for WIZARD KIM: Review Paper—Topic Proposal & Reference Page

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Combat Exposure, Posttraumatic Stress Symptoms and Risk-Taking Behavior in Veterans of the Second lebanon War Vlad Svetlicky, MSw,1 Zahava Solomon, PhD,2 Rami Benbenishty, PhD,3 ofir Levi, PhD,1 and Gadi Lubin, MD1

1 Department of Mental Health, Israel Defense Forces Medical Corps, Ramat Gan, Israel 2 Shappel School of Social Work and Adler Research Center, Tel Aviv University, Tel Aviv, Israel 3 Paul Baerwald School of Social Work, Hebrew University of Jerusalem, Jerusalem, Israel

ABSTRACT Prior research has revealed heightened risk-taking behavior among veterans with posttraumatic stress disorder (PtSD). this study examined whether the risk- taking behavior is a direct outcome of the traumatic exposure or whether this relationship is mediated by p o s tt ra u m a t i c s t r e s s s y m p t o m s . t h e s a m p l e was comprised of 180 traumatized israeli reserve soldiers, who sought treatment in the wake of the Second Lebanon war. Combat exposure was indirectly associated with risk-taking behavior primarily through its relationship with posttraumatic stress symptoms. R e s u l t s o f t h e m u l t i va r i a t e a n a l y s e s d e p i c t t h e implication of posttraumatic stress symptoms in risk- taking behavior, and the role of self-medication and of aggression in traumatized veterans.

Address for Correspondence: Zahava Solomon , Shappel School of Social work and Adler Research Center, tel Aviv University, Ramat Aviv 39040, israel   [email protected]

and a variety of autonomic, affective, and cognitive signs of hyperarousal. Some researchers (4) postulate that the DSM-IV definition of the diagnostic boundary between the presence and the absence of PTSD is not optimal in that many individuals without PTSD are exhibiting part of the symptoms described below. In any case, the experi- ences of these symptoms are a life-altering and complex psychological condition estimated to affect combat vet- erans with or without diagnosis of PTSD (1). There is ample evidence that the development of combat-induced posttraumatic symptoms is related to problems maintain- ing professional, interpersonal and familial relationships. Posttraumatic stress symptoms (PTSS) have also been associated with low self-esteem, with distrust of people (5), with higher incidence of psychological problems, and with poorer employment performance (6). With regard to interpersonal relationships, chronic PTSS have been associated with poor family functioning (7), attachment problems (5), higher incidences of chronic nonpsychi- atric medical conditions (8), marital dysfunction (9), social dysfunction (10), and unfit parenting (11, 12). In a previous study of veterans of the First Lebanon War (13), PTSS were found to correlate with a wide range of general psychiatric symptoms, as measured by the SCL-90.

Moreover, clinical observations and empirical stud- ies suggest that PTSS are associated with an increased tendency for risk-taking behaviors (RTB) (14-16) such as health-risk behaviors (17), substance abuse (14, 18), aggressive and violent behaviors (16, 19), reckless driv- ing (15), and inappropriate behavior at one’s work or study environment (i.e., occupational misbehavior) (20). Although the review points to substantial evidence of RTB resulting from PTSS, a great deal remains to be

InTRoduCTIon Studies of war veterans consistently show that exposure to combat stress is a risk factor for a wide array of psy- chiatric disorders, most notably posttraumatic stress dis- order (PTSD) (1, 2). According to DSM-IV (3), this syn- drome is characterized by posttraumatic stress symptoms including repeated re-experiencing of the traumatic event (unwanted intrusion of trauma-related material into con- scious thoughts, mental images, and dreams), numbing of responsiveness to or reduced involvement with the external world (trauma-related avoidance responses),

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learned about the interrelationships between combat exposure, PTSS and RTB.

