VOLUME 160 SEPTEMBER 1995 MILITARY MEDICINE ORIGINAL ARTICLES NUMBER 9 Authors alone are responsible for opinions expressed in the contribution and for its clearance through their federal health agency. If required. MILITARY MEDICINE, 160,9:425, 1995 Clinical Characteristics of Delayed and Immediate-Onset Combat-Induced Post-Traumatic Stress Disorder LT COL Zahava Solomon*t Yaja Singer, MA* The aim of the current study is to examine the clinical char- acteristics of war-related disturbances among veterans with delayed and immediate-onset post-traumatic stress disorder (PTSD). One hundred twenty-five veterans who sought help for war-related disturbances, 8 years after the 1982 Lebanon War, filled out the PTSD Inventory, Impact of Event Scale, and SCL- 90. Their scores were compared with those of 370 treated combat stress reaction casualties who filled out the question- naires a year after the same war. Findings indicate that veter- ans from the delayed-helpseeking group suffer from a higher rate (92 vs. 59%) and a greater intensity of PTSD, more intru- sive tendencies, and more severe general psychiatric symp- tomatology than those of the immediate-helpseeking group. These findings indicate that a fair number of combatants still seek help for war-related disturbances almost a decade after the war. The complex relationship between delayed-helpseek- ing and delayed-onset PTSD is discussed. Introduction P ost-traumatic stress disorder (PTSD) is the most common and conspicuous psychiatric sequelaeofthe stress of com- bat. It is characterized by re-experiencing the traumatic eventin nightmares and daytime imaging, by the avoidance of stimuli reminiscent of the event, and by persistent symptoms of in- creased arousal. 1 It is often accompanied by depression, anxi- ety, and difficulty in social functtontng." War-related PTSD can occur in three major forms, distin- guished by time of onset and triggering events: (1) acute PTSD, (2) reactivated PTSD, and (3) delayed PTSD. Acute PTSD appears within6 monthsofexposure to the traumatic event. Reactivated *Department of Mental Health, Medical Corps, Israel Defense Force. tThe Bob Shapell School ofSocial Work, Tel Aviv University, Israel. Correspondence: Prof. Zahava Solomon, TheBob Shapell School of Social Work, Tel Aviv University, Ramat Aviv, Tel Aviv 69978, Israel. This manuscript wasreceived for review inJune 1994. Therevised manuscript was accepted for publication in April 1995. Reprint &Copyright ©byAssociation of Military Surgeons of U.S., 1995. Amir Blumenfeld, MD* PTSD may occur months or years after an earlier incident of PTSD seems to have been laid to rest. It may follow a stressful event that is reminiscent, symbolically or realistically, of the original event that caused the first PTSD. 3 Reactivated PTSD is preceded by a symptom-free period, or a period of subclinical disorder. Delayed PTSD is marked,according to the DSM-III-R, 1 by the emergence of symptoms 6 months or more after the traumatic experience. It is diagnosed when the casualty initially seems to respond to the traumatic experience adaptively, but develops the symptoms after an asymptomatic latency period of at least six months. 1 Various researchers have suggested that the delayed emer- gence ofPTSD derives from a premature closureofthe traumatic event, which leaves the trauma latent until it is activated by another event, or until the defense mechanisms that had sup- pressed it break down." Horowitz and Solomon" maintain that delayed PTSD develops when the security and safety at home permitthe relaxation of defense and coping mechanisms, which are subsequently flooded by traumatic memories and feelings. Delayed PTSD has been observed in survivors of the Nazi Holocaust" and the atomic bomb in .Japan," among American World War 11 7 and Vietnam veterans,"and amongIsraeli veter- ans of the 1982 Lebanon War. 9 It has been observed, also, among survivors of a range of natural and manmade disas- ters.'" According to studies, many survivors of these cata- strophic events appear to have adjusted well, onlyto haveman- ifested trauma-related symptoms years later. In general, the literature on delayed PTSD is minimal and consists of a limited number of clinical studies." These and the few empirical studies on the subject are plagued by the funda- mental questionofwhetherwhat is identified as "delayed" PTSD is really such, because it is preceded by a long symptom-free latency period, or whether it is merely delayed help seeking prompted by the exacerbation ofa longstanding clinical or sub- clinical disorder, or another cause."" A survey carried out in the Mental HealthDepartment ofthe Israel Defense Force (IDF)9 of 150 files ofIsraeli combatsoldiers 425 Military Medicine, Vol. 160, September 1995 Downloaded from https://academic.oup.com/milmed/article/160/9/425/4844710 by guest on 21 January 2023