Metaphors and Related Expressions in Older Adults in the Field of Trauma and Stress-related Disorders: A Scoping Review

ABSTRACT

A scoping review was conducted to explore the metaphors and related expressions older adults use to describe extremely stressful events that may lead to Post-Traumatic Stress Disorder (PTSD), Complex PTSD (CPTSD), Prolonged Grief Disorder (PGD), or Adjustment Disorder (AjD). Relevant databases from psychology, gerontology, and related fields were searched. In addition, relevant references found in included papers were considered. Inclusion criteria were: qualitative study, sample of older adults (age 65+), and focus on maladaptive rather than adaptive psychological aspects. Eleven studies focusing on PTSD, 5 on CPTSD, 13 on PGD, and 10 on AjD were included. Metaphors and other expressions related to extremely stressful events were then extracted and analyzed. Multiple linguistic expressions to describe extremely stressful events and stress-related symptoms were identified. Metaphors and related expressions often referred to the body and the theme of moving on with one’s life.

Introduction

Metaphors are expressions that describe a person or an object by referring to something that is considered to have similar characteristics (Cambridge Dictionary, 2020). This can of course also apply to more abstract content such as feelings and experiences. Metaphors are among the most used figures of speech in everyday language (Cambridge Dictionary, 2020) and therefore gained significance in the field of clinical and cultural psychology.

A variety of studies have been conducted in the context of addiction and related disorders (Malvini Redden, Tracy, & Shafer, 2013; Schmitt, 2002a, 2002b; Shinebourne & Smith, 2009, 2010), eating disorders (Bates, 2015), major depressive disorder (Charteris-Black, 2012; Kaviani & Hamedi, 2011; Levitt, Korman, & Angus, 2000; McMullen, 1999; McMullen & Conway, 2002; Reali, Soriano, & Rodriguez, 2016; Schoeneman, Schoeneman, & Stallings, 2004), and post-traumatic stress disorder (PTSD) (Beck, 2016; Ben-Amitay, Buchbinder, & Toren, 2015; Foley, 2015). A recurring theme among the studies about addiction and related disorders, was the theme of emptiness to describe feelings of pain and distress while in a sober state. A need to fill that void/hole would then lead to substance abuse (e.g., “there was this hole and I kept trying to fill this hole … ”; Shinebourne & Smith, 2010, p. 64). Depression was often described in terms of darkness, weight/burden, descent (e.g., metaphors of spatial dimensions such as “up” and down”), and containment (e.g., in terms of being locked up in a container or being a container of sadness themselves; Charteris-Black, 2012). Levitt et al. (2000) explored metaphors of burden used in psychotherapy sessions and found that good therapy outcomes would often lead to the theme of carrying a burden transforming into a theme of unloading a burden (e.g., “I wish I could get this off my back” vs. “I feel like a burden has been lifted from me,” p. 19).

Metaphors are also used for expressing emotions, especially when talking about extremely aversive experiences that are too painful to be addressed directly (Lyddon, Clay, & Sparks, 2001). In the context of PTSD, one study looked at metaphors used by military veterans (Foley, 2015). In this study, one participant stated that the stigma of not admitting weakness had been “cemented” into her consciousness, and had become as “hard as a wall” during her military training. She then used the metaphor of breaking down that wall “brick by brick” to allow herself to show weakness, but also expressed that the wall was very big and that a lot more people were needed to break it down. Metaphors have also been shown to encourage help-seeking behavior by making health messages more appealing and engaging and by reducing stigma (Lazard, Bamgbade, Sontag, & Brown, 2016).

In addition, metaphors can transmit and reflect fundamental concepts and values embedded in a culture (Abernethy, 2002; Meili, Heim, & Maercker, 2019; Rechsteiner, Maercker, Heim, & Meili, 2020; Rechsteiner & Meili, 2018). They have been studied in the context of cultural concepts of distress (Kohrt et al., 2014), a term that was introduced in the Diagnostic and Statistical Manual of Mental Disorders, 5^th edition (DSM-5, American Psychiatric, Association (APA), 2013) and has been concepted to summarize several terms such as “idioms of distress” (Nichter, 2010) or “culture-bound syndromes” (Simons & Hughes, 1985) that have emerged over the years to describe concepts related to mental health and culture. For example, de Jong and Reis (2010) define idioms of distress as an “embodied symbolic language for psychosocial suffering that derives its legitimacy from its shared metaphors, meaning and understanding in a group” (p. 302, italics by authors). Metaphors are also often used in cultural adaptation of mental health interventions (e.g., Bernal, Bonilla, & Bellido, 1995; Heim & Kohrt, 2019; Hinton & Patel, 2017; Smith, Rodríguez, & Bernal, 2011; Spanhel et al., 2021).

Rechsteiner et al. (2020) summarized the results of four studies about metaphors of trauma. Two indigenous communities (Pitaguary from Brazil and Adivasis from India) and two rural communities (mountain villagers of Gondo in Switzerland and the Lemko, an ethnic minority of Poland) were examined. The Pitaguary and Lemko were marked by historical trauma, while the Adivasis and mountain villagers of Gondo had suffered from a natural disaster.

Rechsteiner et al. (2020) found that the most common metaphorical concepts of trauma among all four cultural groups were related to bodily processes, such as shock, burden and wound. In the Pitaguary, Lemko and Gondo villagers, the themes of fight and discontinuity (e.g., “falling,” “barriers,” “difficult transitions”) were of importance. Other concepts were more culture-specific, reflecting sociocultural and historical contexts. For example, only the Gondo villagers and Lemko used the expressions “the end of the world” or “drama” and “tragedy.” The expression “the end of the world” might relate to ontological concepts described in Christian and Jewish scriptures, while “drama” and “tragedy” might originate from the theater genre.

Even for general themes that emerged across all cultural groups, the metaphors used to express it, were sometimes very different. One example is the metaphorical concept of damage. The Pitaguary used culture-specific metaphors related to nature, for example by referring to a damaged person as being like a “dry leaf” or a traumatic experience being like “cutting the branches/trunk of a tree.” The other groups by comparison had less nature-related expressions like “thinking about it harms the body/mind,” “breaking down” and something “hurts.”

For the present scoping review and in our future research, we consider “older people” as a cultural group, assuming that older people experience, understand, and communicate suffering distinctly from other groups of people. This assumption of course needs examination. We plan to conduct an empirical, qualitative study in Switzerland to examine what kind of metaphors and related expressions older adults use to talk about traumatic and other extremely stressful experiences. This review was conducted in preparation of the planned study. It aims to summarize qualitative research on the use of language and metaphors in the context of adversity among older adults.

