Aging & Mental Health

ISSN: 1360-7863 (Print) 1364-6915 (Online) Journal homepage: http://www.tandfonline.com/loi/camh20

Subjective age and perceived distance-to-death moderate the association between posttraumatic stress symptoms and posttraumatic growth among older adults Yuval Palgi To cite this article: Yuval Palgi (2015): Subjective age and perceived distance-to-death moderate the association between posttraumatic stress symptoms and posttraumatic growth among older adults, Aging & Mental Health, DOI: 10.1080/13607863.2015.1047320 To link to this article: http://dx.doi.org/10.1080/13607863.2015.1047320

Published online: 01 Jun 2015.

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Date: 05 November 2015, At: 21:33

Aging & Mental Health, 2015 http://dx.doi.org/10.1080/13607863.2015.1047320

Subjective age and perceived distance-to-death moderate the association between posttraumatic stress symptoms and posttraumatic growth among older adults Yuval Palgi* Department of Gerontology, the Center for Research and Study of Aging, University of Haifa, Haifa, Israel

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(Received 20 September 2014; accepted 28 April 2015) Objectives: Little research has addressed the association between posttraumatic stress (PTS) symptoms and posttraumatic growth (PTG) in the second half of life. This study examined whether subjective age and perceived distance-to-death moderate this association. Method: 339 community-dwelling older adults (age range 50 90; M D 65.44, SD D 9.77) were sampled through random dialing to Jewish residents in the south of Israel. Participants completed a phone-questionnaire on PTS symptoms, level of PTG, subjective age, and perceived distance-to-death. Results: Higher levels of PTS symptoms were both linearly and curvilinearly related to higher PTG. Additionally, subjective age and perceived distance-to-death moderated this association in a linear way, so that the association was strongest in participants who reported younger subjective age and further distance-to-death. Discussion: The findings emphasize the moderating effect of two time perspectives, one that focuses on time since birth and another that concerns the time that remains before death. These two perspectives affect the association between posttraumatic stress and posttraumatic growth within older individuals. Keywords: posttraumatic stress symptoms; posttraumatic growth; subjective age; perceived distance-to-death

Introduction Research on trauma has emphasized the long-lasting effects of being exposed to traumatic events (e.g., Gelkopf, Solomon, & Bleich, 2013). These results have been related both to the deleterious effect of prolonged exposure to high levels of stress (Gelkopf, Berger, Bleich, & Silver, 2012) and to positive psychological change (Tedeschi & Calhoun, 2004). Several studies have demonstrated that the exposure to traumatic experiences in the second half of life may be harmful and may add to other agerelated negative effects (e.g., Dekel & Nuttman-Shwartz, 2009; Ron, 2011). Nevertheless, exposure to long-lasting traumatic experiences may also result in positive psychological change, which is commonly termed posttraumatic growth (PTG, Dekel & Nuttman-Shwartz, 2009; Hobfoll et al., 2008). PTG is assumed to reflect the outcome of a struggle with the consequences of a traumatic exposure. PTG leads to a change in one’s perspectives on life, realization of a new meaning in life, enhanced personal strength, and better interpersonal relations (Tedeschi & Calhoun, 1996, 2004). The association between posttraumatic stress (PTS) symptoms and PTG is well established (Dekel, Ein-Dor, & Solomon, 2012). Findings indicate a paradoxical ‘double-edge sword’, in which a higher level of PTS symptoms is associated with greater PTG (Boals & Schuettler, 2011). Shakespeare-Finch and Lurie-Beck (2014) showed in a meta-analysis that the association between the reaction to trauma and PTG is better represented with a quadratic model, since growth appears to be *Email: [email protected] Ó 2015 Taylor & Francis

greater at the midlevel of traumatic symptomatology. Hence, up to a certain level, processing of trauma-related information and acknowledgment of the impact of the trauma facilitates the psychological growth. Moreover, trauma leads to a new interpretation of other events and thus serves as a trigger of growth (Tedeschi & Calhoun, 1996). Therefore, this study will examine both a linear and a curvilinear relationship between PTS symptoms and PTG, and will look for potential moderating effects of subjective perceptions of aging and dying on these relationships.

