Aviva Goral

The Continuous Traumatic Stress Response Scale (CTSR) was developed to assess traumatic stress responses under ongoing threat. This study evaluated whether the original 11‐item, three‐factor CTSR structure retained psychometric support after the October 7, 2023, attacks and subsequent war in Israel. The cross‐sectional confirmatory factor analysis (CFA) sample used each participant's first available assessment, yielding 756 unique participants; longitudinal analyses included 337 participants who completed both waves. CFA supported the prespecified three‐factor structure of exhaustion/detachment, rage/betrayal, and fear/helplessness, CFI = .994, TLI = .992, RMSEA = .069, 90% CI [.059, .079], SRMR = .048, with standardized loadings from .69 to .90. A one‐factor model showed acceptable but weaker fit, and parallel robust maximum likelihood analyses favored the three‐factor model per Akaike and Bayesian information criteria. Longitudinal CFA supported temporal measurement invariance; latent mean analyses showed no significant change in exhaustion/detachment or rage/betrayal and a small decrease in fear/helplessness. Multigroup CFA supported measurement invariance across sex and age, whereas trauma‐exposure invariance was supported only for a one‐factor sensitivity model. Internal consistency was high for the total scale, Cronbach's α = .908, McDonald's ω = .909, and adequate‐to‐good for subscales. CTSR scores showed good temporal stability, ICC = .812; strong associations with PTSD symptoms, ρ = .699, and functional impairment, ρ = .701; and higher scores among trauma‐exposed participants, d = 0.37. Findings support the CTSR as a valuable research measure and encourage continued evaluation of its three‐factor structure under ongoing threat.

Background: Adolescents exposed to violence are at a higher risk for mental health problems than their peers. Exposure to ongoing violence can potentially lead to Continuous Traumatic Stress (CTS). CTS reactions have never been studied in relation to violence exposure in adolescent samples.Objective: We aimed to validate the Lithuanian version of the Continuous Traumatic Stress Response (CTSR) scale in the adolescent sample, to explore the adolescents' CTS reactions using the person-oriented approach, and to study the relationship between different types of violence and CTS reactions.Method: In total, 321 adolescents (M(SD)_age = 14.19 (1.26)) from Lithuania were included in the current study, of which 181 (56.4%) were female, 135 (42.1%) were male, and 54.5% (n = 175) were continuously exposed to violence over their lifetime. Confirmatory factor analysis (CFA) with measurement invariance across genders and age groups was used to test the structural validity of the CTSR scale. A latent class-analysis approach was used to explore the patterns of CTS reactions.Results: The results showed good structural, convergent, and differential validity of the CTSR scale. Exhaustion/Detachment, Rage/Betrayal, and Fear/Helplessness were more profound in continuous violence exposure versus non-exposure groups, with even higher CTS reactions when recently exposed to violence. Three groups of adolescents with low, moderate, and high CTS reactions were distinguished with the suggested cut-off sum score of CTSR ≥18 for severe CTS reactions. The intensity of exposure to neglect, psychological abuse, physical abuse, and sexual abuse positively predicted Continuous traumatic stress (CTS) response group membership.Conclusions: These results stress the need for psychological support when exposed to continuous interpersonal violence in adolescence.

Current diagnostic criteria for post-traumatic stress disorder (PTSD) do not include symptoms resulting from exposure to ongoing traumatic stress. Thus, existing assessment tools do not fully capture stress symptoms associated with exposure to threats that extend over months or years. We aimed to enumerate the symptoms associated with ongoing exposure to stress and to evaluate the need for a new comprehensive tool designed to assess traumatic stress in these situations. Study methods included focus group sessions, interviews, and a content expert’s workshop. Thematic analysis yielded three main themes: 1. PTSD in its current definition does not capture the whole “traumatic picture” observed in ongoing exposure to threat, 2. Some DSM-5 criteria are not applicable in ongoing exposure to threat, 3. The need for a new tool or modifications of commonly used assessment tools. This study supports the notion that PTSD assessment practices are lacking when assessing traumatic stress in ongoing exposure to threat and highlights the need for a new tool specifically designed for these situations.

Background: Current diagnostic criteria for posttraumatic stress disorder (PTSD) do not include symptoms resulting from exposure to continuous or ongoing traumatic stress. Thus existing assessment tools do not fully capture stress symptoms associated with exposure to threats that extend over months or years. To address this void, we enumerated the symptoms associate with ongoing exposure to stress including those that are distinct from existing PTSD diagnostic criteria. Objectives: To develop the Continuous Traumatic Stress Response Scale (CTSR) and assess its psychometric properties. Method: We sampled 313 adults exposed and unexposed to ongoing security threat between December 2016 and February 2017. Respondents lived in communities bordering the Gaza Strip in southern Israel where they are exposed to frequent rocket attacks, requiring they locate and find shelter in 30 seconds or less. We assessed the concurrent validity of CTSR relative to the Posttraumatic Diagnostic Scale (PDS). Results: On the basis of exploratory factor analysis (EFA), we retained 11 of 25 items measuring three distinct factors: exhaustion/detachment, rage/betrayal, and fear/helplessness. We found moderate concurrence between the scales; that is, the CTSR appears to measure a construct related to, but distinct from PTSD. This conclusion is supported by confirmatory factor analysis (CFA) indicating that each factor significantly contributes to measurement of a higher-order, continuous traumatic stress latent construct. Conclusions: These results support the psychometric properties of CTSR. Future research is required to confirm these findings in other countries and cultures and among individuals exposed to other forms of continuous traumatic stress.