Previous research that investigated this issue revealed inconsistent results. For the most part, studies suggested that both intensive combat exposure and PTSS were associated with post military RTB, and that PTSS plays a mediatory role in the relationship between war-zone traumatic exposure and RTB. Lasko et al. (21) assessed aggression, hostility and anger in Vietnam combat veter- ans with and without chronic PTSD and concluded that these behaviors were more appropriately regarded as part of PTSS, rather than as a direct consequence of military combat. In a similar vein, Taft et al. (22) reported that combat exposure was indirectly associated with aggres- sion primarily through its relationship with PTSS. A study of a civilian sample (23) examined whether expo- sure to traumatic events increases the risk for nicotine dependence or for alcohol or other drug use disorders, independent of PTSS. The findings of this research sup- ported the hypothesis that exposure to traumatic events per se did not increase the risk for substance abuse dis- orders. This conclusion is also consistent with the find- ings of a review of the research literature on PTSD and substance abuse comorbidity among combat veterans (18). Similar conclusions were drawn from studies that examined health-risk behaviors among war veterans with PTSD (17, 24, 25). Fontana and Rosenheck (26) inves- tigated the role of war zone trauma and PTSD in the etiology of antisocial behavior in a large sample of male Vietnam War veterans. Their study found that PTSD played a mediatory role for the effects of war-zone trau- matic exposure on post military antisocial behavior.

Another group of studies, however, is at variance with the above mentioned conclusions, and suggests that the RTB is related to the level of exposure to trau- matic events. For example, Kramer et al. (27) found that suicidal behaviors were observed in Vietnam veterans who did not display trauma-related symptoms or other psychiatric problems. Similarly a study that investigated interpersonal violence in Vietnam veterans with PTSD (28) reported that combat exposure was positively linked with interpersonal violence independent of PTSD.

As demonstrated by the studies described earlier, the extent and nature of RTB in combat induced PTSD remains insufficiently investigated at this time. It is still unclear whether RTB is a direct outcome of the traumatic exposure or whether this relationship is mediated by PTSD. Due to the elevated risk of mortality among trau- matized veterans (29) further research is needed on the

subject of RTB among war veterans. Although in recent years much has been learned about the long-term impact of combat trauma on Israeli veterans, little of the existing research has examined co-existence of risk-taking behav- iors and PTSD. Moreover, the few Israeli studies that were conducted focused only on substance abuse and revealed inconsistent results. Skodol et al. (30) found increased rates of drug and alcohol use among Israeli veterans with PTSD. These findings were at odds with those of previous clinical studies of small samples of Israeli combat veterans (31, 32). More recently, reports by the Israel Anti-Drug Authority show increased usage of drug and alcohol in recent years in Israel (33). Given the rise in mortal- ity among PTSD veterans, substance abuse in Israel and increased exposure of Israeli soldiers to combat violence, investigating the risk-taking behavior among traumatized veterans is a highly relevant, important and timely issue. The primary aim of the current study is to assess the RTB prevalence among Israeli reserve soldiers with and with- out PTSD. Another aim is to investigate the interrelation- ship among combat exposure, PTSS and RTB.

MeThod PARTICIPAnTS And PRoCeduRe Our sampling pool consisted of all male combat reserve soldiers who sought treatment in the IDF Combat Reaction Unit between August 2007 and June 2008 in the wake of the Second Lebanon War. The group consisted of 274 individuals. Data collection started six months after the battles were over and lasted for four months. At the time of the data collection 28 (10%) soldiers were unreachable due to various reasons, 61 (22.1%) refused to participate, and the therapists of 5 (1.8%) soldiers recom- mended against including them in the study due to their mental instability. Eventually, 180 (65.7%) veterans com- pleted the questionnaires; 121 of the questionnaires were administered by the first author (V.S.), and the rest (n=59) were administered by trained and experienced therapists working in the IDF Combat Reaction Unit. The purpose of the study was explained to the participants, they were assured confidentiality, and it was made clear and empha- sized to them that participation in the study is voluntary.

MeASuReS Sociodemographic and military information. Data on sociodemographic and military variables were collected via a questionnaire, completed by the subjects, inquiring

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about their military and civilian background including age, father’s country of origin, education, family status, children, occupational status, military rank, and type of military service.

