A retrospective view on Yom Kippur veterans seeking help 30 years after war: Symptoms, combat exposure and psychoactive substance use.

Post-traumatic Stress Disorder (PTSD) received its first public recognition in 1980 with the publication of the third edition of the DSM (APA, 1980). Yet research pertaining to its clinical and etiological aspects dates from much earlier, starting after World War I and continuing through all subsequent wars.

Along these years attention to these issues has grown, despite the fact that only a small percentage of individuals who undergo a life-threatening event will develop posttraumatic symptoms, and others will experience only a short period of distress before moving on with their lives. Additionally, only a fraction of individuals suffering from PTSD and distress will turn to professionals for psychological help. The larger portion of these individuals will not seek counseling, either due to lack of awareness of the connection between the event and the experienced distress, or for other reasons such as shame and guilt.

However, in the last decade, more than thirty years after the, there has been an increase in the number of Israeli's Yom Kippur war veterans seeking professional help due to the events they experienced then.

In this study we examined the characteristics of posttraumatic distress among these participants and assessed patterns in the development of their distress, from the time of their participation in the Yom Kippur war until the time they made contact with the IDF Combat Reactions Unit (CRU), thirty years or more after the war. Additionally, the study was set to examine the patterns and reasons for use of psycho-active substances during the years that followed the war.

Specifically, we hypothesized that a positive correlation would exist between the characteristics of the traumatic event (combat exposure) and the characteristics of the posttraumatic distress, as expressed by the number of reported symptoms. Additionally, we hypothesized a positive correlation between the use of psychoactive substances and the number of reported symptoms.

Data was derived from the participant medical records of 195 war veterans who sought help from the IDF CRU during the years 2006-2012. Veterans who approached the unit underwent a process of assessment and diagnosis (on the basis of DSM-IV criteria for PTSD) and an open interview (intake). Content analysis (Charmaz, 1995; Pidgeon & Henwood, 1996) was conducted on the transcript of the intake interview, which included a detailed history of the participants from early childhood through military service and war, up to the time at which they sought help. Through this content analysis, central study variables were created: the characteristics of distress (reported symptoms), the traumatic event (combat exposure), and the use of psychoactive substances, including the purposes of their use. Through this systematic and structured process, the verbal representation was transformed into a numerical one, which represented the participants' condition from the time of the war until the time of their approach to the CRU.  

Results showed that 90.8% of the study population suffered from PTSD, while the remainder of the participants suffered from sub-clinical symptoms not reaching the levels of the classified disorder. The direction of mental distress development, as expressed by the symptoms that were reported by the participants, was significant; it indicated a process of exacerbation of subclinical symptoms over the course of the years, reaching the full clinical threshold needed for diagnosis at the time of their approach to the CRU. Additionally, 53.8% of the study population reported the use of psychoactive substances over the course of their lifetime so far. The majority of participants reported the use of psychiatric medication (77.1%), 25.7% used alcohol, and 9.7% used drugs. Analysis also indicated that increases in reports of posttraumatic symptoms prior to registration at the CRU were accompanied by parallel increases in reports of psychoactive drug usage.

The research hypotheses were only partially supported. Of all the traumatic event characteristics, only 'exposure to death of IDF soldiers' was found to have a significant positive correlation with avoidance symptoms at the time of the veteran's arrival at the CRU.  Additionally, non-combat soldiers reported significantly more symptoms of avoidance in comparison with combat soldiers. Rank and file soldiers were more likely to report symptoms of intrusion in comparison to officers, but officers were more likely to report depressive symptoms in comparison to rank and file soldiers. Additionally, it was found that war veterans who were employed at the time of their approach to the CRU reported fewer posttraumatic symptoms, such as sleep disorders, in comparison with unemployed veterans.  Regarding psychoactive substance use, it was found that participants reporting usage at the time of their referral to the CRU reported more symptoms of sleep disturbances, anxiety and physical symptoms, in comparison with participants not reporting psychoactive substance use.

Finally, among all study variables, the participants' background variables, both at the time point of the war itself and at the approach to the CRU, provided the most significant contribution to the development of PTSD as expressed at the time point of the approach to the CRU. These variables - rank, army position and education - had a bidirectional contribution and served both as defensive factors of specific symptoms (intrusion, avoidance and anxiety) and as risk factors for other symptoms (depression and physical symptoms).

Limitations of the study relate to the retrospective nature of data collection and the reliance on participants' memories many years after the traumatic event. The advantage of the study lies in its use of unique methodology, enabling a broader understanding of the individuals seeking help from the CRU than that which would emerge from data resulting from standard questionnaires.  

This study adds to the existing literature regarding the effects of war on war veterans through retrospective examination. Additional studies employing integrative methodology, such as is offered in this study, are needed, in order to explore the relations between ingredients of PTSD (symptoms) and risk and resilience factors. Such research, which would aim to develop our understanding of the disorder and its phenomenology, might assist individuals suffering from its effects and might even prevent the disorder's development years after the event.