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BackgroundDespite extensive research, symptom structure of posttraumatic stress disorder (PTSD) is highly debated. The network approach to psychopathology offers a novel method for understanding and conceptualizing PTSD. However, extant studies have mainly used small samples and self-report measures among sub-clinical populations, while also overlooking co-morbid depressive symptoms.MethodsPTSD symptom network topology was estimated in a sample of 1489 treatment-seeking veteran patients based on a clinician-rated PTSD measure. Next, clinician-rated depressive symptoms were incorporated into the network to assess their influence on PTSD network structure. The PTSD-symptom network was then contrasted with the network of 306 trauma-exposed (TE) treatment-seeking patients not meeting full criteria for PTSD to assess corresponding network differences. Finally, a directed acyclic graph (DAG) was computed to estimate potential directionality among symptoms, including depressive symptoms and daily functioning.ResultsThe PTSD symptom network evidenced robust reliability. Flashbacks and getting emotionally upset by trauma reminders emerged as the most central nodes in the PTSD network, regardless of the inclusion of depressive symptoms. Distinct clustering emerged for PTSD and depressive symptoms within the comorbidity network. DAG analysis suggested a key triggering role for re-experiencing symptoms. Network topology in the PTSD sample was significantly distinct from that of the TE sample.ConclusionsFlashbacks and psychological reactions to trauma reminders, along with their strong connections to other re-experiencing symptoms, have a pivotal role in the clinical presentation of combat-related PTSD among veterans. Depressive and posttraumatic symptoms constitute two separate diagnostic entities, but with meaningful between-disorder connections, suggesting two mutually-influential systems.

This study examined different variables as predictors of treatment entry and treatment dropout among veterans with military-related posttraumatic stress disorder (PTSD). First, we examined predictors of treatment entry versus refusal of treatment. Among the veterans who started therapy, we examined predictors of treatment completion. Symptom severity of PTSD, depression, and anxiety at baseline were measured. Daily functioning at baseline was also measured. Results indicate that the younger the veterans were, the more likely they were to refuse treatment. Dropout from treatment was also predicted by younger age at referral, as well as by past treatment, higher number of years of education, and higher depression levels at baseline. Two conclusions can be drawn from the results. First, it may be beneficial to increase awareness of treatment options for PTSD among younger veterans as this may increase treatment consent rates. Second, to reduce treatment dropout in veteran patients with PTSD, therapists should take into consideration both past treatment and baseline depression levels as risk factors for dropout.

BACKGROUND. Despite extensive research, symptom structure of posttraumatic stress disorder (PTSD) is highly debated. The network approach to psychopathology offers a novel method for understanding and conceptualizing PTSD. However, extant studies have mainly used small samples and self-report measures among sub-clinical populations, while also overlooking comorbid depressive symptoms. METHODS. PTSD symptom network topology was estimated in a sample of 1489 treatment-seeking veteran patients based on a clinician-rated PTSD measure. Next, clinician-rated depressive symptoms were incorporated into the network to assess their influence on PTSD network structure. The PTSD-symptom network was then contrasted with the network of 306 trauma-exposed (TE) treatment-seeking patients not meeting full criteria for PTSD to assess corresponding network differences. Finally, a directed acyclic graph (DAG) was computed to estimate potential directionality among symptoms, including depressive symptoms and daily functioning. RESULTS. The PTSD symptom network evidenced robust reliability. Flashbacks and getting emotionally upset by trauma reminders emerged as the most central nodes in the PTSD network, regardless of the inclusion of depressive symptoms. Distinct clustering emerged for PTSD and depressive symptoms within the comorbidity network. DAG analysis suggested a key triggering role for re-experiencing symptoms. Network topology in the PTSD sample was significantly distinct from that of the TE sample. CONCLUSIONS. Flashbacks and psychological reactions to trauma reminders, along with their strong connections to other re-experiencing symptoms, have a pivotal role in the clinical presentation of combat-related PTSD among veterans. Depressive and posttraumatic symptoms constitute two separate diagnostic entities, but with meaningful between-disorder connections, suggesting two mutually-influential systems.