Although there has been a steady increase in research on trauma sequelae involving younger people over the last decades, few studies focus specifically on older adults (Cook, McCarthy, & Thorp, 2017; Pless Kaiser, Cook, Glick, & Moye, 2019). As life expectancy rises and more people reach old age, the need to develop and offer adequate treatment for older adults who have suffered traumatic or other extremely stressful events in their lives rises as well. The World Health Organization World Mental Health Surveys conducted in 24 different countries found that 70% of respondents had experienced one or more lifetime traumata, suggesting that experiencing a traumatic event at least once in life is very common (Kessler et al., 2017). Older adults carry the memories of these experiences into old age and often do not seek help due to having been raised in an environment still high in stigma against mental disorders (Böttche, Kuwert, & Knaevelsrud, 2019; Rössler, 2016). Collective experiencing of traumatic events such as World War II also leads to the normalization of traumatic experiences for entire generations, reducing help-seeking behavior (Böttche et al., 2019; Hiskey & McPherson, 2013).

Barely any research has focused on metaphors – or more broadly – cultural concepts of distress in older adults. Switzer, Wittink, Karsch, and Barg (2006) conducted a qualitative study about depressed older adults and found that participants expressed an attitude of “personal responsibility” to deal with depression and used orientational and movement metaphors to describe this. Being depressed was compared to being “stuck, mired and not making progress” (p. 1213). Managing depression, on the other hand, was associated with “pulling oneself up and out of depression, moving forward and beyond the depression” (p. 1213). The idiom “pull yourself up by your bootstraps” was expressed multiple times by different participants.

In another study, van Wijngaarden, Leget, Goossensen, Pool, and The (2019) explored metaphors related to aging in a sample of older adults with a death wish. The study participants expressed extremely negative attitudes toward old age and about themselves being or becoming old. Several metaphors to describe aging emerged. Aging was compared to a struggle against “their own bodies and the ongoing deterioration process” (p. 253). Aging was also compared to victimhood, as many losses such as health, privacy and even identity were associated with it. These losses led to helplessness, unwanted dependency, and ultimately, a sense of fatality. The metaphor of a void was used to express the perceived emptiness of the days and world. Stagnation and captivity were both metaphors used to describe a feeling of being blocked and trapped, associated to the wish of fleeing and running away. Participants described themselves using terms such as “a broken man” or “a total wreck” (breakdown), as being “like a third wheel and having no function” (redundancy; p. 256). They reduced themselves to subhuman levels by defining themselves with expressions like “a piece of dirt” or “a slice of meat.” The participants felt they were a burden to themselves, but mostly to others, and society. Aging was compared to going through a second childhood due to behaving and being treated like a child again.

These two studies exemplify how older adults use suffering related metaphors in everyday language. They also show how useful metaphors can be to express attitudes and feelings, evoking a variety of images that give good impressions of sentiments that might otherwise be difficult to express.

The present scoping review focuses on metaphors and related expressions of trauma and stressor-related disorders in older adults. In the discussion, we will contrast our results with Rechsteiner et al. (2020) findings and examine if any age-specific trends of these expressions can be observed. We collected qualitative studies involving older people who have experienced traumatic or extremely stressful events that may lead to these disorders. From the original studies, we extracted quotations of the study participants to identify linguistic expressions used to describe their experiences. Four kinds of trauma- and stressor- related disorders were considered: PTSD, complex post-traumatic stress disorder (CPTSD), prolonged grief disorder (PGD), and adjustment disorder (AjD). These disorders all share a common characteristic: they have an extremely stressful event at their root.

PTSD is a long-established diagnosis that was first included in the DSM-III in 1980 (American Psychiatric Association (APA), 1980). CPTSD, PGD, and AjD are newer concepts. AjD is included (with a new definition) in the International Classification of Diseases, 11^th edition (ICD-11) and the DSM-5 (Maercker et al., 2012), while CPTSD is only included in the ICD-11 (Brewin et al., 2017). Diagnostic criteria for the inclusion of PGD in both diagnostic manuals were proposed by Prigerson and MaCiejewski in 2006. It is included in the ICD-11 (World Health Organization, 2019) and will also be included in the DSM-5-TR (Prigerson, Boelen, Xu, Smith, & Maciejewski, 2021). When defining the concept of trauma- and stressor-related disorders, we always refer to the ICD-11 unless stated otherwise.

Methods

Qualitative studies about trauma and stressor-related disorders with samples of older people were screened and selected. Qualitative studies often include snippets of transcribed interviews or focus group discussions, which were examined to identify metaphors or other related expressions.

Search strategy

The literature research was conducted by the first author in English in June and July 2020. No time criteria were considered for this literature research. Two strategies were used to find relevant studies. First, common psychology, gerontology, and related databases such as AgeLine, Abstracts in Social Gerontology, APA PsycArticles, APA PsycBooks, APA PsycExtra, APA PsycInfo, APA PsycTests, PSYNDEX Literature with PSYNDEX Tests, SocINDEX, and PubMed were searched. In addition, Google Scholar was consulted. The search terms were: Study (“qualitative research or qualitative study or qualitative methods or interview”) AND Population (“older adults or elderly or geriatric or geriatrics or aging or senior or seniors or older people or aged 65 or 65+”) AND Stress-related disorders (“trauma or PTSD or CPTSD or post-traumatic stress disorder or complex post-traumatic stress disorder or traumatic events or trauma history” OR “prolonged grief disorder or complicated grief or persistent complex bereavement disorder or grief or loss or bereavement or mourning” OR “adjustment disorder or adjustment or adaptation or stress or distress or crisis or life event”). Due to the still rather new diagnostic categories of CPTSD, PGD, and AjD, using only the official terms for the literature research was not very fruitful, hence, broader terms were included. Additionally, a more specific search was conducted, for example by looking for qualitative studies about older adults, who have experienced child sexual abuse, as this is one of the most common causes of CPTSD (Maercker, 2019). Similarly, to find studies which might indirectly deal with an AjD, terms such as “divorce or breakup or relationship issues or relationship problems or illness or health issues or health problems or disability or moving or financial issues or financial problems” were looked up. The first author then assessed if the found studies somewhat reflected the concepts of CPTSD, PGD, and AjD or were unfit to be included in the scoping review.