Subjective age, PTSD, and PTG Among older adults, perspectives regarding the time lived and the time left to live are known to be independently related to one’s adaptive functioning (Shrira, Bodner, & Palgi, 2014). Chronological age might play a central role in understanding developmental processes in younger ages, but this measure is less effective in the second half of life (Baars, 2013). Hence, in the second half of life, subjective evaluations of age become better predictors of the status of one’s aging than is chronological age (Diehl et al., 2014). Findings show that subjective evaluations of age are good predictors of better physical functioning (Montepare, 2009), lower mental distress, and higher well-being (Bergland, Nicolaisen, & Thorsen, 2014; Choi & DiNitto, 2014; Keyes & Westerhof, 2012; Westerhof & Barrett, 2005), as well as decreased mortality risk (Kotter-

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Gr€uhn, Kleinspehn-Ammerlahn, Gerstorf, & Smith, 2009). In line with these findings, Solomon, Helvitz, and Zerach (2009) found that veterans suffering from PTSD report older subjective age in comparison to veterans without PTSD. The authors suggested that these findings reflect a vicious cycle in which trauma affects self-perception and self-perception may in turn reduce the well-being and even life expectancy. This finding can be further explained by the subjective weathering hypothesis (Benson, 2014), according to which traumatic exposure may lead to perceptions of older subjective age when emotional and cognitive levels of maturity do not match the surrounding demands. The original theory posits that this change occurs due to incongruence between early life experiences and later adult roles or responsibilities, incongruence that derives from the consequences of the trauma (Foster, Hagan, & Brooks-Gunn, 2008). Drawing on this theory, it is suggested that traumatic exposure later in life may demand social, cognitive, physical, or mental resources that may be beyond one’s accumulated strength. When these demands add to the difficulties brought about by aging, the person must use flexible adaptation to cope with the trauma. Incongruence between one’s ability to accept and adapt to these demands might be accelerated by the trauma on the one hand and by the demands of aging on the other hand. It may then affect the age identity by changing self-perceptions, as found by Solomon et al. (2009). Consequently, younger subjective age may buffer the association between PTSD symptoms and PTG. Nevertheless, it is unclear whether any correlation will be found between subjective age and PTG in older adults. Perceived DtD, PTSD, and PTG Perceived distance-to-death (DtD) refers to the way in which individuals perceive the time that they have until death (Kotter-Gr€ uhn, Gr€ uhn, & Smith, 2010). This perception is a good predictor of physical functioning and mortality (Griffin, Loh, & Heskeyh, 2013; Kotter-Gr€uhn et al., 2010). Birren and Cunningham (1985) refer to feelings and perceptions that appear shortly (years or months) before death as tertiary aging and attribute them to accelerated functional deterioration. Starting at midlife, perceived DtD becomes more dominant due to the elevation in the death anxiety. According to the terror management theory (Pyszczynski & Kesebir, 2011), traumatic exposure produces posttraumatic distress, and this distress disrupts mechanisms of anxiety-buffering that normally provide protection against anxiety in general and against death anxiety in particular. Therefore, traumatized individuals may be pessimistic and may believe death is near, with these perceptions augmenting distress due to trauma exposure. Indeed, one of the frequent symptoms following trauma is perception of death as closer. However, it is unclear whether perceived DtD is related to PTG in older adults. Hence, different mechanisms underlie the way in which subjective perspectives regarding one’s age or the