Background The Israel Mental Health Act of 1991 stipulates a process for involuntary psychiatric hospitalization (IPH). A patient thus hospitalized may be discharged by either the treating psychiatrist (TP) or the district psychiatric committee (DPC). The decision rendered by the DPC is often at odds with the recommendation of the TP. Although much has been written about the ethical issues of restricting patients’ rights and limiting their freedom, far less attention has been devoted to the psychiatric, medical, and social outcome of legal patient discharge against the doctor’s recommendation. Methods In our study we examined the outcomes of the decisions made by the DPC using readmission data, an internationally recognized indicator of the quality of hospital care, and compared them to the outcomes of patients discharged by the TP. All IPH discharges resulting from the DPC’s determination for the year 2013 (N = 972) were extracted from the Israel national register. We also collected all IPH discharges owing to the TP’s decision for 2013 (N = 5788). We defined “failure” as readmission in less than 30 days, involuntary civil readmission in less than 180 days, and involuntary readmission under court order in less than 1 year. Results The rehospitalization pattern was compared in the two groups of patients discharged from their psychiatric hospitalization during 2013 (index discharges) and followed up individually for a year. We found a statistically significant difference between the DPC and the TP group for each of the time frames, with the DPC group returning to IPH much more frequently than the TP group. Using cross-sectional comparison with logistic regression adjusted for age, gender, diagnosis and length of hospitalization, we found the probability of a decision failure in the TP group was significantly less with an OR of 0.7 (95% CI .586–.863), representing a 30% adjusted decrease in the probability for failure in the TP group. Conclusions The results we present show that the probability of decision “failure” (readmission) was found to be significantly higher in the DPC group than in the TP group. It is often assumed that IPH patients will fare better at home in their communities than in a protracted hospitalization. This is frequently the rationale for early discharge by the DPC (30.1 days vs. 75.9 DPC and TP groups, respectively). Our results demonstrate that this rationale may well be a faulty generalization.

Background Restraint or seclusion measures in acute psychiatric care are used as a last resort when all other methods for removal of physical threat have failed. The purpose of this study is to find a correlation between coercive measures, demographic characteristics within this patient group, and factors associated with shortened periods of restriction. Methods This is a one-year retrospective study conducted in a male acute closed ward of a psychiatric hospital in Israel. The data from January 1, 2014 to December 31, 2014 were retrieved from the records of patients who underwent restraint and/or seclusion interventions during this period. The analyzed data included age, psychiatric diagnosis, marital status, education, race, ethnicity, length of hospital stay, legal status during admission, type of coercive measure (mechanical restraint, seclusion), number and duration of coercive episodes, reasons for coercion, time of event, number of previous hospitalizations, aggression in past and present treatment, and treatment during events. Results During this time period, there were 563 admissions in the study ward. Over this period, 176 subjects (31.3%) underwent 488 restraints and/or seclusions. 98% were aggressive in the past. (Although some results reached statistical significance, we prefer to emphasize here only the most important results, while the others will be presented in the text.) Patients with personality disorders were physically limited for the longest time, while schizophrenia patients were restricted for the shortest time compared with other diagnoses (p = 0.007). A negative correlation was found between the length of coercion and the number of academic female nurses on duty (p = 0.005), as well as the administration of sedative medications during the restricting procedure. Conclusions We believe that the presence of registered, academic female nurses on duty and medication administration during coercive measures can reduce the length of restriction.