The second strategy used to find relevant literature was the snowball method. Particularly relevant studies were selected and their authors and sources were screened for more qualitative studies related to old age and stress-related disorders.

To be included in the scoping review, the studies needed to have conducted qualitative research and examined samples of people aged 65 years or older. Studies that examined wide age ranges including the target age group (e.g., from 50 to 100 years) were also included, if the participants were at least 50 years old. The studies needed to focus on the psychopathological aspects of trauma, grief, and very stressful experiences that could potentially trigger an AjD. Studies that focused only or overly on resilience or coping strategies were excluded.

The concepts of CPTSD and AjD are rather new and difficult to identify among studies of classic PTSD and various distressing experiences, respectively. For this reason, the first and second authors individually rated the selected studies by their abstracts on a scale from one to five points, assessing the suitability of each study to be included in the scoping review. The ratings were then compared and in case of disagreement averaged or discussed between the authors. The rating system considered to what extent the research topic, research question, context, and the experiencing of symptoms reflected the criteria of a CPTSD or an AjD diagnosis. Table 1 depicts the rating system of CPTSD in more detail. The rating system for AjD was very similar. Studies rated below 3 points were excluded from the review. Most of the studies included were rated 3 or 4 points. 5 out of 5-point ratings were rare.

Table 1. Rating system used for the assessment of suitable studies about CPTSD.

Rating	Interpretation
1/5	The context is not suitable for a CPTSD diagnosis and/or the research question does not focus on the experiencing of symptoms that fit a CPTSD diagnosis.
2/5	The context is suitable for a CPTSD diagnosis, but the research question does not focus (enough) on the experiencing of symptoms that fit a CPTSD diagnosis.
3/5	The context is suitable for a CPTSD diagnosis, but the research question focuses only moderately on the experiencing of symptoms that fit a CPTSD diagnosis.
4/5	The context is suitable for a CPTSD diagnosis and the research question focuses on the experiencing of symptoms that fit a CPTSD diagnosis.
5/5	The study directly addresses CPTSD or indirectly addresses CPTSD by describing a context and an experiencing of symptoms that fulfil the CPTSD diagnosis criteria.

A flowchart of the exclusion process is depicted in Figure 1. After the initial literature research, 19 PTSD, 6 CPTSD, 19 PGD, and 16 AjD studies were identified as being potentially suitable for the purpose of this scoping review. Thirteen studies were excluded due to focusing only or overly on resilience or coping strategies. Another 3 studies were excluded because they were rated with less than 3 points by the first and second author. Lastly, another 5 studies were excluded due to not presenting any quotations by the participants, resulting in 11 studies about PTSD, 5 about CPTSD, 13 about PGD, and 10 about AjD. The studies that were finally included are listed in Table 2.

Figure 1. Flowchart depicting the exclusion process of the selected studies.

Table 2. List of the selected studies, including information about their research topic, sample, and methodology.

	Study	Research Topic	Sample Size	Sample Age	Study Country	Methods
PTSD
1	Bowland (2015)	African American trauma survivors in mixed-age housing	N = 25 (women)	49–77	USA	interview
2	Davison et al. (2006)	late-onset stress symptomatology among aging combat veterans	N = 47	54–89	USA	focus group interview
3	Dennis (2016)	insights into traumatic experiences of Lakota elders	N = 25	55–98	USA	interview
4	Duchin and Wiseman (2019)	memoirs of child survivors of the Holocaust: processing and healing of trauma through writing	N = 13	77–90	Israel	interview
5	Hiskey and McPherson (2013)	older adults’ constructs of trauma	N = 42	67–91	UK	focus group interview
6	Nivala and Sarvimäki (2015)	lifelong struggle of Finnish World War II veterans	N = 20 (men)	77–87	Finland	interview
7	O’Rourke et al. (2016)	Holocaust survivors’ memories of past trauma and the functions of reminiscence	N = 269	M = 80.4, SD = 6.87	Israel	open-ended questions based on Reminiscence Functions Scale (Robitaille, Cappeliez, Coulombe, & Webster, 2010), answered verbally
8	Palgi, Bensimon, and Bodner (2017)	impairment in mentalization among older adults exposed in adulthood to potentially traumatic life events	N = 16	65–90	Israel	interview
9	Pope et al. (2020)	trauma experiences of older homeless men	N = 18 (men)	50–71	USA	interview
10	Sixsmith, Sixsmith, Callender, and Corr (2014)	wartime experiences and their implications for the everyday lives of older people	N = 40	80–90	UK	interview
11	Stanko et al. (2018)	when reliance on religion falters: religious coping and post-traumatic stress symptoms in older adults after multiple disasters	N = 119	no age range indicated	USA	open-ended questions on a sheet, answered verbally
CPTSD
12	Band-Winterstein (2015)	elderly women’s “lived experience” of lifelong intimate partner violence	N = 31 (women)	60–83	Israel	interview
13	Bowland, Biswas, Kyriakakis, and Edmond (2011)	spiritual struggles and resilience in older female trauma survivors	N = 36 (women)	55–83	USA	spiritually focused intervention, participants’ expressed thoughts and responses to topics covered during each group sessions were noted
14	Park et al. (2016)	Korean survivors of the Japanese “comfort women” system	N = 16 (women)	83–95	South Korea	interview
15	Souto et al. (2015)	older Brazilian women’s experience of psychological domestic violence	N = 11 (women)	66–85	Brazil	interview
16	Teshuva and Wells (2014)	experiences of aging and aged care in Australia of older survivors of genocide	N = 21	65+	Australia	interview
PGD
17	Bennett and Vidal-Hall (2000)	widowhood in later life, narratives of death	N = 19 (women)	60+	UK	individual & group interview
18	Costello and Kendrick (2000)	grief and older people: the making or breaking of emotional bonds following partner loss in later life	N = 12	M = 74	UK	interview
19	Damianakis and Marziali (2012)	older adults’ response to the loss of a spouse: the function of spirituality in understanding the grieving process	N = 24	65–82	Canada	group therapy intervention, all sessions were audio recorded
20	Dimond, Caserta, and Lund (1994)	understanding depression in bereaved older adults	N = 10	57–73	USA	interview
21	Farinasso and Labate (2015)	the bereavement experience in elderly widows	N = 6 (women)	no age range indicated	Brazil	interview
22	Fenge (2014)	developing understanding of same-sex partner bereavement for older lesbian and gay people: implications for social work practice	N = 4 older LGBT people N = 3 agencies working with older LGBT people	no age range indicated	UK	interview
23	Hybholt et al. (2020)	life after bereavement by suicide	N = 20	61–79	Denmark	interview
24	Jenkins, Edmundson, Averett, and Yoon (2014)	older lesbians and bereavement: experiencing the loss of a partner	N = 55 (women)	55–82	USA	online survey with open-ended questions
25	Moore (2008)	older poor parents who lost an adult child to AIDS in Togo, West Africa	N = 7	54–80	West Africa	interview
26	Pilkington (2005)	grieving a loss: the lived experience for elders residing in an institution	N = 10	70–92	Canada	dialogue, audio recorded
27	Smith et al. (2011)	elders’ experiences of the death of an adult child	N = 31	M = 72.63	USA	focus group interview
28	van Humbeeck, Dillen, Piers, Grypdonck, and Van Den Noortgate (2016)	the suffering in silence of older parents whose child died of cancer	N = 9	70+	Belgium	interview
29	Wilson and Supiano (2011)	experiences of veterans’ widows following conjugal bereavement	N = 6 (women)	59–82	USA	interview
AjD
30	Allen and Roberto (2014)	how older women in rural Appalachia with gynecological cancer construct and interpret their experience with cancer	N = 20 (women)	51–82	USA	interview
31	Borkan et al. (1991)	injury narratives from elderly hip fracture patients	N = 80	M = 80	USA	interview
32	Forssén (2012)	lifelong significance of disempowering experiences in prenatal and maternity care	N = 20 (women)	no age range indicated	Sweden	interview
33	Lee et al. (2013)	narrative exploration of older people’s transitions into residential care	N = 8	65–97	UK	interview
34	Moult et al. (2020)	how older adults understand and manage distress	N = 18	65–91	UK	interview
35	Nielsen, Minet, Zeraiq, Rasmussen, and Sodemann (2017)	everyday life conditions experienced by older migrants and their reasons for specific age- and health-related behavior during the conduct of everyday life.	N = 16	56–96	Denmark	interview
36	Perez (2013)	older Cuban American exiles’ ambiguous loss of leaving the homeland	N = 20	67–97	USA	interview
37	Schnell, Patel, Steinhauser, Ammarell, and Tulsky (2012)	discussions of the kidney disease trajectory by elderly patients and nephrologists	N = 29 patients N = 11 nephrologists	65–88	USA	individual & focus group interview
38	Singh et al. (2018)	mental health problems and idioms of distress among older adult internally displaced persons in Georgia	N = 75 older adults N = 45 key informants	60+	USA	interview
39	Sun et al. (2020)	adaptation of older adults’ transition to nursing homes in mainland China	N = 11 residents N = 5 staff members	76–93	China	interview