time left to live might enhance PTG in older adults with a history of exposure to traumatic experiences. It is assumed that older individuals who perceive themselves as younger than their chronological age will find it easier to cope with both trauma burden and the demands of aging. In addition, those who rate their death as further away will find it easier to protect against their death anxiety following trauma. This study examines the effect of subjective evaluation of age or perceived DtD on the association between PTS symptoms and PTG. It is possible that subjective evaluations of older age and shorter DtD represent perceptions of one’s aging and dying processes, thus accounting for individual differences in the development of PTG. Therefore, it is hypothesized that higher levels of PTS symptoms will be related both linearly and curvilinearly to higher levels of PTG. However, since these associations have not been studied in older adults before, it is yet unclear whether younger subjective age or longer perceived DtD will also be related to higher PTG. The second hypothesis is that PTS symptoms will interact with subjective age and with DtD, so that the relationship between PTS and PTG will be strongest when one feels younger or further away from death.

Method Participants and sampling design A polling company sampled participants through an inregion random digit dialing methodology. All participants were Jewish, living in the south of Israel in the region that surrounds the Gaza Strip, and all were age 50 years old or above. Sampling used the national telephone directory, which provides regional and community-specific phone number information. The interviews were conducted between 12 January and 24 February 2014, 14 months after a military operation in which more than eight hundred rockets were fired at the area. During those 14 months, 63 rockets were targeted at the area, among them 24 rockets were fired during the time of the interviews (The Meir Amit Intelligence and Terrorism Information Center, 2014). The sample was stratified by age group (50 64, 65 90), gender, and place of living. Two-thirds of the sample lived in the city of Sderot and one-third lived in rural communities, a percentage that was compatible with previous representative studies in the area (see Gelkopf, Solomon, Berger, & Bleich, 2008; Gelkopf et al., 2012). 12,609 phone calls were conducted in 3159 households; in 2374 households, someone picked up the phone; 930 of these households included eligible interviewees (over age 50); 254 potential interviewees refused to participate in the survey; 232 additional potential interviewees could not be interviewed because of hearing problems or cognitive incapacity; 105 participants filled only the initial part of the survey and refused to complete the rest of the interview, either because the interview was too long or because they did not want to refer to some of the questions. The final sample consisted of 339 participants who completed the entire survey, between age 50 and 90, with an average age of 65.44 (SD D 9.77). About half of

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Table 1. Descriptive statistics for the study variables.

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M/ % SD

1

2

3

4

5

6

7

8

9

10

11

12 13

(1) PTS symptoms 2.04 .98 – (2) Subjective agea 13.27 13.32 ¡.20 – (3) Perceived DtDb 21.10 15.34 ¡.18 .26 – (4) PTG 2.94 1.19 .45 .04 ¡.02 – (5) Age 65.44 9.77 ¡.10 .02 ¡.23 ¡.18 – (6) Genderc 56.0% – .10 ¡.03 ¡.05 .07 ¡.03 – (7) Education 13.57 3.24 ¡.33 .09 .11 ¡.23 ¡.07 .07 – (8) Marital statusd 69.9% – .05 .03 ¡.07 ¡.07 .17 .24 ¡.05 – (9) Place of livinge 66.1% ¡.37 .04 .08 ¡.29 .03 ¡.07 .18 ¡.12 – (10) Subjective health 3.20 1.09 ¡.42 .32 .28 ¡.07 ¡.22 ¡.04 .25 ¡.13 .31 – (11) Exposure to rockets 3.85 1.32 .34 ¡.01 ¡.04 .31 .16 ¡.09 ¡.08 ¡.12 ¡.39 ¡.10 – (12) Illness or disabilityf 40.4% .25 ¡.23 ¡.16 .05 ¡.06 .00 ¡.13 .13 ¡.21 ¡.57 .11 – (13) Depression everf 37.2% .34 ¡.15 ¡.16 .13 .06 ¡.20 ¡.13 21 ¡.15 ¡.27 .07 .28 Note: Total N D 339. aHigher scores indicate that the participant feels younger than his/her actual age. bHigher scores indicate that the participant expects to live longer. 1 D man, 2 D woman. d1 D currently married, or living with a partner, 2 D currently unmarried. E1 D Sderot, 2 D rural communities. F0 D no, 1 D yes.  p < .05, p < .01, p < .001.

