Traumatic exposure and its sequelae in Bedouin members of the Israel Defense Forces

1. 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

2. 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

3. Related publications • 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

4. Project Partnership مُـشارَكَשותפות The Bedouin Community Needs Assessment Initiative • The Rambam Medical Center • UJA-NY • Municipality of Zarzir

5. The Bedouins • 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

6. Reasons for the study • Limited but striking examples of severe mental health problems in Bedouin veterans • Known risk factors: • Indications of greater vulnerability during service and post discharge • Affinity to the enemy • Complex socio-political circumstances • Religion becoming prominent, military service condoned

7. 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?

8. Methods • 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.

9. SPTSS (Carlson, 2001) • 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.

10. Background • 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.

11. Background (continued) • 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): • 43% served 1-4 yrs, 28% 5-15, 10% 16-29. • Half defined themselves as secular, half as traditional; none as religious.

12. Traumatic and Stressful Events

13. Psychiatric outcomes • 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?).

14. 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.

15. PTSD rates in other studies • 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 Stripand 28% among those exposed to armed-conflict-associated-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 1998-20007 1 Ben-Ya'akov, 2005; 2de Jong et al., 2003 3 Bramsen et al., 2000; 4Mehlum and Weisaeth, 2002; 5Finkelstein, 2004; 6Solomon et al., 1994; 7 Koren et al., 2005

16. 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.

17. Conclusions • Bedouin servicemen are a group at a higher 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.

18. Conclusions • Delayed onset and somatic presentation may 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 deliberateoutreach efforts.