non-combatants, of whom 6% were medics), who filled out questionnaires on admission for evaluation at the CRU.Dependent variables were mental health measures and included two PTSD measures (Clinician-Administered PTSD Scale and PTSD Checklist for DSM-5), Beck Depression Inventory, Dissociative Experience Scale, and Brief Symptom Inventory. Military profession (medics vs. non-medics) and status (combatant vs. non-combatant) were the independent variables. Background variables were also examined. RESULTS: We found no substantial differences between medics and non-medics in the mental health measures. When looking at combat and non-combat separately, the non-combat medics (CMs), in general, were in better mental health conditions than the other three groups- CMs, non-medic combatants, and non-medic non-combatants-all of whom had similar scores in the mental health measures. However, compared to the rest, non-CMs took considerably longer years before approaching the CRU. CONCLUSIONS: The elapsed time to seek help for non-MCs was explained by their reluctance to seek help, not being combatants, and being medics who are portrayed as resilient. Recommendations for encouraging this subgroup to seek help were given.

[WHAT DO WE KNOW ABOUT THE TREATMENT OF PRISONERS OF WAR?]

INTRODUCTION: The question of what we know about the treatment of soldiers who are prisoners of war and kidnapped civilians is more relevant today than ever. On October 7, 2023, for 239 Israelis, the transition from an independent and autonomous person to a captive was a sharp, brutal transition that interrupted the continuity of life. Taking prisoners of war (POWs) at this time included, in addition to soldiers, kidnapped civilians, older men, women, teenagers, children and toddlers. The existing knowledge about the treatment of such diverse populations, and in such large numbers, is scarce. Hence, it is a great challenge for all care providers when the POWs return home.

Behavioral Self-Blame in PTSD-Etiology, Risk Factors, and Proposed Interventions.

BACKGROUND: Feeling out of control during a traumatic event may evoke behavioral self-blame (BSB) to avoid feeling helpless following trauma by restoring one's sense of control. BSB is a common, persistent, and treatment-resistant post-traumatic stress symptom. The present study investigates the etiology and risk factors of BSB following a traumatic event and the reasons for its persistence over time. METHOD: Subjects were a group of 546 Israeli ex-combat soldiers (M age = 24.93 ± 5.657) registered in an Israel Defense Forces (IDF) combat reaction clinic. All completed the Peritraumatic Dissociative Experiences Questionnaire (PDEQ), the Brief Symptom Inventory (BSI), and the PTSD Checklist for the DSM-5 (PCL-5). Item 10 of the PCL-5 served to measure BSB. The PDEQ and BSI measured distress and feeling out of control during the event. We used descriptive analyses of the data, t-test, and linear regression analysis to reveal the relationship between the research variables. RESULTS: Feeling out of control during a traumatic event often increases BSB and post-traumatic stress symptoms. A significant correlation emerged between continuing distress characterizing individuals who experience a persistent lack of control and BSB. Female combat soldiers were at a higher risk of BSB than their male counterparts. CONCLUSION: Loss of control experienced during a traumatic event may result in persistent long-term feelings of lack of control over one's behavior.

Risk Factors Associated With Various Severities of Suicidal and Non-Suicidal Self-Harm Among Israel Defense Forces Soldiers-A Nested Case-Control Study.

OBJECTIVE: Severe suicide attempt is a major risk factor for completed suicide. The aim of the present study was to focus on suicide behavior and timing to gain better understanding of these populations. METHOD: The nested case-control retrospective study based on medical records of 246,866 soldiers, who demonstrated suicide attempts of varying severity, including death by suicide were compared with soldiers who did not demonstrate such behavior. RESULTS: Risk for death by suicide was associated with males, military seniority of less than 12 months. High frequency of visits with mental health care professionals was associated with being severe suicide attempters (SAs). Moderate suicide attempts were associated with being a male, visiting a primary care physician frequently, and belonging to one of the two latest immigrant groups in Israel (Ethiopians and former Soviet Union). Mild suicide attempts were associated with having a psychiatric diagnosis on the enlistment day, visiting a mental health care professional at high or average frequency, visiting a primary care physician at high or average frequency, being a male, and being born in the former Soviet Union. While the proportion of males demonstrating suicidal behavior was higher than the females', severe SAs were higher among females. There was a clear tendency of female suicide attempters at all levels to act toward the end of their military service. CONCLUSIONS: Although half of the SAs were females, their characteristics may be similar to those of the male SAs, contrary to the sex differences in suicide behavior among civilians.