the participants were female (56%), most participants were married (69.9%), and the average number of years of formal schooling was 13.57 (SD D 3.24). Demographic characteristics of the sample are presented in Table 1. The telephone interviews were carried out by experienced interviewers in either Hebrew or Russian, lasting 15 25 minutes. Informed consent was obtained at the beginning of the interview. Recruitment and administration were approved by the Ethics Committee of the University of Haifa. Measures Covariates included the following demographic variables: age, gender, marital status (1 D married or living with a partner, 2 D single, divorced, or widowed), years of education, and place of living (1 D Sderot, 2 D rural communities). Self-rated health, chronic illness or disability, as well as any incidence of depression, were also used as covariates. These covariates were chosen because they had been previously shown to be related to PTS symptoms, subjective age, or perceived DtD (e.g., Gelkopf et al., 2012; Griffin et al., 2013; Shrira et al., 2014; Stephan, Demulier, & Terracciano, 2012). Self-rated health was assessed by asking ‘As a whole, how do you rate your health?’ Participants were requested to rate their response on a Likert scale ranging from 1 (not good at all) to 5 (very good), as done by Benyamini, Idler, Leventhal, and Leventhal (2000). Self-report of chronic illness or disability was measured by asking ‘Do you have a chronic health problem, illness, or disability?’ (0 D no, 1 D yes), as done by Van Doorslaer et al. (2000). Incidence of depression was measured by asking ‘During the course of your life, has there been a period of two weeks or more during which you felt depressed most of the time?’ (0 D no, 1 D yes), as done by Morin, LeBlanc, Daley, Gregoire, and Merette (2006).

Exposure to rocket fire was assessed by asking participants to endorse any of the eight possible exposures: (1) I heard or saw a rocket fall; (2) a rocket fell close to me; (3) my house was hit; (4) I was physically injured; (5) someone I know was physically injured; (6) a family member or a close relative was physically injured; (7) one of my acquaintances was killed; and (8) a family member or a close relative was killed, as detailed in Gelkopf et al. (2012). A summary score was used. Subjective age was measured by asking participants to specify, in years, how old they felt most of the time, and then subtracting that number from their chronological age, as done by Keyes and Westerhof (2012) as well as by Stephan et al. (2012). Higher scores indicate that the participant felt younger than his or her actual chronological age. Perceived DtD was assessed by asking participants to indicate until what age they expected to live, as done by Heintz, Krol, and Levin (2013), and then subtracting that number from their chronological age. Higher scores indicated that participants expected to live longer. PTS symptoms were assessed with the PTSD checklist (Weathers, Litz, Herman, Huska, & Keane, 1993), adapted to the fifth edition of the Diagnostic and Statistical Manual (DSM-5; American Psychiatric Association, 2013). This questionnaire is a 20-item measure of PTS symptoms. For each symptom participants are asked to choose their response on a 5-point Likert scale from 1 (not at all bothered) to 5 (extremely bothered). Participants were asked to rate each symptom while thinking of the most stressful event related to rocket fire that they had reported. If they found it difficult to select a specific event, they were asked to provide a general report about their life under rocket fire. Due to the chronic nature of the stressor, the questions referred specifically to symptoms experienced during the previous month. A continuous measure of PTS symptoms was computed by averaging scores across all items (range: 1 to 5). Higher scores indicated higher levels of PTS symptoms. Reliability was excellent