Objective: We aimed to assess whether peritraumatic threat experienced during a period of armed conflict predicted subsequent depression symptoms.Method: Ninety‐six Israeli civilians provided real‐time reports of exposure to rocket warning sirens and subjective sense of threat, twice daily for 30 days, during the 2014 Israel–Gaza conflict. Depression symptoms were reported 2 months after the conflict. Mixed‐effects models were used to estimate peritraumatic threat levels and peritraumatic threat reactivity (within‐person elevations in threat following siren exposure). These were then assessed as predictors of depression symptoms at 2 months in an adjusted regression model.Results: Individual peritraumatic threat level, but not peritraumatic threat reactivity, was a significant predictor of 2 months depression symptoms, even after controlling for baseline depression symptoms.Conclusions: The findings imply that in situations of ongoing exposure, screening for perceived levels of peritraumatic threat might be useful in identifying those at risk for developing subsequent depression symptoms.

Objectives: The current study examined whether peritraumatic threat predicted posttraumatic growth (PTG), and whether the relationship between peritraumatic threat and PTG was mediated by post-traumatic stress (PTS) symptoms. Design: A prospective experience sampling study. Methods: 96 Israeli civilians provided smartphone reports of their rocket warning siren exposure and peritraumatic threat, twice daily for 30 days, during the 2014 Israel-Gaza conflict. PTS symptoms data were collected one month after entry to the study, PTG data were collected five months after entry to the study. PTG predictors were assessed using a hierarchical multivariate regression model. A mediation analysis was conducted to assess the indirect effect of peritraumatic threat on PTG via PTS symptoms. Results: One month PTS symptoms and level of exposure to the conflict were both significant PTG predictors. After controlling for potential covariates, the relationship between peritraumatic threat and PTG scores was fully mediated by PTS symptoms. Conclusions: PTS symptoms mediated the relationship between peritraumatic threat and subsequent PTG. Screening trauma survivors for levels of threat and PTS symptoms may be helpful in tailoring therapeutic approaches that will aid in alleviating stress symptoms on one hand and increase the likelihood of growth and better health outcomes on the other.

In 2003, we published a study on the Israeli workforce in emergency medicine (EM). We repeated the study in 2012 to assess changes in the workforce that have occurred in the interval decade. This is an observational cross-sectional study of the physician workforce in EM in Israel in 2012. An online survey was sent to the ED medical directors of all general hospitals in Israel querying the numbers of physicians working in the ED, as well as the specialty and level of training of those manning the ED at various times during the day. The workforce in 2012 was compared to that of 2003. Twenty-four of 28 (86 %) EDs responded. Certified EM specialists have increased from 59 to 164 since 2003. Disparities continue regarding their presence in the ED. Most EM specialists are scheduled during the day whereas they are virtually absent during the night. A total of 58 EM specialists were scheduled countrywide for the weekday day shift and only one overnight. The preponderance of EM specialists working during the day and the large number of supervised and unsupervised residents working at night has not changed substantially since 2003. Eleven departments reported having an EM specialist present during the evenings whereas in 2003, only two departments reported so. Since 2003, there are more certified EM specialists and more specialist coverage in the ED into the evening hours. Most ED providers are still not emergency physicians, and there is still a preponderance of EM specialist coverage during the day and a lack thereof overnight.

Provision of healthcare is considered a basic human right. Delivery and uptake is affected by many complex factors. Routine vaccinations are provided free of charge in Israel to all residents. The Palestinian Israeli Collaborative Research (PICR) group conducted research on vaccine impact at eight primary care facilities in east Jerusalem (EJ) and central Israel (IL) which allowed assessment and comparison of interactions of these Arab and Jewish populations, respectively, with healthcare services. Families attending clinic with a child under five years old were invited to participate. Utilisation of healthcare was assessed using data from standardise questionnaires completed after enrolment, using proxies of vaccination status, antibiotic use, primary care physician and hospital visits as well as demographics such as household size. Differences between EJ and IL were assessed using chi squared tests; univariate analyses identified potential confounders which were tested in a multiple logistic regression model for any independent associations between region and outcome. Children in EJ were significantly more likely to live in larger households, with tobacco smokers, to have been breastfed, hospitalised and used antibiotics recently than those in IL, who were significantly more likely to have recently seen a primary care physician (all p < 0.01). Receipt of routine vaccinations, given at well baby clinics, was similar between the regions at above 95 % (p = 0.11), except for influenza which was delivered separately at primary physician clinics to 5 % (EJ) and 12 % (IL). Receipt of pneumococcal vaccine when paid for separately was significantly higher in IL than EJ (3 % vs 31 %). Multivariate analysis identified the most important independent predictors of these differences as region, age and household size. Healthcare in Israel is of a very high standard, but it is not uniformly utilised within the community in all geographical areas, though in some key areas, such as uptake of most routine childhood vaccination, equality seems to be achieved. To ensure excellent healthcare is achieved across the population, inequalities must be addressed, for instance in health promotion and other activities, which could improve and normalise health outcomes.