Transcript Traumatic exposure and its sequelae in Bedouin members of

Traumatic exposure and its
sequelae in Bedouin members
of the Israel Defense Forces
Yael Caspi, Sc.D., M.A.
Department of Psychiatry
Rambam Medical Center,
Haifa, Israel
Presented at the WFMH Conference
on Transcultural Mental Health
Minneapolis, MN October 2007
Co-authors:
Ortal Saroff, PhD Department of Psychology,
University of Haifa, Israel
Najla Suleimani, SW Department of Social
Services, Zarzir, Israel
Ehud klein, MD Department of Psychiatry,
Rambam Medical Center, Haifa, Israel
Related publications
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Caspi, Y., Saroff, O., Suleimani, O., Klein, E. (in
print). Trauma exposure and posttraumatic reactions
in a community sample of Bedouin members of the
Israel Defense Forces. Depression & Anxiety
Caspi, Y., Carlson, E., Klein, E. (2007) Validation of a
screening instrument for posttraumatic stress
disorder in a community sample of Bedouin men
serving in the Israeli Defense Forces. Journal of
Traumatic Stress, Vol. 20, No. 4, August 2007, pp.
517–527
Project Partnership َ‫שותפות ُمـشا َر َك‬
The Bedouin Community Needs Assessment Initiative
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The Rambam Medical Center
UJA-NY
Municipality of Zarzir
The Bedouins
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Nomadic tribes
Historical alliance with the State of Israel
A distinct minority among the Arab citizens of
Israel
Lifestyle combines traditional customs with
modern Western practices
Northern tribes are primarily secular
Voluntary-based service in the IDF
Reasons for the study
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Limited but striking examples of severe mental
health problems in Bedouin veterans
Known risk factors:
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Indications of greater vulnerability during service
and post discharge
Affinity to the enemy
Complex socio-political circumstances
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Religion becoming prominent, military service
condoned
Barriers to care
Misdiagnosis: PTSD with Psychotic
Features or culturally-specific response?
 Shame as the overriding factor
 Inappropriateness of treatment (talk
therapy, group sessions)
 Spiritual bind - need for forgiveness?
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Methods
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Relationship building
Door-to-door recruitment by local recruiters from
the different tribal families
Measures included the Structured Clinical
Interview for Axis I DSM-IV Disorders (SCID);
List of traumatic events; HSCL-25; Screen for
Posttraumatic Stress Symptoms (SPTSS; Carlson,
2001); substance abuse; physical health and
related functioning.
SPTSS (Carlson, 2001)
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Self-report screening instrument for PTSD
symptoms.
17 items, rated on a 10-point scale from
“Never” (0) to “Always” (10).
Responds to “how much that thing has
happened to you during the past two weeks”.
Not keyed to a single event.
Background
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372 Bedouin men were identified through community
outreach efforts, of whom 348 (93.5%) agreed to
participate.
317 (91%) completed the interview over 19 months.
Those who served in combat positions were (in
descending order) trackers, in the infantry, in
specialized units trained in urban fighting and in the
border police.
Those enlisted in non-combat units were mostly in the
education or transportation corps; only eight were with
the civilian (‘blue’) police .
Background (continued)
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Participants averaged 30 yrs of age, mostly
married (57%) or single (41%) with more than 3
children; 75% served in combat units, most were
discharged (58%) and of those 38% were
unemployed.
Length of service (positively associated with
traumatic exposure):
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43% served 1-4 yrs, 28% 5-15, 10% 16-29.
Half defined themselves as secular, half as
traditional; none as religious.
Traumatic and Stressful Events
Assaultive violence
combat 67%, terror 4,
Interpersonal violence 3, Domestic
violence in childhood 15
73.8
Other injury or
shocking experience
Serious MVH accident 21, other 3,
child with a life-threatening
/incurable illness 3
25.5
Learning about
trauma to others
Serious injury in MVH accident 23, 61.2
military 18; diagnosed with a lifethreatening illness 16; other 11
Sudden death of
a close friend/relative
Any trauma
[circles of loss]
83.0
96.5
Psychiatric outcomes
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Stringent definition of trauma yielded 75% exposed to
Potentially Traumatizing Events, mostly combat.
Of the total sample, 27% had SCID diagnoses: 14.5% had
PTSD, 12.5%: MDD, anxiety disorders, alcohol abuse.
PTSD was present in 20% of the trauma-exposed group,
mostly comorbid with MDD and/or alcohol abuse.
Those with PTSD were significantly more likely to have
been discharged from the military by the time of the
interview (delayed onset?).
Reminder!
Our participants were recruited by
community outreach efforts.
The PTSD rate of 20% found in our sample
represents individuals who for the most part
have not been recognized as suffering from
trauma-related disability.
PTSD rates in other studies
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8% among those exposed to war trauma from a general
population sample in Israel1
17.8% among general sample of Palestinian refugees in the
Gaza Strip and 28% among those exposed to armed-conflictassociated-violence2
Peacekeeping forces, where rates ranged from 3%3 to 16%4
15.8% among Ethiopian refugees resettled in Israel5
37% of Jewish veterans with combat stress reaction, 23% of
former POWs, and 14% of comparison group6
16.7% among IDF soldiers with physical injuries from
combat during combat between 1998-2000 7
1 Ben-Ya'akov,
et al., 1994;
2005; 2de Jong et al., 2003 3 Bramsen et al., 2000; 4Mehlum and Weisaeth, 2002; 5Finkelstein, 2004; 6Solomon
et al., 2005
7 Koren
Impact of PTSD
PTSD but not trauma exposure alone was
associated with higher rates of alcohol and
tobacco use, self-assessed and diagnosed health
problems, somatic symptoms, self–perceived
health-related impairment in daily functioning
and more frequent use of primary and specialty
medical care services.
Conclusions
• Bedouin servicemen are a group at a higher
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risk for both trauma exposure and PTSD.
Possibly due to sample size, trauma exposure
alone was generally not associated with
psychiatric and health-related impairment.
Most of those with PTSD were never diagnosed
or treated for trauma-related problems.
Conclusions
• Delayed onset and somatic presentation may
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affect ‘disease explanation’: punishment
(patient) vs. malingering (provider).
Primary care providers are the natural agents
of care in traditional communities.
Early detection of trauma-related problems in
servicemen from minority backgrounds may
necessitate deliberate outreach efforts.