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(Cronbach’s a D .934). A measurement for diagnosis of probable PTSD was also computed by using DSM-5 (American Psychiatric Association, 2013) PTSD diagnostic criteria B, C, D, and E (i.e., one or more intrusion symptoms, one or more avoidance symptoms, two or more negative alterations in cognition and mood, and two or more alterations in arousal and reactivity). A rating of three or more on each item was classified as a positive symptom (see also Gelkopf et al., 2012). PTG was assessed by the posttraumatic growth inventory-short form (PTGI-SF, Cann et al., 2010). This questionnaire consists of 10 items from the original PTGI (Tedeschi & Calhoun, 1996). Respondents were asked to rate each item on a scale that ranged from 1 (I did not experience this change) to 5 (I experienced this change to a great deal). The mean of the 10 items was computed for individuals who responded on at least 80% of the items in this questionnaire, with a range of 1 to 5. Reliability was excellent (Cronbach’s a D .898). Data analysis As some of the participants found it difficult to answer questions related to their traumatic experience and to provide evaluations regarding their approaching death, missing values in the independent and dependent variables were subjected to a multiple imputation procedure (Rebok et al., 2014). Ten imputations were conducted, and pooled results were used. Analyses with and without multiple imputations led to very similar findings. All variables were then mean-centered. Linear and quadratic models were used to examine the first hypothesis regarding the association between PTS symptoms and PTG. Covariates (age, gender, education, marital status, place of living, self-rated health, exposure to rockets, illness or disability, and incidence of depression) were entered in the first step of the multiple hierarchical regression. PTS symptoms, subjective age, or perceived DtD were entered in the second step. The quadratic term of PTS symptoms was added in the third step. The second hypothesis was examined with another multiple hierarchical regression in which the first two steps were identical to the ones used in the first model. In the third and fourth steps, the interaction between PTS symptoms and subjective age (or perceived DtD in a separate running) and the quadratic term of PTS symptoms and subjective age (or perceived DtD in a separate running) were entered in addition to the linear interaction. Significant linear interactions in the second hypothesis were investigated with the PROCESS computational tool (Hayes, 2013). Results Almost a quarter (24.8%) of the participants endorsed symptoms that fit the criteria for probable PTSD according to the DSM-5 (American Psychiatric Association, 2013), with higher percentage among participants from the city of Sderot (33.9%) than among participants of rural communities (7.0%). Moreover, participants fitting PTSD criteria reported a higher level of PTG (M D 3.41, SD D

.69) than did those who did not fit the PTSD criteria (M D 1.59, SD D .55), t[327] D ¡21.83, p < .001. PTS symptoms were related to older subjective age, r D ¡.20, p < .001, and to shorter DtD, r D ¡.18, p < .005. No significant correlation was found between age and PTS symptoms, r D ¡.10, p D .061. Subjective age and perceived DtD were only moderately correlated, r D .26, p < .001, suggesting that these variables represent separate constructs (see also Shrira et al., 2014). PTS symptoms were positively correlated with PTG, r D .45, p < .001. However, subjective age was not significantly correlated with PTG, r D .04, p D .521, and neither was perceived DtD, r D ¡.02, p D .668. For more details see Table 1. Next, a hierarchical regression analysis examined whether the quadratic component of the relationship between PTS symptoms and PTG accounts for additional share of the variance beyond that explained by the linear effect. A linear regression in which covariates were entered in Step 1 showed that individuals who reported higher PTS symptoms, B D .48, b D .38, t[289] D 5.85, p < .001, and older subjective age, B D .01, b D .11, t[289] D 2.07, p < .05, also reported greater PTG. The quadratic effect was significant beyond the linear effect B D ¡.24, b D ¡.25, t[288] D ¡3.76, p < .001. Note that the quadratic correlation was negative, indicating that a moderate level of PTS symptoms was associated with a high level of PTG, whereas a low and a high level of PTS symptoms were related to a lower level of PTG. Similarly, a linear regression analysis showed that individuals who reported higher PTS symptoms, B D .46, b D .37, t[289] D 5.64, p < .001, as well as shorter perceived DtD, B D .00, b D .01, t[289] D .11, p D .914, also reported greater PTG. The quadratic effect was significant beyond the linear effect, B D ¡.24, b D ¡.25, t[288] D ¡3.76, p < .001. The second hypothesis was tested with two further steps, using the same first two steps as in the initial hierarchical regression. The linear interaction between PTS and subjective age was entered in Step 3. Results show significant interaction, B D .01, t[288] D 2.48, p < .05, accounting for an additional 2% of the variance in PTG. The overall model explained 30% of the variance in PTG. The interaction between the quadratic term of PTS symptoms and subjective age was entered in the fourth step. No significant contribution of this quadratic term was found, B D ¡.00, t[286] D .91, p D .37. A computational procedure (Hayes, 2013) that estimated linear effects when subjective age values were §1 SD from the mean was also conducted. For individuals who scored 1 SD below the mean of subjective age (i.e., reporting older subjective age), each additional PTS score was associated with a significant increase of .37 points in the PTG level, B D .37, t[288] D 3.97, p < .001. For individuals who scored 1 SD above the mean of subjective age (i.e., reporting younger subjective age), each additional PTS score was associated with an increase of .65 points in the PTG level, B D .65, t[287] D 6.07, p < .0001. After controlling for the effect of covariates in Step 1, and examining the main effects in Step 2, the linear

