A Longitudinal Investigation of the Relationship between Posttraumatic Stress Symptoms and Posttraumatic Growth in a Cohort of Israeli Jews and Palestinians during Ongoing Violence

April A Longitudinal Investigation of the Relationship between Posttraumatic Stress Symptoms and Posttraumatic Growth in a Cohort of Israeli Jews and Palestinians during Ongoing Violence Brian J. Hall 0 1 Leia Y. Saltzman 0 1 Daphna Canetti 0 1 Stevan E. Hobfoll ) 0 1 0 1 Department of Psychology, The University of Macau , Macau (SAR) , People's Republic of China, 2 Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland, United States of America, 3 School of Social Work, Boston College, Boston, Massachusetts, United States of America, 4 School of Political Science, University of Haifa , Haifa , Israel , 5 Department of Behavioral Sciences, Rush University Medical Center , Chicago, Illinois , United States of America 1 Academic Editor: Jon D. Elhai, Univ of Toledo, UNITED STATES - Funding: This research was made possible in part by a grant from the National Institute of Mental Health (RO1MH073687) and the Ohio Board of Regents. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Meta-analytic evidence based on cross-sectional investigations between posttraumatic growth (PTG) and posttraumatic stress disorder (PTSD) demonstrates that the two concepts are positively related and that ethnic minorities report greater PTG. Few longitudinal studies have quantified this relationship so the evidence is limited regarding the potential benefit PTG may have on post-traumatic adjustment and whether differences between ethThe current study attempts to fill a substantial gap in the literature by exploring the relationship between PTG and PTSD symptom clusters longitudinally using a nationally representative cohort of 1613 Israelis and Palestinian Citizens of Israel (PCI) interviewed via telephone on three measurement occasions during one year. Latent cross-lagged structural models estimated the relationship between PTG and each PTSD symptom cluster, derived from confirmatory factor analysis, representing latent and statistically invariant PTSD symptom factors, best representing PTSD for both ethnic groups. PTG was not associated with less PTSD symptom severity in any of the four PTSD clusters, for Jews and PCI. In contrast, PTSD symptom severity assessed earlier was related to later reported PTG in both groups. Competing Interests: The authors have declared that no competing interests exist. This study demonstrates that PTSD symptoms contribute to greater reported PTG, but that PTG does not provide a salutatory benefit by reducing symptoms of PTSD. The Al Aqsa Intifada, a period of conflict in Israel lasting close to five years, produced an environment in which high numbers of civilians were repeatedly exposed to bombings and terror attacks. Bleich, Gelkopf, and Solomon [1] found that nearly half of a nationally representative sample of Israelis reported direct, or indirect (through family member or friend), exposure to terrorism. The high levels of exposure among the general population highlighted the clinical significance of understanding the nuances in the association between mental health outcomes and repeated, and long lasting, exposure to terrorism. Studies have documented the association between exposure to political violence and terrorism and mental health problems [24]. Among the most investigated of these problems is posttraumatic stress disorder (PTSD). Although it is important to evaluate the pathological responses to exposure, it is now well known that relatively few people exposed to terrorism develop PTSD [5], even in populations that face continued exposure and chronic conditions of deprivation [6]. A burgeoning effort has been undertaken to expand Tedeschi and Calhouns [7] theoretical work on possible positive adaptations that emerge as a result of coping with potentially traumatic events (PTE), a construct they named posttraumatic growth (PTG). PTG is broadly defined as a positive psychological change experienced as a result of the struggle with highly challenging life circumstances and trauma [8]. PTG does not solely involve a return to pre-trauma levels of functioning (e.g. resiliency [9]), nor does it speak to the capacity to resist developing psychological disorders [10]. Rather, it is defined as achieving an enhanced level of functioning, sense of meaning or spirituality, and developing closer relationships with others that exceed pre-trauma functioning. In order for growth to occur, Tedeschi and Calhoun [7] posited that some level of distress would be necessary to bring about cognitive processes needed to facilitate growth. To what extent psychological distress is related to PTG overtime, and whether PTG may lead to reductions in psychological distress has not been widely explored in the literature PTG and Posttraumatic Stress Disorder The relationship between PTG and psychological distress is one of the most widely debated issues in the PTG literature. In their early theoretical contributions, Tedeschi and Calhoun [7] suggested that an individual can report growth and psychological distress at the same time, and that these two dimensions are unrelated to each other. However, few studies support the viewpoint that PTG and psychological distress are unrelated [11, 12]. Cross-sectional studies have demonstrated inconsistent empirical findings regarding the relationship between PTG and PTSD symptom severity. Several studies suggest that PTG is positively associated with PTSD symptom severity such that greater PTG is related to greater PTSD symptom severity [10, 1315]. While others have demonstrated that PTG is associated negatively with PTSD symptom severity such that more PTG is related to less PTSD symptom severity [16, 17]. A recent meta-analysis of 42 studies (N = 11,469) provided greater clarity on this association and demonstrated a significant positive relationship between PTSD and PTG (r = .315) [18]. However, the cross-sectional nature of these studies limits the utility of these findings, and fails to solidify the temporal nature and quality (i.e., positive or negative) of the relationship between PTSD symptom severity and PTG. Longitudinal studies can elucidate these relationships further, and allow for testing of several potential temporal associations such that: 1) PTG leads to less PTSD symptom severity, 2) PTG leads to greater PTSD symptom severity, 3) PTSD symptom severity leads to greater PTG, 4) PTG and PTSD symptom severity are unrelated, and 5) PTSD symptom severity leads to less PTG, an association that has received less theoretical and empirical support. Only two published studies examined the relationship between PTG and PTSD over time [19, 20]. These studies supported the 3rd pathway described above, demonstrating that PTSD symptom severity is associated with greater PTG subsequently reported. However, one study did not have measurements of the main study variables available at each time point [ (...truncated)