Combat exposure. A self-report questionnaire consist- ing of 18 items was used in this study. The questionnaire was initially devised by Dekel et al. (6) to assess the level of exposure to battlefield stressors in soldiers of the Yom Kippur War. A factor analysis with varimax rotation revealed four factors that explained 64.1% of the variance. Factor 1 consisted of seven items relating to exposure to injuries and death (e.g., “I saw a lot of dead soldiers”). Factor 2 consisted of four items describing experiencing life-threatening situations (e.g., “I found myself in a situ- ation where I was not sure whether I’d come out alive”). Factor 3 consisted of four items describing injury to the enemy (e.g., “I killed enemy soldiers”). Factor 4 consisted of three items describing dysfunction in one’s army (e.g., “I was in a situation where support did not arrive when required”). The internal consistency reliability estimate for the four factors ranged from .69 to .92. Previous stud- ies indicate similar internal consistency reliability, from .76 to .91 (6).

Life functioning. The impact of the war on veterans’ daily functioning was assessed by the Life Functioning Scale, derived from the Psychotherapy Outcome Assessment and Monitoring System-Trauma Version (POAMS-TV; 34). Respondents were asked to rate each of 11 areas related to their daily life (e.g., work, social relationships and physical health) on a 5-point Likert- type scale (0, “barely functioning” to 4, “functioning very well”). The internal consistency reliability estimate for Life Functioning Scale was .90.

Posttraumatic stress symptoms (PTSS). The PTSD Inventory (35), a self-report scale, was used to assess posttraumatic stress symptoms. The questionnaire con- sists of statements tapping DSM-IV (3) symptom crite- ria. Subjects were asked to indicate on a 4-point scale ranging from “never” to “very often” the frequency with which they had experienced the described symptom during the preceding month. The average rate of the reported symptoms reflected the general rate of PTSS severity. The internal consistency reliability estimate for this Inventory was .94. The scale was also found to have good psychometric properties, including high convergent validity compared with clinical interviews based on the SCID (36). Since we used here both PTSD and PTSS, following the DSM-IV definition, the PTSD assessment was made when no less than the following

symptoms were present: at least one intrusive symptom, three avoidant symptoms, two arousal symptoms, and functional impairment in at least one daily life field as measured by the Life Functioning Scale (criterion F). PTSS, however, reflects only the symptom criteria.

Risk-taking behavior. The Cognitive Appraisal of Risky Events questionnaire (CARE; 37) was used to assess frequency of involvement in 30 hazardous behaviors. Subjects were asked to indicate, on a 5-point scale rang- ing from “not at all” to “very frequently,” the frequency with which they had experienced the described behavior within the preceding six months. Our initial factor analy- sis with varimax rotation resulted in eight factors with low reliability. The removal of three items describing danger- ous sport activities resulted in seven factors that explained 66.4% of the variance. Factor 1 consisted of five items relating to occupational misbehavior (e.g., “Truancy from class or absence from work”; “Procrastinating on tasks or assignments”). Factor 2 consisted of six items describing severe violence (e.g., “Punching or hitting someone with a fist”). Factor 3 consisted of four items describing sub- stance abuse (e.g., “Mixing drugs and alcohol”). Factor 4 consisted of three items describing risky sexual activities (e.g., “Sex without protection against sexually transmit- ted diseases”). Factor 5 consisted of three items describing reckless driving (e.g., “Driving after drinking alcohol”). Factor 6 consisted of three items describing engagement in dangerous sport activities (e.g., “Rock or mountain climbing”). Factor 7 consisted of two items describing aggressiveness (e.g., “Getting into a fight or argument”). The internal consistency reliability estimate for the seven factors ranged from .69 to .83.

dATA AnALySIS Data analyses were comprised of several steps. In addi- tion to descriptive statistics the bivariate relationships between each of the dependent and independent vari- ables were examined. Furthermore, hierarchical regres- sion analyses were conducted to assess the independent and cumulative contribution of each of the predictors (i.e., sociodemographic variables, war exposure and posttraumatic stress symptoms) to the independent variable, namely, severity of the risk taking behavior.