interaction between PTS and perceived DtD, entered in Step 3, accounted for an additional 3% of the variance in PTG, B D .01, t[288] D 3.21, p < .005. The overall model explained 30% of the variance in PTG. No significant contribution of this quadratic term was found, B D ¡.00, t[286] D ¡.64, p D .52, suggesting that the perceived DtD moderates the association between PTS symptoms and PTG linearly but not curvilinearly. Hayes’ (2013) computational procedure showed that when perceived DtD was 1 SD below the mean (i.e., nearer death), every additional PTS score was associated with a significant increase of .31 points in the PTG level, B D .31, t[288] D 3.38, p < .001. At a perceived DtD of 1 SD above the mean (i.e., further death), every additional PTS score was associated with a significant increase of .67 points in the PTG level, B D .67, t[288] D 6.46, p < .0001. The two-way linear interaction between PTS symptoms and subjective age in predicting PTG is presented in Figure 1(a). The two-way linear interaction between PTS symptoms and the perceived DtD in predicting PTG is presented in Figure 1(b). As can be seen in these figures, the relationship between PTS symptoms and PTG was stronger among individuals who felt younger and further away from death. Finally, conducting the same regression analyses for PTG, but with age as the moderator while controlling for either subjective age, B D ¡.005, t[288] D .82, p D .414, or for perceived DtD, B D ¡.006, t[288] D .92, p D .357, yielded no significant interaction between PTS symptoms and age.

Discussion This study investigated how perceptions regarding the processes of aging or dying affect the complicated relations between PTS symptoms and PTG. The analyses show strong linear as well as curvilinear associations between PTS symptoms and PTG. This finding is in line with previous studies that showed growth is facilitated and maintained by endorsement rather than by the absence

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of PTS symptoms (Dekel et al., 2012), and that this association is quadratic in nature (Shakespeare-Finch & Lurie-Beck, 2014). That is, the more traumatic the experience is, the greater the growth is, at least up to a moderate level. It appears that one needs to process and acknowledge the results of the trauma in order to make positive changes. Yet, when experiencing very high levels of trauma, growth is no longer possible and its indications remain at lower levels. Additionally, subjective age and subjective DtD were not directly related to PTG. Only after controlling for relevant covariates did subjective age predict PTG. This finding is surprising given that previous studies found subjective age to be unrelated to the future time perspective (Weiss & Lang, 2012), whereas the perceived DtD was strongly related to the future time perspective (Demiray & Bluck, 2014). Perhaps PTG represents more than mere positive future time perspective. Apparently, subjective evaluations of age and longevity, which represent awareness to one’s aging and dying processes, are not directly related to PTG in the second half of life. Nevertheless, in line with the second hypothesis, feeling younger, as well as perceiving death as further away, was related to a steeper association between PTS symptoms and PTG. This finding fits well with Solomon et al.’s (2009) results, according to which veterans suffering from PTSD report older subjective age than do veterans with no PTSD, suggesting that subjective age and DtD are associated with the level of PTG under high levels of PTS symptoms. Thus, the deleterious impact of PTS symptoms may be attenuated by the favorable effect of perceptions of age or longevity, and these perceptions may themselves contribute to the psychological growth. Nevertheless, it is also possible that the mechanisms underlying these associations differ for subjective age and for DtD. In line with the subjective weathering hypothesis (Benson, 2014), trauma may increase incongruence between one’s chronological age and social, cognitive, physical, or mental demands, also affecting the older age identity, which may in turn later increase PTG. On the