The Israel Mental Health Act of 1991 stipulates a process for involuntary psychiatric hospitalization (IPH). A patient thus hospitalized can be discharged by either the treating psychiatrist (TP) or the district psychiatric committee (DPC). The decision rendered by the DPC is often at odds with the recommendation of the TP. This study attempts to compare the variance between the TP and the DPC decisions in different geographical regions in Israel.We examined the outcomes of decisions made by the DPC using readmission data - an internationally recognized indicator of the quality of hospital care - and compared them to the outcomes of patients discharged by the TP. All IPH discharges resulting from the DPC's determination for the year 2013 (N = 972) were taken from the Israel National Register. We also collected information regarding all IPH discharges owing to the TP's decision for 2013 (N = 5788). We defined "failure" as readmission in fewer than 30 days, involuntary civil readmission in fewer than 180 days, and involuntary readmission under court order in less than 1 year.The re-hospitalization pattern was compared in the two groups of patients discharged from psychiatric hospitalization during 2013 (index discharges) and followed up individually for a year. We found a statistically significant difference between the success rates of the various regional DPCs and the hospital TP groups, with the TP average (74.5% national success rate) success significantly better than the DPC groups (66.7% national success rate). Moreover, the variance between the decisions made in the different geographical regions in the two groups was also statistically significant (σ2 variance was 80.4 and 27.1 for the DPC and TP groups, respectively).The results we present indicate that the variance of decision "failure" (readmission) and "success" across the various geographical regions was found to be significantly better in the TP group than in the DPC group. We consider it likely that whereas TPs discharge IPH patients in accordance with well-accepted clinical approaches, the DPC's decisions are based on interpretations of the law (regarding, e.g., the patient posing a physical threat) and on the DPC's understanding of what is meant by the patient's "best interests." We suggest introducing more formal psychiatric training for the legal staff of the DPCs and building a structured and standardized method for reviewing the patient. Moreover, we propose using "soft paternalism" as an approach, which would justify limitations on individual liberties for the benefit of persons being restricted, provided that they are unable to make a choice that would be consistent with their own interests. This is often an appropriate and perhaps a more practical approach, one that the DPC could adopt in place of the present conservative approach, which requires a specific standard of "proof" of major illness to qualify as insanity requiring hospitalization.

The goal of the study was to determine the long-term prevalence of combat-related treatment seeking and posttraumatic stress disorder (PTSD) in Israel's veterans deployed to the Second Lebanon War (2006) and "Operation Cast Lead" in the Gaza Strip (2009).The prevalence of treatment seeking and DSM-IV-TR diagnoses among Israel Defense Force (IDF) veterans was assessed using seven and five year's surveillance and records. The whereabouts and combat exposure of veterans during the war was determined based on the IDF's Operations Directorate records.Overall prevalence of treatment seeking was 1.32% and 0.38% in the Second Lebanon War and "Operation Cast Lead", respectively. The prevalence of treatment-seeking veterans from the Second Lebanon War and in "Operation Cast Lead" was significantly higher in soldiers deployed to high combat-exposure zones (2.19% and 3.1%, respectively), relative to low combat-exposure zones (0.24% and 0.06%, respectively), and relative to soldiers deployed elsewhere (0.26% and 0.02%, respectively). PTSD prevalence was similar among treatment-seeking veterans deployed in high combat-exposure zones in both combats.There is a gap of anywhere between 3% and 11% between treatment seeking by IDF veterans following war deployment and the actual prevalence of PTSD in this soldier population.

To compare the mental health status of those who participated in combat related activities during their service with that of soldiers whose army service did not include combat related activities Method: A representative sample extracted from the National Population Register of non-institutionalized residents aged 21 or older of Israel was used in this crosssectional survey. Data on mental health disorders, sociodemographic background and army service were collected using face-to-face computer-assisted interviews.Combat experience per se was not associated with lifetime diagnosis of PTSD. Former combat soldiers had significantly lower lifetime prevalence and 12 months prevalence of any mood or anxiety disorders including PTSD.This work is in line with previous literature showing that combat exposure, as such, has limited contribution to lifetime PTSD in some groups of veterans. The inverse relationship between combat exposure and PTSD might be explained by the selection of potential combatants among all recruits and by the heightened preparedness to military life stressors.