ReSuLTS SoCIodeMogRAPhIC And MILITARy ChARACTeRISTICS The participants’ mean age was 29.95 years (SD=5.82; range= 20 to 54 years). Most of the 180 men were

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Israeli-born (82.8%; N=149) and had a high school edu- cation (69.4%; N = 125). Slightly more than half (55.6%; N=100) were not married and only 35% (N=61) had children. The majority of participants (70%; N=126) were employed at the time of the study. Approximately half the participants (46.7%; N=84) were infantry sol- diers and only 8.9% (N=16) were officers.

RISk-TAkIng BehAvIoRS The majority of the respondents (84%; N=152) reported “frequent” or “very frequent” participation in at least one type of RTB during the previous six months. Sixty- eight veterans (37.6%) reported “frequent” or “very fre- quent” occupational misbehavior, 45 (24.8%) reported “frequent” or “very frequent” aggressive behavior, 10 (5.7%) were involved in “frequent” or “very frequent” severely violent behavior, 22 (12.1%) reported “fre- quent” or “very frequent” substance abuse, 19 (10.3%) reported “frequent” or “very frequent” reckless driving, 23 (12.8%) reported “frequent” or “very frequent” risky sexual activities, and 5 (2.6%) reported “frequently” or “very frequently” engaging in dangerous sports. The last two types of RTB, risky sexual activities and dangerous sports were not significantly correlated with other study variables and are thus not reported in further analyses.

PTSd Seventy-one percent (N=128) of participants met the full criteria for PTSD. Results show that 17 (9%) participants experienced occasional intrusive symptoms during the preceding month, while 162 (90%) experienced them “often” or “very often,” in the same period; 33 (18%) participants experienced occasional avoidant symptoms in the preceding month, while 133 (74%) experienced them “often” or “very often”; 26 (14%) participants expe- rienced occasional numbing symptoms in that period, while 151 (84%) reported experiencing them “often” or “very often”; 16 (9%) participants experienced occasional arousal symptoms during the preceding month, while 157 (87%) experienced them “often” or “very often.” Table 1 presents the means and Standard Deviations of the PTSS and symptom cluster severity.

SoCIodeMogRAPhIC ChARACTeRISTICS And RISk-TAkIng BehAvIoR A series of analyses were conducted to determine if there were RTB group differences with regard to sociodemo- graphic characteristics. Analyses of variance (ANOVAs) provided RTB mean score comparisons across the follow-

ing variables: age, education, family status, occupational status, having children, and type of military service. Results of the ANOVAs revealed significant group differences. Violent behavior was significantly associated with age (F(3,176)=3.67; p<0.05), (1,171)=8.94; p<0.01), occupa- tional status (F(3,174)=4.19; p<0.01), and type of military service (F(3,177)=3.61; p<0.01). Substance abuse was sig- nificantly associated with age (F(3,174)=5.83; p<0.001), family status (F(2,177)=11.07; p<0.001), parenthood (t(174)=3.71; p<0.001), occupational status (F(3,172)=3,10; p<0.05), and type of military service (F(3,175)=6.08; p<0.001). No association was found between sociodemo- graphic characteristics and other types of RTB. Finally, younger, single and childless participants exhibited a higher tendency to participate in risk-taking behaviors.

CoMBAT exPoSuRe And RISk-TAkIng BehAvIoR An examination of combat exposure revealed that, on a scale of 4 slightly less than half the participants (43.5%; N=78) reported “intermediary” and “high” lev- els of exposure to injuries and death. Significantly more than half (70.4%; N=127) reported “intermediary” and “high” levels of exposure to life-threatening situations. Only 11.2% (N=20) of participants reported “interme- diary” and “high” levels of exposure to enemy casual- ties. One third of participants (29.6%; N=53) reported “intermediary” and “high” levels of exposure to their own army’s malfunctioning.

Pearson correlation between combat exposure and risk- taking behaviors revealed significant but weak correlations (Table 2). Generally, findings suggest that more intense battle exposure is associated with a higher tendency to participate in risk-taking behaviors. More intense expo- sure to enemy casualties had the strongest association with higher tendency to participate in risk-taking behaviors like substance abuse (r=0.25; p<0.01) and reckless driving (r=0.17; p<0.05). More intense exposure to dysfunction in one’s army had the strongest association with higher ten- dency to participate in RTB such as occupational misbe- havior (r=0.25; p<0.01), severe violence (r=0.24; p<0.01), and aggressive behavior (r=0.26; p<0.01).