Data extraction and analysis

Table 2 contains the main characteristics of all included studies: the research topic, the size and age of the sample, as well as the country of the study. The method (e.g., interview) used in the study was also listed. The oldest study to be included was published in 1991 (Borkan, Quirk, & Sullivan, 1991), the newest in 2020 (Hybholt et al., 2020; Moult, Kingstone, & Chew-Graham, 2020; Pope, Buchino, & Ascienzo, 2020; Sun et al., 2020). Most of the studies were published after 2010 (32 of 39) showing that the interest in these research topics is new and increasing, with 5 studies being published in 2020 alone. In some cases, the study authors had age ranges that went below the desired criteria of 65 years or more. We still included these, if the participants were at least 50 years old (or 49 in the case of Bowland, 2015). Some authors only offered the average age or did not indicate an age range at all. The known age range in the selected studies spans from 49 to 98 years. Most studies included men and women. Studies that focused only on one gender were mostly about women and were found often in the context of CPTSD and PGD. In fact, 4 of the 5 studies in the context of CPTSD examined female-only samples. Most of the studies were conducted in the USA (15 of 39). Many were conducted in the UK (7 of 39) and Israel (4 of 39). Almost all the studies used interviews to collect data.

Results and conclusions of the studies were considered if they were relevant to the purpose of this scoping review. However, the focus was on the transcripts and relevant quotations found in the articles. To have a better overview of the quotations and facilitate reproducibility, only block quotations were examined, unless the articles did not provide any. In that case, shorter quotations were analyzed. The quotations were extracted from the studies, imported, and coded in the computer program MaxQDA for qualitative and mixed methods data (VERBI Software, 2019) to obtain a reliable overview and identify patterns. They were analyzed according to thematic analysis after Braun and Clarke (2006) to identify commonly expressed topics among older adults who have experienced an extremely stressful event. Metaphors were identified using the systematic metaphor analysis by Schmitt (2017). The systematic metaphor analysis follows a heuristic and abductive approach for interpreting metaphors in the social sciences and is organized in three steps. First, metaphorical expressions are identified and collected word-by-word. Second, these metaphorical expressions are categorized into concepts. Last, these metaphorical concepts are interpreted taking into consideration social, cultural, and historical context.

A summary of themes and metaphors for each stress-related disorder was produced, before comparing and searching for patterns across the four disorders as well. Data were interpreted and conclusion were drawn, taking into consideration other aspects of the original studies (e.g., their own conclusions) and already existing literature related to the topic.

Results

In the following section, we present metaphors and other expressions extracted from the original studies. First, expressions used in the context of each stress-related diagnostic category (PTSD, CPTSD, PGD and AjD) are highlighted, followed by an overview of expressions that are used in the context of all four disorders.

Post-traumatic stress disorder

Eight themes were found in studies related to PTSD. The most prominent ones were: i) body and damage (i.e., body, wounds, illness, and pain); ii) fight (i.e., fighting, war or violence in general) and iii) path (i.e., moving on, leaving behind, and letting go). Fairly common, as well, were: iv) loss, v) death, vi) containment, vii) hell, and viii) breaking/fixing.

Body and damage. In their trauma-related narratives, some participants referred to their body. Examples for this kind of expressions are: “having too many negative things in your face” [1, p. 177],¹ “it starts your brain thinking” [2, p. 104], “If somebody can get over it they should get over it because it comes from in there (points to chest)” [5, p. 693] and “It’s painful to me … I keep telling myself, I can’t keep bumping my head like this” [9, p. 152]. In these examples, participants ascribe thoughts and feelings to parts of the body (e.g., head or heart), rather than talking about their experiences in the first person. Expressions related to the body in the form of being wounded, ill and or in pain were common, as well. Some examples for this are: “accept the wounds of the past that have slightly healed but will never be forgotten” [4, p. 288], “my dear husband couldn’t stand the pain left behind by our departed son; so, he died of depression” [8, p. 278], “People would probably say I’m a poor, traumatized man with problems, that he was sick and wounded and that he’d suffered a lot. After captivity, I suffered for five years. I didn’t sleep nights, couldn’t fall asleep. I thought people are chasing me, want to beat me and I thought people want to put me in prison again.” [8, p. 278]. Very often the older adults expressed being “hurt” (e.g., “My mental state is very bad these days. I feel burned out from the inside. I only see darkness and I have no peace and quiet. I miss my children, my husband, my grandchildren and my brothers. It hurts me a lot.” [8, p. 276]) and “suffering” (e.g., “My husband was not able to contain all the suffering that the son had left behind” [8, p. 276]).