Trauma causes variable risk of posttraumatic stress symptoms (PTSS) owing to yet-unknown genome–neuronal interactions. Here, we report co-intensified amygdala and ventromedial prefrontal cortex (vmPFC) emotional responses that may overcome PTSS in individuals with the single-nucleotide polymorphism (SNP) rs17228616 in the acetylcholinesterase (AChE) gene. We have recently shown that in individuals with the minor rs17228616 allele, this SNP interrupts AChE suppression by microRNA (miRNA)-608, leading to cortical elevation of brain AChE and reduced cortisol and the miRNA-608 target GABAergic modulator CDC42, all stress-associated. To examine whether this SNP has effects on PTSS and threat-related brain circuits, we exposed 76 healthy Israel Defense Forces soldiers who experienced chronic military stress to a functional magnetic resonance imaging task of emotional and neutral visual stimuli. Minor allele individuals predictably reacted to emotional stimuli by hyperactivated amygdala, a hallmark of PTSS and a predisposing factor of posttraumatic stress disorder (PTSD). Despite this, minor allele individuals showed no difference in PTSS levels. Mediation analyses indicated that the potentiated amygdala reactivity in minor allele soldiers promoted enhanced vmPFC recruitment that was associated with their limited PTSS. Furthermore, we found interrelated expression levels of several miRNA-608 targets including CD44, CDC42 and interleukin 6 in human amygdala samples (N=7). Our findings suggest that miRNA-608/AChE interaction is involved in the threat circuitry and PTSS and support a model where greater vmPFC regulatory activity compensates for amygdala hyperactivation in minor allele individuals to neutralize their PTSS susceptibility.

BackgroundAcute stress disorder involves prominent symptoms of threat avoidance. Preliminary cross-sectional data suggest that such threat-avoidance symptoms may also manifest cognitively, as attentional threat avoidance. Confirming these findings in a longitudinal study might provide insights on risk prediction and anxiety prevention in traumatic exposures.MethodAttention-threat bias and post-traumatic symptoms were assessed in soldiers at two points in time: early in basic training and 23 weeks later, during advanced combat training. Based on random assignment, the timing of the repeat assessment occurred in one of two schedules: for a combat simulation group, the repeat assessment occurred immediately following a battlefield simulation exercise, and for a control group, the assessment occurred shortly before this exercise.ResultsBoth groups showed no threat-related attention bias at initial assessments. Following acute stress, the combat simulation group exhibited a shift in attention away from threat whereas the control group showed no change in attention bias. Stronger threat avoidance in the combat simulation group correlated with severity of post-traumatic symptoms. Such an association was not found in the control group.ConclusionsAcute stress may lead some individuals to shift their attention away from threats, perhaps to minimize stress exposure. This acute attention response may come at a psychological cost, given that it correlates with post-traumatic stress disorder (PTSD) symptoms. Further research is needed to determine how these associations relate to full-blown PTSD in soldier and civilian populations.

We describe a patient at acute suicide risk. His Rorschach protocol was analyzed using Exner's Comprehensive System and a number of psychoanalytic scales. The results pointed at a predominance of borderline defenses, identification with abusers and victims, symbiotic and violent interpersonal relations, self-fragmentation, and intertwined dynamics of suicide and pedophilia. Traumata internalization led to negative body experience, re-staging of the struggle with abusers in relation to his body, feelings of being infested by the trauma, and ruthless self-attacks. His suicide dynamics consist of blurred self-other boundaries, ecdytic fantasies, trauma internalization, and an attempt to exterminate a bad object through self-destruction.