Table 1. Means and std. deviations of PTSS and symptom clusters severity

Sliding scale from 1-“never” to 4-“very often”

PtSS intrusion Avoidance Numbing Arousal

Mean 2.6 2.7 2.4 2.3 2.8

SD 0.7 0.8 0.8 0.7 0.8

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PTSd And RISk-TAkIng BehAvIoR We used independent tests to compare RTB between subjects with and without PTSD. The findings revealed significant differences (Table 3). Generally, the find- ings suggest that participants who were diagnosed with PTSD reported a higher tendency for RTB than veter- ans without PTSD. Means of occupational misbehavior (t(177)=-7.45; p<0.001), severe violence (t(178)=-4.85; p<0.001), substance abuse (t(176)=-3.85; p<0.001), reckless driving (t(176)=-4.19; p<0.001), and aggressive behavior (t(169)=-5.34; p<0.001) among participants who have PTSD were higher. The prevalence of RTB beyond moderate frequencies among PTSD veterans showed that 58.7% of participants reported occupa- tional misbehavior, 27.5% of participants reported aggressive behavior, 12.8% of participants reported substance abuse, 8.2% of participants reported reckless driving, and 3.1 % reported severe violence.

Pearson correlation between PTSS and risk-taking behaviors revealed strongly significant and strong asso- ciations (Table 4). Generally, findings suggest that more severe PTSS is associated with higher tendency to engage in RTB. More severe intrusive symptoms had the stron- gest association with a higher tendency to participate in risk-taking behaviors like severe violence (r=0.45;

p<0.01) and aggressive behavior (r=0.41; p<0.01). More severe arousal symptoms had the strongest association with a higher tendency to participate in RTB like occu- pational misbehavior (r=0.55; p<0.01), and aggressive behavior (r=0.52; p<0.01). More severe avoidant symp- toms had the strongest association with higher tendency to participate in RTB like occupational misbehavior (r=0.38; p<0.01). More severe numbing symptoms had the strongest association with higher tendency to par- ticipate in RTB like occupational misbehavior (r=0.53; p<0.01), and severe violence (r=0.46; p<0.01).

PRedICTIng RISk-TAkIng BehAvIoR To investigate whether the relation of combat exposure to RTB was mediated by PTSS, we employed hierarchi- cal multiple regression analysis with RTB as the depen- dent variable. Sociodemographic characteristics (i.e., yes/no academic degree, yes/no children, not married/ others, married/others, self employed/others, employed/ others, unemployed/others) were entered first, fol- lowed by combat exposure events (i.e., life-threatening situations, dysfunction in one’s army, enemy casualties, injuries and death), and PTSS (i.e., intrusion, arousal, avoidance, numbing). Results of this analysis are pre- sented in Table 5.

Table 2. Pearson correlation between RTB factors and Combat Exposure situations

* p<0.05, ** p<0.01, *** p<0.001

Aggressive behavior

Reckless driving

Substance abuse

Severe violence

occuptnl misbhvr

General index of the RtB

0.25** 0.19* 0.26** 0.19** 0.26** 0.32** General index of the Combat Exposure

0.17* 0.13 0.22** 0.17* 0.16* 0.22** injuries and death

0.10 0.16* 0.12 0.05 0.20** 0.18* Life-threatening situations

0.12 0.17* 0.25** 0.15* 0.08 0.22** Enemy casualties

0.26** 0.15* 0.19** 0.24** 0.25** 0.29** Dysfunction in one’s army

PtSD (N=128) Non PtSD (N=52)

