Long-term effects of cumulative adversity:
The relationship between adversity type, wellbeing, and physical disability
Amit Shrira
The Interdisciplinary Department of Social Sciences,
Bar-Ilan University
SHARE-Israel Wave 2 First Results Conference
The Van Leer Jerusalem Institute , October 17th 2012
Pablo Picasso (1937) Guernica
Cumulative Adversity
 Definition: Exposure to a wide spectrum of
potentially traumatic events
 Depletion vs. Inoculation: Exposure to adverse life
events may generate vulnerability, but may also foster
resilience (Bonanno et al, 2011; Ryff et al., 2012; Seery et al., 2010)
Cross-sectional analyses on cumulative
adversity in SHARE-Israel – reported in:
Shmotkin, D., & Litwin, H. (2009). Cumulative adversity and depressive
symptoms among older adults in Israel: The differential roles of selforiented versus other-oriented events of potential trauma. Social
Psychiatry and Psychiatric Epidemiology, 44, 989-997.
Shrira, A., Palgi, Y., Ben-Ezra, M., & Shmotkin, D. (2011). How do
subjective well-being and meaning in life interact in the hostile world?
Journal of Positive Psychology, 6, 273-285.
Shrira, A., Shmotkin, D., & Litwin, H. (2012). Trauma at different points
in the life course and current mental health: Findings from SHAREIsrael. American Journal of Orthopsychiatry, 82, 251-259.
Keinan, G., Shrira, A., & Shmotkin, D. (2012). The association between
cumulative adversity and mental health: Considering dose and primary
focus of adversity. Quality of Life Research, 21, 1149-1158.
Study aim:
To examine whether cumulative
adversity (reported at W1)
predicts W2 well-being and physical
disability, focusing primarily on
(1) Different types of adversity
(2) The moderating effect of
distress (depressive symptoms)
(1) Different types of adversity
Self vs. Other:
A largely overlooked distinction made by the DSM-IV
(1994) in the definition of traumatic event
“The person experienced or witnessed or was confronted
with an event or events that involved actual or
threatened death or serious injury, or a threat to the
physical integrity of self or others”.
Self-oriented adversity
Frida Kahlo (1946) The little deer
Other-oriented adversity
Michelangelo (1498-99) Pietà
The potentially traumatic
infliction primarily targets the
The potentially traumatic
infliction affects the self by
primarily targeting others
(e.g., being at risk of death due to illness or
accident, being a victim of violence)
(e.g., witnessing people killed, learning
about the death of a loved one)
Further dividing adversity type, as suggested by Shmotkin (2008)
Bereavement & health vulnerabilities are “on time events” (Neugarten, 1996). Yet,
evidence suggest they have a stronger effect on late-life well-being than other
adversity types (e.g., Kraaij et al., 2002)
(2) The
moderating effect of
depressive symptoms
Cumulative adversity has a small to medium effect on
functioning, and most older adults remain resilient even when
experiencing many adverse events throughout life (Ferraro &
Shippee, 2009; Kraaij et al., 2002)
Yet, those who suffer high levels of distress (i.e., neuroticism)
are more sensitive to the accumulation of adverse events (e.g.,
Kendler et al., 2004)
(1) Cumulative adversity would predict lower
well-being and higher physical disability in W2
Cumulative adversity would have a strong negative
effect on W2 outcomes when focusing on:
(2) Self-oriented adversity rather than on otheroriented adversity
(3) Bereavement and health vulnerabilities rather
than on other event types
(4) Those who reported high level of depressive
symptoms rather then on their low-level depressive
symptom counterparts
1,248 respondents from SHARE-Israel Drop-Off sample
who participated in both W1 and W2
Mean age=62.5 (SD=9.7), 57.2% women; 73.4% Israeli
veteran Jews, 6.2% from former USSR, 20.4% Arab Israelis;
average education level of upper secondary education
*** W1 Predictors ***
1) Cumulative adversity: various summations of events reported from a
list of 17 difficult life events (Shmotkin, 2008) were used to create (a)
overall adversity; (b) self/other-oriented adversity (c)
2) Depressive symptoms: sum of symptoms reported from a list of 12,
dichotomized to 0-3 (n=874) and 4+ (n=372) (Euro-D; Prince et al.,
1999) (KR-20=.77)
*** W2 Outcome measures ***
1) Life satisfaction: a single item with a 0-10 scale
2) Quality of life: CASP-12 (Hyde et al., 2003) – 12 items. (α=.82)
3) Activities of daily living (ADL) (Katz et al., 1970) – 6 daily activities
4) Instrumental activities of daily living (IADL) (Lawton & Brody,
1969) – 7 daily tasks (KR-20=.83)
The relationship between W1 adversity indices and W2 outcome measures
Note. N=1248. Y axis values refer to standardized regression coefficients (βs) after
controlling for age, gender, origin, and education.
*p<.05, **p<.001, ***p<.0001
The Cumulative adversity X Depressive symptoms Interaction for
predicting W2 life satisfaction and ADL
Blue slope=Low level of depressive symptoms (EURO-D < 4)
Red slope=High level of depressive symptoms (Euro-D ≥ 4)
Note. Similar interactions were found for quality of life and IADL. Interactions remained
significant after controlling for age, gender, origin, education, and the main effects of
cumulative adversity and depressive symptoms.
Summary and conclusions:
A differential outlook on cumulative adversity
Cumulative adversity, especially healthrelated self-oriented adversity, predicts
lower well-being and higher physical
disability. Other-oriented adversity, with
the exception of bereavement, does not
affect well-being and physical disability.
Although most Israeli older adults are
resilient to cumulative adversity, those
who suffer from high level of depressive
symptoms are especially sensitive to the
negative effects of adversity.
Potentially Traumatic Events Inventory
Experienced the death of a spouse (O)
Experienced the death of a child or grandchild (O)
Had a loved one at risk of death due to illness or accident (O)
life hardships Experienced extremely severe economic deprivation (S)
Was at risk of death due to illness or serious accident (S)
Needed long term care due to difficulty in caring for herself/himself (S)
Provided long term care to a disabled or impaired relative (O)
Lost a loved one in a war or in military service (O)
Witnessed the serious injury /death of someone in war or military action (O)
Experienced the injury or the death of a loved one in a terrorist act (O)
Was wounded in war or military action (S)
Witnessed a terrorist act in which she/he was not harmed personally (O)
Was wounded in a terrorist act (an attack by terrorists against civilians) (S)
Victimization Was the victim of crime (such as robbery ) (S)
Witnessed an accident in which someone was seriously injured/killed (O)
Was the victim of violence or abuse (S)
Experienced sexual assault (rape or harassment) (S)

"That Which Does Not Kill Me, Makes Me Stronger"...and Weaker