Fight. Older adults sometimes also used expressions that were related to fighting, war, or violence in general to describe their experiences. An example for this is how a participant of Dennis (2016) study about the traumatic experiences of Lakota elders describes the boarding school he was forced to attend to as a child. He compares it to a “Marine boot camp” or a “little prison” and says they would “march [them] to the dining room, march [them] back” [3, p. 16]. In the same study another interesting metaphor was found: “[…] you had to keep your rank, the pecking order. Anytime you throw people together, you have to have a pecking order” [3, p. 16]. Another example comes from an aging veteran in the study of Davison et al. (2006) who had had a heart attack in recent years: “I felt I was in combat. […] And I said, ‘Terry [his wife], I’m going to beat this.’” [2, p. 103]. Another veteran in the same study said: “if you sit at home, you’re defeated” [2, p. 107] using the metaphor of a fight similarly to the other participant. In the study of Nivala and Sarvimäki (2015) about Finnish World War II veterans a participant referred to himself as “a man who has been a bit knocked about” [6, p. 496] when talking about being very lucky to have had a life companion.

Path. Expression related to moving on, leaving behind, and letting go emerged particularly in one study about older adult’s constructs of trauma (Hiskey & McPherson, 2013). Participants used expressions such as “get on with your life” [5, p. 691], “put your feelings in your pocket” [5, p. 692], “get over it, they should get over it” [5, p. 693], “you put it in the past and leave it there” [5, p. 693], expressing a common attitude of repression and moving on with one’s life. Other statements related to repression alone could be found in Davison et al. (2006) such as: “I blocked the war out” [2, p. 101] or “But other people have been through a lot of things and you never hear them mention it for the simple reason it would probably bother them to mention it, so they just blank it out. And the best way is with booze.” [2, p. 101].

Loss. Multiple quotations referenced loss, such as the loss of one’s youth (e.g., “my lost childhood” [7, p. 5], “I had no youth because of the war” [7, p. 7]), the loss of everything in one’s possession (“I’ve lost everything – intimacy, love and support.” [8, p. 277], “I had nothing in life when the war ended” [6, p. 496]), or the loss of one’s purpose (“Nobody needs me now because I cannot give anything to anyone.” [8, p. 276]).

Death. Other quotations referenced death, multiple of them found in Davison et al. (2006): “I mean, old soldiers never die; they try not to. But they fade away.” [2, p. 99], “You lose hope and you lose the will to live. And if you lose the will to live, then you’re a dead duck.” [2, p. 103], and “If you fear and believe that you’re finished, then you’re finished. You’re going to just decay.” [2, p. 107]. In a study about homeless men, a participant described being homeless as being “almost like a dagger, like putting a nail in the coffin” [9, p. 151].

Containment. A few times, sentiments related to containment were expressed. In some cases, the containment refers to feeling like a prisoner: “I drew a girl surrounded by barbed wire and below it I wrote: ‘I’m still trapped in the Holocaust.’” [7, p. 8] and “As a prisoner of war, there were a lot of deaths, and a lot of deaths that we saw happen were just at the beginning of being prisoners. We felt that a lot of them just mentally [gave up] because they figured they had no hope. It’s the same thing that I experience now as an older person.” [2, p. 103]. In other cases, the containment refers to something, which needs to be contained (“The writing is to help myself cope. I have always felt that if I write something down, I give it a structure and a framework. It contains it instead of having it ‘running wild’ and doing whatever it pleases.” [4, p. 286] or freed from containment to find relief (“It was probably a good thing that I screamed. I got it out that way, and then things moved on.” [6, p. 496]. Lastly, hell was also referenced a few times (e.g., “has made my world a hell” [8, p. 276]) and breaking/fixing (e.g., “to fix it […] fix your things that were broken” [11, p. 300], “everything I dreamt of disintegrated” [7, p. 6]).

Complex post-traumatic stress disorder

In CPTSD related studies, seven themes emerged: i) body and damage, ii) fight, iii) nature, iv) aloneness (i.e., being alone or lonely), v) waste/loss, vi) death, and vii) path. Body and damage was the most prominent theme.

Body and damage. Bodily expressions were found in association with emotions, e.g., “It is the anger I swallow. I have this pain in my stomach because [of] the anger I feel [for] him” [15, p. 5]. Another participant from another study said: “My whole body is sick. I am sick with fear. My nerves have made me sick … Nerves can make a person sick. A sick woman without an actual disease.” [12, p. 312]. Both studies were about women who had experienced domestic abuse (Band-Winterstein, 2015; Souto, Merighi, Guruge, & de Jesus, 2015). Among the CPTSD studies, many participants expressed being in pain, being hurt or suffering. One participant used a metaphor of a wounded bird to describe how she was feeling (“I feel like a wounded bird”) and that she was “so wounded in [her] heart” [12, p. 316].

Fight. Some comparisons related to fighting, war or violence in general emerged in the context of CPTSD. When talking about her abusive husband one participant described him as being a “ticking time bomb” and wondered when he “will light the fuse already” [12, p. 312]. In the same study (Band-Winterstein, 2015), a participant expressed being there as “a target” [12, p. 316] to be hurt by her abusive husband. In the study about domestic abuse by Souto et al. (2015), a participant referred to an old saying to explain why she preferred to keep silent when confronted with her abusive daughter: “One does not fight alone” [15, p. 6]. Of notice is the similarity to the statement of two participants in Band-Winterstein’s (2015): “I am fighting this battle alone” [12, p. 315] and “I am struggling through life all alone” [12, p. 318].