N M SD N M SD

General index of the RtB 127 2.02 0.53 53 1.43 0.33 t(178)=-7.45***

occuptnl misbhvr 126 3.25 1.01 53 2.08 0.83 t(177)=-7.45***

Severe violence 127 1.57 0.65 53 1.12 0.32 t(178)=-4.85***

Substance abuse 125 1.85 0.97 53 1.31 0.52 t(176)=-3.85***

Reckless driving 125 1.79 0.82 53 1.28 0.46 t(176)=-4.19***

Aggressive behavior 120 2.58 1.09 51 1.67 0.85 t(169)=-5.34***

Table 3. Means and standard deviations of RTB according to PTSD appearance

*** p<0.001

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Multiple regression analysis demonstrated additive effects for sociodemographic characteristics, level of combat exposure, and PTSS (r2=0.43), F(15,162)=7.36; p<0.001. The most important contribution was made by PTSS and explained 24% of the variance. Less but still significant contributions were found to come from socio- demographic characteristics (11%) and combat exposure intensity (8%). RTB was significantly associated with level of arousal and numbing symptoms, level of exposure to

dysfunction in one’s army, and occupational status. When PTSS was statistically controlled for the contribution of combat exposure to RTB was nullified.

dISCuSSIon The first purpose of the current research was to assess the prevalence of risk-taking behaviors among Israeli reserve soldiers with and without PTSD. The results show that the majority of combat veterans (84%) reported a sig- nificant engagement in at least one type of RTB during the six months preceding the study. The PTSD veterans scored significantly higher than the non-PTSD subjects on all measures of RTB. It also seems that younger vet- erans were at a higher risk for RTB. These findings are consistent with earlier studies that suggest that RTB dis- turbance may be an especially prevalent problem in help- seeking combat veterans with PTSD (14-16, 38).

The second and main aim of this study was to exam- ine the inter-relationship among the level of combat exposure, posttraumatic stress symptoms, and risk- taking behavior. More specifically, the independent and cumulative contributions of combat exposure and posttraumatic stress symptoms to risk-taking behavior were assessed. Results revealed a significant contribu- tion of PTSS to RTB. Furthermore, PTSS promoted the relationship between combat exposure and RTB. These findings are consistent with previous studies (16-18, 21-25) and confirm the conclusion that more severe PTSS is associated with higher tendency for RTB regardless of level of combat exposure.

Several possible explanations for the relationship between RTB and PTSS are suggested. First, RTB may serve as a maladaptive attempt to temporarily relieve posttraumatic stress symptoms. For instance, the ’’Self- medication’’ and ’’Tension reduction’’ models outlined by Khantzian (39) postulate that PTSD develops first and alcohol addiction or abuse are reinforced sec-

Numbing Avoidant Arousal intrusion General index of PtSS

0.54** 0.35** 0.60** 0.45** 0.59** General index of the RtB

0.53** 0.38** 0.55** 0.39** 0.54** occuptnl misbhvr

0.46** 0.27** 0.45** 0.45** 0.48* Severe violence

0.30** 0.20** 0.23** 0.18** 0.27** Substance abuse

0.30** 0.16* 0.33** 0.25** 0.31** Reckless driving

0.41** 0.30** 0.52** 0.41** 0.48** Aggressive behavior

Table 4. Pearson correlation between RBT factors and PTSS

* p<0.05, ** p<0.01, *** p<0.001

Table 5. Regression coefficients, R2 and R2 Change values for sociodemographic variables, Combat Exposure and PTSS predicting for RTB

Standardized beta

Predictor Variable Step 1 Step 2 Step 3

Step 1. Sociodemographic characteristics

Academic degree (yes/no) 0.13 0.11 0.03

Children (yes/no) 0.06 0.06 -0.02

Family status (not married/others) 0.27 0.17 0.20

Family status (married/others) 0.07 0.04 0.04

occupation status (self employed/others) -0.12 -0.17 -0.16*

occupation status (employed/others) -0.22* -0.23* -0.21*

occupation status (unemployed/others) -0.05 -0.05 -0.19*

Step 2. Combat Exposure

Life-threatening situations 0.03 -0.04

Dysfunction in one’s army 0.18* 0.06

Enemy casualties 0.12 0.07

injuries and death 0.07 0.03

Step 3. PtSS

intrusion 0.05

Arousal 0.32**

Avoidant -0.05

Numbing 0.27**

R2 Change 0.11** 0.08** 0.24***

R2 0.11 0.19 0.43

* p<0.05, ** p<0.01, *** p<0.001

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ondarily in order to reduce tension (e.g., 17). In other words, veterans use RTB as a destructive coping strategy to temporarily reduce or numb the negative effect the posttraumatic stress symptoms.