Personality disorders and cause-specific mortality: a nationwide study of 2 million adolescents.

BACKGROUND: Personality disorders are prevalent in 6-10% of the population, but their risk for cause-specific mortality is unclear. The aim of the study was to assess the association between personality disorders diagnosed in late adolescence and all-cause as well as cause-specific (cardiovascular-related, external-related) mortality. METHODS: We performed a longitudinal study on a historical prospective cohort based on nationwide screening prior to recruitment to the Israeli army. The study participants were 16-19-year-old persons who attended the army screening (medical and cognitive, including screening for psychiatric disorders) between 1967 and 2006. Participants were followed from 1967 till 2011. RESULTS: The study included 2 051 606 subjects, of whom 1 229 252 (59.9%) were men and 822 354 (40.1%) were women, mean age 17.36 years. There were 55 508 (4.5%) men and 8237 (1.0%) women diagnosed with personality disorders. The adjusted hazard ratio (HRs) for coronary, stroke, cardiovascular, external-related causes and all-cause mortality among men with personality disorders were 1.34 (1.03-1.74), 1.82 (1.20-2.76), 1.45 (1.23-1.71), 1.41 (1.30-1.53) and 1.44 (1.36-1.51), respectively. The absolute rate difference for all-cause mortality was 56.07 and 13.19 per 105 person-years among men and women, respectively. Among women with personality disorders, the adjusted HRs for external-related causes and all-cause mortality were 2.74 (1.87-4.00) and 2.01 (1.56-2.58). Associations were already evident within 10 years of follow-up. CONCLUSIONS: Personality disorder in late adolescence is associated with increased risk of cardiovascular, external- and all-cause mortality. Increased cardiovascular mortality is evident before the age of 40 years and may point to the importance of lifestyle education already in youth.

Traumatic Brain Injury Severity in a Network Perspective: A Diffusion MRI Based Connectome Study.

Traumatic brain injury (TBI) is often characterized by alterations in brain connectivity. We explored connectivity alterations from a network perspective, using graph theory, and examined whether injury severity affected structural connectivity and modulated the association between brain connectivity and cognitive deficits post-TBI. We performed diffusion imaging network analysis on chronic TBI patients, with different injury severities and healthy subjects. From both global and local perspectives, we found an effect of injury severity on network strength. In addition, regions which were considered as hubs differed between groups. Further exploration of graph measures in the determined hub regions showed that efficiency of six regions differed between groups. An association between reduced efficiency in the precuneus and nonverbal abstract reasoning deficits (calculated using actual pre-injury scores) was found in the controls but was lost in TBI patients. Our results suggest that disconnection of network hubs led to a less efficient network, which in turn may have contributed to the cognitive impairments manifested in TBI patients. We conclude that injury severity modulates the disruption of network organization, reflecting a "dose response" relationship and emphasize the role of efficiency as an important diagnostic tool to detect subtle brain injury specifically in mild TBI patients.

The effect of the Suicide Prevention Program (SPP) on the characteristics of Israeli soldiers who died by suicide after its implementation.