Nature. The use of references to nature was prominent in the CPTSD studies. In two cases the metaphor of being an animal was used to dehumanize the aversive behavior of an aggressor. In a study about Korean comfort women (Park, Lee, Hand, Anderson, & Schleitwiler, 2016) a participant called Japanese soldiers animals (“The Japanese soldiers were like animals. They were animals.” [14, p. 10]). Similarly, a victim of domestic violence refers to her husband as an animal when describing his behavior (“he climbs on top of me like an animal” [12, p. 311]). As already mentioned before in the example of the metaphor of a “wounded bird” [12, p. 316], references to nature were sometimes also used to describe one’s own state of mind. Another example for this is feeling like “an empty shell” [12, p. 318] or having a “heavy stone in [one’s] soul” [12, p. 311]. A participant described their time as having “passed like wind or waves” [14, p. 12] to express that they were unable to lead a normal life. A participant in the study by Teshuva and Wells (2014) about older survivors of genocide cited the Russian poem “The Autumn of Life” to express how she felt about her painful past: “Thousands of pains and memories that come flooding back … Some hair going grey and the rain falling and all those questions that remain unanswered” [16, p. 528].

There were several expressions related to being alone or lonely, which was mentioned either in the context of battle (see above) or in general (e.g., “I’m not alone, but I’m alone with myself” [12, p. 311]). Expressions related to path, were found as well (e.g., “it is about keeping on keeping on” [13, p. 328], “try not to think about it and go on” [12, p. 317]). In addition, expressions related to waste and loss were used in this context (e.g., “all the wasted years” [12, p. 315], ”my entire life was for nothing, a big loss” [12, p. 318]).

Lastly, death was a recurring topic. One participant expressed the wish to flee domestic abuse in age: “But tomorrow came with old age and one feels as though one is dying; and before she dies, she is finally trying to get out of the situation… ” [12, p. 319]. Another participant, on the other hand, compared her suffering to dying: “I’m not living in a peaceful environment. If she left here, it would be the greatest happiness of the world for me because I suffer too much. I just quietly take all of it. I’m dying.” [15, p. 6]. In Park et al. (2016) one woman stated that she “want[s] to think, [she’s] already dead.” [14, p. 12].

Prolonged grief disorder

Regarding PGD, 6 themes could be identified in total: i) body and damage, ii) numbness, iii) aloneness, iv) loss (of a part of oneself), v) void (i.e., hole or emptiness), and vi) path. Expressions related to body and damage were again the most common ones.

Body and damage. Once more, thoughts and feelings were ascribed to parts of the body. For example, when describing her reaction to the news her husband had died, a participant mentioned that her “head refused to accept” it [21, p. 29]. A mother who found out about their adult child’s death expressed: “My heart just went. I just felt like I’m just here, but I’m not really here anymore. They might as well kill me too.” [27, p. 572]. Other participants in the same study (Smith, Nunley, Kerr, & Galligan, 2011) referred to the heart as well, when expressing the painful loss of their child: “I have the feeling as if somebody has just cut half of my heart out or a portion of it” [27, p. 572]. As well as: “When people say a heart aches, it really aches” [27, p. 572]. In general, participants frequently expressed being in pain and suffering.

Numbness. The theme of numbness emerged in the PGD studies. Some older adults expressed a state of numbness when confronted with the death of their loved ones. “I felt completely numb” [17, p. 420], “you’re just in a complete fog” [17, p. 422], “I felt like a ghoul” [29, p. 85] are some examples that express this state of mind. “I just felt like I’m just here, but I’m not really here anymore. They might as well kill me too. I just feel like I’m not here sometimes. I’m just going through the motions of life” [27, p. 572] and “I have no desire to go out, I do not feel like dressing up, many days I do not even want to shower, I’m just going through the motions” [21, p. 30] reveal that this numbness sometimes persists even after the initial confrontation with news of a loss.

Being alone or feeling lonely was a recurring theme in the PGD studies (e.g., “now it’s just me” [29, p. 87], “without him I feel very lonely at times” [18, p. 1378]). Other expressions were, losing a part of oneself (e.g., “My husband and I were so close it’s like we were one people, when you get married you’re like one person … It’s part of your life it’s part of you … It’s like you lost a part of your life … you lost a part of you” [19, p. 60]) or the loss leaving behind a hole (e.g., “we all put on this wonderful brave face, err, that’s hiding this big hole inside that’s umm, forever there” [17, p. 424]).

A few expressions related to path or repression in general could be found. For example, a participant in a study about bereavement by suicide (Hybholt et al., 2020) said that “you need to try to pull yourself up by the bootstraps” [23, p. 7] and keep busy. “It’s time to let go” [29, p. 84], “I feel like I’m umm moving on” and “life goes by” [29, p. 89] were other expressions with this sentiment. Some participants admitted that despite outwardly seeming well, they still grieved on the inside (“I stop crying outwardly, but I cry inside myself.” [25, p. 298], “I still have hidden grief when I am out with my friends” [27, p. 570], “I guess because I shelved a lot of it, people actually thought I was ok” [28, p. 609]).

Adjustment disorder

In general, less expressions could be identified among the AjD-related studies in comparison with the studies in the context of the other three stress-related disorders. Very few consistent themes stood out, nonetheless five could be identified: i) body and damage, ii) breaking/fixing, iii) death, iv) containment and v) path.

Body and damage. A slightly more common topic than the others was again body and damage, although most of the expressions simply related to the body and not necessarily to damage. There were again some instances were thoughts and feelings were ascribed to the associated organs. For example, in a study about internally displaced persons in Georgia, a participant describes how watching TV and reading newspapers lately causes him distress: “I cannot watch TV anymore. I read newspapers, but lately it is causing nerve problems as well” [38, p. 43]. Another example ascribing a state to an organ is: “war, fear and flight has made my brain foggy” [35, p. 1035]. Some participants mentioned suffering.

Breaking/fixing. The topic of breaking/fixing was mentioned a few times in the AjD studies (e.g., “All that crumbled. The entire country crumbled.” [36, p. 602], “I didn’t want her to know because I knew she’d fall apart” [34, p. 6], “I’m just worn out, with the tests, and just not getting anywhere, and I decided, as of right now, I’m just not going to do anything … the pain, it hardly ever stops.” [30, p. 1031]). Death was referenced a few times (e.g., “it feels like a death […] Cuba is dead to a certain extent.” [36, p. 614], “I will die with [Cuba] in my heart” [36, p. 613], “wish I could be put to sleep” [31, p 953]).