According to Herman (40), there are several reasons that may cause trauma survivors to engage in risky behav- iors after exposure. These behaviors, as aforementioned, may be the trauma survivors’ attempts to regulate their internal emotional state. For example, traumatized indi- viduals who are unable to dissociate effectively from their painful experiences may try to produce similar numbing effects by resorting to alcohol and drug use. Trauma sur- vivors may also use alcohol or drugs to control the hyper- arousal and intrusive symptoms associated with PTSD. In addition, risky behaviors may be a result of the psychopa- thology caused by the exposure to trauma. For example, a war veteran who is dissociating may fail to adequately respond to danger signals or may misinterpret dangerous situations and thus increase his risk for further victimiza- tion. Finally, due to guilt, shame or shattered self-esteem, trauma survivors may feel undeserving of safety, care or protection and, therefore, do not seek out protection.

Another perspective is related to Berkowitz’s (41) cognitive-neoassociationistic model. This model postu- lates that the experience of a dysphoric effect is likely to activate associative networks of anger-related feelings, thoughts, memories and aggressive inclinations, making aggressive behavior more likely. According to Berkowitz (41, 42) and other aggression theorists (43), bodily reac- tions and higher order cognitive processing influence the expression of aggression. When people do not feel well, they are more likely to experience feelings of anger and hostility which, in turn, may arouse memories, and aggressive inclinations, all of which increase the tendency for risky behaviors. Attribution processes and prior learn- ing play an important role in most conceptualizations of aggression and may be particularly significant for com- bat veterans suffering from posttraumatic stress symp- toms. The suggestion is that the anger-related thoughts and hostile attributions of these individuals are likely to be heightened due to prior experiences of trauma, fear and life-threatening situations, and a hypersensitivity to potential threats in the environment (44). In other words, traumatized war veterans are likely to be aggressive and display maladaptive and inadequate behaviors.

Findings of the present study may have important clinical implications. Theoretical models interpreted in light of these findings suggest that the identification and treatment of dysphoric symptomatology should

also be incorporated into high-risk behavior manage- ment interventions for combat veterans, experiencing symptoms of PTSD.

This study has several limitations that should be noted. First, the sample used was of reserve soldiers who sought treatment in an IDF Combat Reaction Unit between August 2007 and June 2008 in the wake of the Second Lebanon War and may not be representative of the larger veteran population. This study should be replicated in a cohort of regular service soldiers and veterans of other wars. The study data are based on memories of events that occurred several months in the past and are based on self-report. Therefore the findings should be inter- preted with caution. Memories of combat experiences may have changed with the passing of time and may be variously affected by posttraumatic stress symptoms and negative affect (45). Participants seeking compensation may have exaggerated their reports of combat exposure, psychopathology and negative affect, and/or aggression, inflating the observed associations (46). Unfortunately, it is impossible to determine from our data whether any demographic factors have changed after the war. Hence, we adopted the assumption that these factors were left unchanged. Nevertheless, this study limitation should be taken into account when interpreting the results of this study. Finally, the help-seeking status of participants may also limit the ability to generalize from the current findings to the larger population of veterans not seeking care or compensation.

Further research is needed to examine a broader array of variables (e.g., cognitive and information-processing systems, social support, coping patterns, and more) that co-exist with PTSS and PTSD but may represent dif- ferent emotional experiences, in order to enhance our understanding of the full associative network leading to risk-taking behavior among military veterans.

Despite these limitations, this study contributes to better understanding of risk-taking behavior in this population. Findings indicated that PTSS largely account for the effect of combat exposure on risk-taking behavior. Further research in this area and better under- standing of the disorder may serve to mitigate the severe interpersonal and health consequences associated with such maladaptive behavior.

References Kulka AR, Schlenger WE, Fairbank JA, Houfh RL, Jordan BK, Marmar 1. CR, Weiss DC. Trauma and the Vietnam War generation: Report of findings from the national Vietnam veterans’ readjustment study. New York: Brunner/Mazel, 1990.

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