OBJECTIVE Diabetes is a risk factor for an accelerated rate of cognitive decline and dementia. However, the relationship between cognitive function and the subsequent development of diabetes is unclear. RESEARCH DESIGN AND METHODS We conducted a historical-prospective cohort study merging data collected at premilitary recruitment assessment with information collected at the Staff Periodic Examination Center of the Israeli Army Medical Corps. Included were men aged 25 years or older without a history of diabetes at the beginning of follow-up with available data regarding their general intelligence score (GIS), a comprehensive measure of cognitive function, at age 17 years. RESULTS Among 35,500 men followed for a median of 5.5 years, 770 new cases of diabetes were diagnosed. After adjustment for age, participants in the lowest GIS category had a 2.6-fold greater risk for developing diabetes compared with those in the highest GIS category. In multivariable analysis adjusted for age, BMI, fasting plasma glucose, sociogenetic variables, and lifestyle risk factors, those in the lowest GIS category had a twofold greater risk for incident diabetes when compared with the highest GIS category (hazard ratio 2.1 [95% CI 1.5–3.1]; P < 0.001). Additionally, participants in the lowest GIS category developed diabetes at a mean age of 39.5 ± 4.7 years and those in the highest GIS group at a mean age of 41.5 ± 5.1 years (P for comparison 0.042). CONCLUSIONS This study demonstrates that in addition to a potential causal link between diabetes and enhanced cognitive decline, lower cognitive function at late adolescence is independently associated with an elevated risk for future diabetes.

Suicide is a tragic, extreme, and unusual act which evokes powerful emotions. Doctors, psychologists, social workers, lawyers and Renaissance men are trying to research factors leading to suicide. They believe that finding the critical factors may reduce the incidence of suicide. The causative factors leading to suicide are complicated and diverse. A society's moral stance on the issue of suicide influences an individual's inclination to implement the act itself. There is a wide variety of viewpoints between different societies. Societies, with a supportive view, that treat suicide as a noble act, have a high incidence of suicide. Those with a condemning view, that may even deem suicide as a criminal act, have a lower suicide rate. Society's view of suicide is linked to the question of responsibility for the act itself. The responsibility is composed of moral, public and legal obligations. The question is: should most of the responsibility be the deceased's or society's medical and paramedical personnel, who might be held responsible for not recognizing the warning signs and not preventing the act itself. We wish to contend that a professional, cultural, public and legal approach that preserves an individual's responsibility for one's own decisions - even one of self-destruction - will prevent a moral judgment and criticism of the deceased. The aforementioned may decrease the incidence of suicide seen with a neutral approach that foregoes the deceased's individual responsibility. The second section of the article deals with the legal aspects of the act of suicide as expressed in the legislation for the treatment of the mentally ill. The assumption is that the law reflects the viewpoint of a society, thereby influencing the tendencies and processes within. Therefore, a change or amendment to the law may influence the attitude towards it, and the prevalence of the phenomenon in the long run.

Background The association between exposure to Isotretinoin, the development of depression and suicide attempts is controversial. Objective To retrospectively assess pattern of utilization of mental health services in the Israeli Defense Forces (IDF) during a 5-year period for all subjects exposed to Isotretinoin in comparison to a control group consisting of army conscripts suffering from psoriasis. All subjects were young adults (18 to 21 years old) in compulsory military service. Method Exposure to Isotretinoin mandates reporting and marking as a coded medical profile in the IDFs' computerized medical record of each conscript and soldier. Medical data, tracked by military medical profiles, were summarized from medical records of all subjects treated by Isotretinion during the years 1999–2003 and for the control group for the same period. Use of mental health services was the a-priori defined primary outcome measure. Results During the study period 1419 subjects were exposed to Isotretinoin and 1102 suffered from psoriasis. Utilization of mental health services was highest for the index group wherein 17.2% (245/1419) of subjects were evaluated or treated compared to 12.5% in the control group (psoriasis). The inter-group differences were statistically significant; Chi-square = 15.9 ( df = 2), p = 0.0003. Conclusions We suggest that psychiatric evaluation be regularly undertaken prior to initiation of Isotretinion treatment in young adults at risk, as well as providing follow-up visits during and at completion of treatment.

This study verified variations in suicide rates throughout the days of the week among Israel Defense Force soldiers during 1974 - 2001. Results confirmed the findings of most previous studies. The first workday was associated with a 60% increase in suicide rate among young men. This increase was not observed among female reserve or professional soldiers. This finding might indicate a particular susceptibility of men to contextual and situational factors. The explanation of the increased suicide risk on the first workday stresses such processes as the broken-promise effect as well as difficulty in facing the demands of service and transitions from the weekend to the workweek.