The theme of containment could be identified with several participants expressing the sentiment of being trapped such as “I feel trapped and alone” [35, p. 1035], “All my life I liked doing so much for myself and for other people and now I’m stuck.” [31, p. 952] and “The situation I’m in … I think about it a whole lot because that’s no way to live … it seems like I’m going around in circles.” [37, p. 499] One woman in a study about older people’s transitions into residential care (Lee, Simpson, & Froggatt, 2013) jokingly referred to other residents as “inmates” [33, p. 53]. Lastly, a couple of quotations were related to path: “it was stressful but I just had to get on with it, I just had to get on” [34, p. 5], “I always feel better having been out and had a good, gossip, usually we start off with all our ailments then we have a good laugh and get on with it, oh yes, having a laugh is very important, you feel better with your friends because we all suffer from one thing or another” [34, p. 6]. Lastly, one example related to path, but focusing more on repression in general, was: “I try to slough it off. I got to do this, I got to do that. Just hang in there.” [37, p. 499]

Overarching themes in trauma and stressor-related disorders

Having analyzed and identified themes for PTSD, CPTSD, PGD and AjD, we explored if any of the themes could be found across more than one of the stress-related disorders. Table 3 offers a simplified overview of the four stress-related disorders and each theme that could be identified in them.

Table 3. Themes identified in the studies related to PTSD, CPTSD, PGD and AjD.

	PTSD	CPTSD	PGD	AjD
body and damage	x	x	x	x
path	x	x	x	x
loss	x	x	x
death	x	x		x
fight	x	x
containment	x			x
breaking/fixing	x			x
aloneness		x	x
hell	x
nature		x
numbness			x
void			x

It becomes apparent that the theme of body and damage is the most consistent one, with metaphors and related expressions about the body, wounds, illness, and pain being the most common ones in all the stress-related disorders. Another theme that could be identified in all four disorders was path. Loss was prominent in PTSD, CPTS and PGD, although in different “shades.” While PTSD offered a more general theme of loss, the loss in CPTS was heavily connected to waste. In PGD the loss referred to losing a part of oneself. Expressions related to death could be found in PTSD, CPTSD and AjD. Fight was a recurring topic only in PTSD and CPTSD. The themes containment and breaking/fixing appeared only in the PTSD and AjD studies. Both CPTSD and PGD offered quotations relevant to aloneness. Hell in PTSD, nature in CPTSD, numbness and void in PGD were unique themes that could be identified only in the respective disorders.

Discussion

This scoping review aimed to collect qualitative studies with older-aged samples to identify metaphors and related expressions used to describe traumatic or other extremely stressful experiences that may lead to PTSD, CTSD, PGD, and AjD. We collected a total of 39 relevant studies with the most found in the PGD context, followed by PTSD and AjD and the fewest in the CPTSD context. We identified several metaphors and related expressions and multiple disorder-specific and transdiagnostic patterns. There is a rich material of metaphorical expressions on the studied topic in older people, although they were never collected in this context before.

Referring to the metaphorical concepts of trauma found among the four cultural or indigenous group samples summarized by Rechsteiner et al. (2020), it can be observed that several of the identified themes in this scoping review reflect the ones found in these groups. As Rechsteiner et al. (2020) concluded in their article, the results of our analyses, as well, show that the most common linguistic expression among older adults are those related to bodily processes (body and damage), and this, across all four diagnoses. Similarly, the theme of fight was a recurring theme in PTSD and CPTSD related studies. Metaphors or related expressions associated with fighting, war, or violence in general, might be associated with the externally caused and life-threatening nature of events associated with PTSD and CPTSD.

A few of the recurrent themes we identified were novel. This could mean that they are either specific to CPTSD, PGD and AjD, or that they are specific to old age. Particularly outstanding is the topic of path found in the context of all stress-related disorders. It seems reasonable to assume that this theme might be specific to old age due to older adults’ tendency to have an attitude of repression, being raised in a time in which psychology was not an established empirical science yet and people with mental disorders were stigmatized (Böttche et al., 2019; Rössler, 2016). Additionally, survivors of historical traumata such as World War II developed an attitude of normalizing trauma, due to everyone of their generation having had to suffer from it (Böttche et al., 2019; Hiskey & McPherson, 2013).

In fact, one of the studies we included in our scoping review came to similar conclusions themselves. Hiskey and McPherson (2013), who explored older adults’ constructs of trauma, found that the participants in their study considered traumatic experiences to be part of life. This sample did not consider war as being traumatic because everyone had experienced it and had suffered to the same degree. Instead, “unusual” difficult experiences that were also socially stigmatizing at the time were considered traumatic (e.g., a divorce). Hiskey and McPherson’s (2013) participants used coping mechanisms characterized by avoidance and non-disclosure, such as not talking about the traumatic experience to anyone and moving on with life. Fear of being incarcerated in a mental health institution was a reason for non-disclosure. In addition, disclosure was considered an act of self-indulgence and weakness. The authors argue that a strong belief in the virtue of independence might have further strengthened these attitudes.

A similar sentiment regarding how to handle emotional distress was found in a study by Switzer et al. (2006), which focused on depression. In this study, participants regarded the management of depression as an individual responsibility, achieved through action and hard work. The study by Moult et al. (2020) about how older adults understand and manage distress (included as one of the studies in the AjD context), further emphasizes the importance of self-management in older adults. Stigma prevented some of the participants to seek help, but even the participants who consulted their general practitioner and were offered medication and/or “talking therapies” were unsatisfied with these solutions. Instead, participants expressed a preference for managing their distress by performing independent activities such as reading, gardening, and walking. Seeking social support and attending community groups and church were also seen as preferable coping strategies.

Despite around 70% of the population experiencing a traumatic event at least once in their life (Kessler et al., 2017), PTSD lifetime prevalence rates are nonetheless rather low. The World Health Organization World Mental Health Surveys found that PTSD lifetime prevalence was 4% in the total sample and up to 6% among the trauma exposed in a cross-national sample of 24 countries (Koenen et al., 2017). This shows that the majority of people who experience a traumatic event respond with resilience and manage to overcome these extremely stressful experiences at some point in their life. Seen from this perspective, metaphors with the theme of path may reflect an attitude of resilience and acceptance rather than repression for some individuals.

The other “unique” themes we identified, reflect aspects of the respective disorder context. In the case of CPTSD, the themes of “aloneness” and “waste/loss” were recurrent. It makes sense that victims of traumatic experiences that have lasted or repeated themselves over many years would feel like these years spent suffering were wasted and lost. Similarly, the feeling of being alone and loneliness could stem from not getting any help and having to endure this suffering on their own for a prolonged period of time.