BACKGROUND: Suicide is major cause of death in the IDF. The Suicide Prevention Program (SPP) led to significant reduction in yearly rates of suicide. A study regarding demographic changes of those who died by suicide was done to further investigate its affect. METHOD: Nested case control retrospective study based on medical and HR data gathered between 1992 and 2016. Participants were divided into four groups: soldiers who died by suicide and non-suicidal soldiers, before and after SPP implementation. RESULTS: Multivariate analysis with suicide as the binary logistic dependent variable before and after implementation of the SPP among four groups revealed that before SPP the OR was higher for males (OR, 7.885; 95% CI, 5.071-12.259;p < 0.001) compared to after (OR, 3.281; 95% CI, 1.600-6.726; p = 0.001). For support unit soldiers the values before SPP were OR, 14.962 and 95% CI, 8.427-26.563 (p < 0.001) while after SPP they were OR, 6.304 and 95% CI, 3.334-11.919 (p < 0.001). After SPP, OR was higher for psychiatric diagnosis at recruitment (OR, 5.830; 95% CI, 2.046-16.612; p =  0.001) than before SPP (OR, 2.422; 95% CI, 1.526-3.842; p < 0.001).For soldiers from Ethiopian ethnicity, after SPP values were higher (OR, 8.130 and 95% CI, 2.868-23.047 (p < 0.001) compared to before (OR, 3.522; 95% CI, 1.2891-6.650; p < 0.001). For those of Druse religion before values (OR, 4.027; 95% CI, 2.211-7.331; p < 0.001) were significant but not after. CONCLUSIONS: While the SPP succeeded in reducing risk of suicide in situational factors, dispositional risk factors were not affected by the SPP. The OR decreased in critical masses and rose in unique and smaller groups.

Early psychological intervention following the 2014 Nepal snowstorm.

The following is a case study of the blizzard of October 2014, an Israeli rescue team, the Special Mental Health Team (SMHT) of the Israeli Defense Forces Medical Corps, was sent to the disaster area to rescue Israeli trekkers. The SMHT intervention was provided immediately following the traumatic events with the purpose of lowering stress-related symptoms, shortening recovery time and reducing post-traumatic stress disorder symptoms that could occur in the future. Forty Israeli trekkers were assessed by SMHT: 75 % (n = 30) had mild acute stress reaction (ASR) symptoms and 25 % (n = 10) had severe acute stress disorder (ASD) symptoms. All participating trekkers receiving the intervention as a way to alleviate symptoms reported no symptoms of ASR and ASD following the intervention. Trekkers with mild ASR reported full recovery after 1 week and trekkers with ASD reported full recovery after 3 months. This case study describes the psychological intervention conducted by SMHT for the surviving trekkers following the blizzard and aims to extend the knowledge base of mental health intervention at the early phases of disaster. A research study should be conducted to develop a measurement tool capable of evaluating the effect of a short-term intervention conducted in the field.

Characteristics of the suicidal soldier in the Israeli Defense Force-a review of literature.

Suicide is the third leading cause of death among adolescents in most Western world countries. Similar findings have been reported among adolescents in Israel (including the Israeli army) in times of peace; nonetheless, suicide rate has decreased significantly in recent years. In Israel, IDF service is mandatory and adolescents are obligated to serve by law. Therefore, the IDF is responsible under state and moral law to care for the physical and mental health of its soldiers. Additionally, there is an understanding that the Israeli soldiers represent a mentally healthy population as prior to their enlistment they undergo a series of tests and evaluations to determine their suitability for service. The IDF is one of the few organizations in the world that is comprised of the majority of a country's healthy adolescent population. International literature defines this population (i.e., the adolescent population) as having the highest risk of suicidality. Moreover, the risk of suicide increases in the face of two additional circumstances within the context of military service: the army service as a stressor and the availability of weapons. The IDF invests significant resources in delineating the characteristics of suicidal soldiers, realizing its importance for suicide prevention during military service. This article reviews studies regarding complete suicide cases of Israeli soldiers in the aim of characterising a 'suicidal soldier's profile' to inform better screening and prevention policies.

A military suicide prevention program in the Israeli Defense Force: a review of an important military medical procedure.

The phenomenon of suicide during military service is not unique to the Israeli military and other armies. Soldiers' age--adolescence--is a known factor contributing to suicide, in light of psychological processes of identity formation and self-definition, the stresses of military service, and above all, the availability of weapons. The stigma of seeking help deters some soldiers from getting the assistance they need when they need it most, thus contributing to the higher suicide rate. In the previous decade the IDF initiated intensive and structured preventive procedures aimed at reducing suicide rate among soldiers. The IDF's Suicide Prevention Program (SPP) was grounded in professional knowledge and backed by military policy changes, both critical to the implementation and change processes. The SPP includes thorough psycho-education and guidance, supervision, greater accessibility of mental health officers, and lower accessibility of nonessential weapons. The SPP has succeeded in reducing the suicide rate by almost 50 %. The aim of this article is to review the background of the design of the IDF's SPP and its major components, leading to the current success.