Delayed-onset PTSD in Israeli combat veterans: Correlates, clinical picture, and controversy

Delayed-onset posttraumatic stress disorder (DPTSD) has been under medicolegal debate for years. Previous studies examining the prevalence and underlying mechanisms of DPTSD have yielded inconclusive findings. Thus, a question still remains regarding the prevalence and underlying mechanism of this phenomenon. This study examined the clinical picture and correlates of DPTSD. Six hundred and seventy-five Israeli veterans from the 1982 Lebanon War, 369 with antecedent combat stress reaction (CSR), and 306 without CSR were assessed prospectively, 1, 2, and 20 years after the war. Veterans were divided into four groups, according to the time of first PTSD onset (first onset at 1983, 1984, and 2002, and no-PTSD onset). Participants completed self-report questionnaires tapping various psychological resources (social support, ways of coping, locus of control), as well as a variety of psychiatric symptoms. Dptsd was found among 16.5 % of the sample. In addition, a longer delay in PTSD onset was associated with an attenuated clinical picture. This was found across a variety of psychiatric measures. We have also found that the vast majority of veterans were already symptomatic before the delayed onset of PTSD, thus negating the idea of an “all or nothing” phenomenon. Antecedent CSR was associated with a shorter delay in PTSD onset after the war. Several psychological resources were found to contribute to the delay in PTSD onset. Social support, internal locus of control, and problem-focused coping were positively associated with the duration of delay (DOD) in PTSD onset, while emotion-focused coping was negatively associated with DOD. Also, both emotion- and problem-focused coping mediated the association between social support and DOD. These results clearly show that DPTSD is by no means a negligible phenomenon, but rather one that occurs among a substantial number of war veterans. Also, our results seem to suggest that veterans with DPTSD present a unique, attenuated clinical picture compared to those who have experienced a more immediate PTSD onset. In addition, the results of this study indicate that DPTSD is associated with psychological resilience. It seems that veterans who, after the war, have more psychological resources at their disposal are able to endure the effects of combat for a longer period of time. Finally, DPTSD does not appear after a fully non-symptomatic period, but rather may be the result of the exacerbation of already-existing PTSD symptoms. The results of this study also have important clinical and legal implications, which are thoroughly discussed.