The themes of numbness, loss (of a part of oneself) and void found in the PGD studies reflect common reactions and feelings associated with grieving. For example, the first stage in the Five Stages of Grief model by Kübler-Ross (1969) is “denial.” When confronted with the news of having lost a beloved person, one might at first have a hard time believing and accepting this extremely distressing information, resulting in a feeling of numbness. Later, the absence of the loss makes itself known in everyday life as the deceased person is not there anymore. Depending on the context and relationship to the deceased, several aspects of everyday life change. For example, a recently widowed woman used to living with her husband, will now live alone and have lost the one person she probably used to interact with the most in her life. It is only reasonable that this kind of loss is noticeable and elicits the feeling that something is missing, be it a part of oneself or a void left behind in one’s life. Similarly, feeling alone or lonely is a consequence that can be expected, following these changes.

One of the studies we had to exclude due to not presenting any quotations, analyzed metaphors of grief in bereaved rural elders (Steeves & Kahn, 2005). One common metaphor category Steeves and Kahn (2005) identified was “grief as an alien, malignant, entity that would attack people” (p. 200). Participants struggled against “grief attacks,” tried not to get overwhelmed by them and acknowledged the courage needed to win against it. Another metaphor category the authors identified, was the one of “negatively charged energy.” Grief would build up inside of the participants, negatively affecting everything in their life, until this energy could be discharged, for example by crying. The last metaphor category the authors identified, was of grief as “fact.” The participants compared the death of their spouses to an object in the world. This objectification of the loss, the turning of an absence into a presence, made it easier to handle it. If this study had been included in our scoping review, the first metaphor category for grief (malignant entity) would have been categorized under the theme of fight. The second metaphor category (negatively charged energy), on the other hand, would have been considered an expression reflecting the theme of containment. Strikingly, both of these themes were not prominent themes in the current review in the context of PGD. This could be an indication that our results might have looked different if we had access to the quotations of every study relevant to our research question.

The results of the analyses of AjD studies are less consistent overall, maybe due to heterogeneity of the original studies, with the critical life events ranging from illnesses or injuries, to transitions to nursing homes, to migration or displacement. Creating subcategories according to these very different critical life events in the AjD category might lead to more insightful results and should be considered in future research.

All in all, the strongest findings regard the theme of body and damage. This theme could be found across all four trauma- and stress-related disorder categories and was the most recurrent theme within each of them. At least in the case of metaphorical concepts of trauma, expressions related to bodily processes seem to be universal as they could also be found among four very different cultural groups (Rechsteiner et al., 2020). In general, people who have experienced a traumatic event are considered wounded, at least in developed Western countries (Henrich, Heine, & Norenzayan, 2010). However, this kind of linguistic expression may hold even more meaning for older adults. It may reflect several aspects of the relationship of older adults with their bodies. For one, the importance of physical health, as with age the probability of developing chronic illnesses and disabilities increases. It may also reflect a tendency of somatizing mental disorders, either due to focusing more on the physical aspects of a problem, stigmatization, or lack of education in regards of newly established psychological concepts. A few researchers theorized that somatization of emotional distress is common enough world-wide that “psychologization” of emotional distress might be a cultural concept of distress specific to Western culture (Kirmayer, 2001; Ryder, Yang, & Heine, 2002). In this case, our findings imply that this psychologization is a rather new phenomenon and that older generations are not as affected by it as younger generations. More research is needed to explore the hypothesis of “psychologization” in Western cultures, and to better understand its cultural meaning.

We conclude that it is worthwhile to study the metaphorical expressions of traumatic or extremely stressful experiences in older people, because there are several specific issues that the metaphors draw attention to and that could otherwise be easily overlooked in the work with older people. Particularly the attitude of repressing or accepting one’s suffering and instead moving on with life, which emerged in our analysis and is supported by other research (Hiskey & McPherson, 2013; Switzer et al., 2006) seems a crucial element that needs to be taken into consideration to develop more fitting and appealing mental health messages and interventions for older adults. It might be considered a cultural concept of distress that is specific to old age. The studies by Switzer et al. (2006) and Moult et al. (2020) suggest that older adults might prefer a more “self-oriented” and less “clinical” approach. Messages and interventions that promote more individual responsibility, action and control might be more appealing for older adults. In addition, focusing on social support, implementing, or facilitating community groups attendance in mental health interventions might result it more acceptance and positive effects regarding mental health therapy among older adults.

Limitations

Some limitations of this scoping review need to be considered. First, although the literature search and screening of relevant studies was extensive, it was performed by only one person due to limited resources. Some studies that were relevant for the review might therefore have been overlooked. However, the list of pre-selected studies has been thoroughly discussed between the authors and the final selection confirmed by consensus. Second, inclusion criteria for the review initially were rather broad and studies that were considered as moderately suitable were included. One reason for this is that the field of trauma and stressor-related disorders offers only a limited number of qualitative studies with older adults. In addition, (parts of) the concepts of CPTSD, PGD and AjD are rather novel. In a few years from now, when more qualitative literature on these diagnostic categories will be available, results might be different. The last limitation to be considered is that the quotations from the original studies offered a very restricted possibility to analyze the use of metaphors and other related expressions by older adults. Access to the entire transcript of the interviews might have given more insight. However, as almost none of these studies focused specifically on metaphors or speech patterns in general, it is questionable to what degree the original transcripts would have revealed more content. It is noticeable that a handful of studies were more suitable than others, with their quotations offering many linguistic expressions relevant to the research question of this review, while other studies were less useful in this regard. The amount and selection of presented quotations in the studies included in this review, as well as the literature search, inclusion, and exclusion process of studies in general, are factors that influence the final findings of our review. We cannot exclude biases.

Conclusion

In conclusion, this scoping review offers an overview of qualitative research related to PTSD, CPTSD, PGD, and AjD with samples of older adults. It offers an analysis of the kinds of metaphors and related expressions older people use to describe traumatic and other extremely stressful experiences. These findings give helpful insight into the way older adults express themselves when talking about their suffering and is the first step in developing a culturally adapted treatment for people of old age. More research is recommended for this field. This review provides a basis for, among others, the ethnopsychological study we plan to conduct with older adults in Switzerland soon.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This research was supported by the Hamburg Foundation for the Advancement of Research and Culture (Hamburger Stiftung zur Förderung von Wissenschaft und Kultur).

Notes

¹ Annotated in the brackets following a quotation is the number of the study the quotation stems from (see Table 2) and the page where the quotation can be found in the original article.