b 4.5

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Post traumatic growth

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Close perceived DtD (-1 SD)

Far perceived DtD (+1 SD)

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Figure 1. The moderating effect of (a) subjective age and (b) perceived DtD on the association between PTS symptoms and PTG.

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other hand, according to the terror management theory (Pyszczynski & Kesebir, 2011), posttraumatic distress may disrupt the ability to buffer death anxiety, and may lead to the adoption of pessimistic perception regarding the approach death, thus restricting subsequent PTG. Previous evidence has shown that younger subjective age or perception of death as further away are related to better physical functioning, mental health, and well-being (Keyes & Westerhof, 2012; Montepare, 2009; Shrira et al., 2014). This study adds to the few studies that examined PTG in older adults (Lev-Wiesel & Amir, 2003; Park, MillsBaxter, & Fenster, 2005). Its main conclusion is that older individuals can also have good and effective growth after prolonged exposure to trauma (Dekel & NuttmanShwartz, 2009; Hobfoll et al., 2008). The present findings suggest that psychological changes that occur in the second half of life, and especially one’s subjective perception of time, are associated with the way in which the traumatic experience is incorporated into one’s intra-psychic. Individuals who suffer from higher levels of PTS symptoms and can perceive their aging or dying in a more favorable way may also have higher levels of growth. Growth-related processes appear to characterize older adults who perceive themselves as younger or further away from death. However, for PTG to occur in individuals with younger subjective age or perception of longer DtD, they must experience high levels of PTS symptoms. Several caveats are in order. First, the cross-sectional design of this study makes it impossible to determine the direction of the causal effect. Future face-to-face, longitudinal designs are required to strengthen the current findings. Furthermore, the study did not examine whether PTG is associated with better psychological functioning. Further research should focus on the association between PTG and constructs, such as meaning in life or optimism to rule out the possibility that PTG represents illusionary deceptive growth (e.g., Maercker & Zoellner, 2004). Finally, although this study was meant to examine the consequences of long exposure to rocket fire on older adults’ mental health, a wider age range may enable a better understanding of possible lifespan differences. In sum, this study is the first to examine subjective representations of age and DtD and their relations to PTG, as well as the interaction between PTS symptoms and subjective age or perceived DtD in predicting PTG. The findings have theoretical and practical implications. Theoretically, they suggest that perceptions of age-related and dying-related processes are important and independent factors in the development of PTG. More specifically, they show that high levels of PTSD and PTG are found in individuals whose perceptions of aging are favorable. Researchers should therefore be directed to better understand these mechanisms, and more sensitive to subjective perceptions regarding aging or longevity in interpreting the process of PTG. Practically, it is important that clinicians working with the elderly will be aware of the fact that traumatic experience can be accompanied with significant psychological growth among older adults when perceptions regarding aging or dying are positive.

Future studies should attempt to develop interventions that improve growth by affecting these perceptions.

Disclosure statement No potential conflict of interest was reported by the author.

Funding This study was supported by a research seed grant [grant number 45978] from the Center for Research and Study of Aging at the University of Haifa and from the Myers-JDC-Brookdale Institute.

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Subjective age and perceived distance-to-death moderate the association between posttraumatic stress symptoms and posttraumatic growth among older adults.

Little research has addressed the association between posttraumatic stress (PTS) symptoms and posttraumatic growth (PTG) in the second half of life. T...
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