Lifelong posttraumatic stress disorder: evidence from aging Holocaust survivors

Abstract

Despite the fact that 50 years have passed since the Nazi regime and the Holocaust the psychic sequelae are far from being overcome. The majority of Holocaust survivors and World War II veterans still list their experiences as the “most significant stressors” of their lives. The literature provides ample evidence that posttraumatic stress disorder among survivors persists into old age. However, there is still a need to define the differences in frequency, clinical presentation, severity, and comorbid conditions among aging Holocaust survivors. Age at the time of trauma, cumulative lifetime stress, and physical illness are reported to have a positive association with more severe posttraumatic symptomatology. The presence of comorbid Axis i psychiatric disorders (Diagnostic and Statistical Manual [DSIVI]), has been the focus of research by our group, demonstrating that their interaction with earlier trauma leads to a course of chronic, debilitating disease. Despite reactivation of traumatic symptoms during aging and continuous mental suffering, the majority of Holocaust survivors show good instrumental coping and preserved functioning.

A pesar que han transcurrido 50 años desde el régimen nazi y del Holocausio, las secuelas psiquicas aun no han sido superadas. La mayoria de los sobrevivientes del Holocausto y los veteranos de la II Guerra Mundial todavia relatan sus experiencias como los “factores estresantes más significativos de sus vidas”. La literatura ofrece una amplia evidencia acerca de la persistencia del trastorno de estrés postraumático entre los sobreviventes a lo largo de los años. Sin embargo, aun existe la necesidad de definir las diferencias en cuanto a frecuencia, presentación clinica, severidad y comorbilidad entre los sobrevivientes de edad avanzada-del Holocausto. Se ha informado que la edad en que ocurrió la experiencia traumática, la acumulación de factores estresantes a lo largo de la vida y la enfermedad fisica presentan una asociación positiva con la sintomatologia postraumática más severa. La presencia de algún trastorno psiquiátrico del eje. I (del Manual Diagnóstico y Estadistico, DSM) ha sido el foco de investigación de nuestro grupo y se ha demostrado que la interacción con traumas precoces conduce a una enfermedad de curso crónico y debilitante. A pesar de la reactivación de sintomas traumáticos durante el envejecimiento y el continuo sufrimiento mental. la mayoria de los sobrevivientes del Holocausto muestran una adecuada adaptación y un buen funcionamiento en la vida diaria.

Cinquante ans nous séparent du régime nazi et de l'Holocauste mais ce temps écoulé n'a pas effacé les séquelles psychiques chez les survivants, loin de là. Pour la majorité de ceux qui ont subi l'Holocauste et des vétérans de la Seconde Guerre Mondiale, cette période constitue le «stress le plus éprouvant» de leur existence. L'état de stress post-traumatique persiste chez les survivants même lorsqu'ils atteignent un âge avancé, comme le démontrent de nombreuses données rapportées dans la littérature. Il serait toutefois nécessaire de mieux définir les différentes modes de présentaion des troubles rencontrés chez les survivants âgés de l'Holocauste: fréquence, présentaion clinique, sévérité, comorbidité. Il existe une corrélation positive entre la plus grande sévérité de l'état de stress post-traumatique et l'âge du sujet au moment du traumatisme, la répétition d'événements stressants au cours de la vie et l'existence de pathologies somatiques. Nous avons centré nos recherches sur des sujets souffrant également de troubles psychiatriques de l'Axe I (classification du DSM Manuel Diagnostique et Statistique des Troubles Mentaux) et nous avons pu établir que l'interaction entre ces troubles et l'existence d'un événement traumatique antérieur aboutit à une évolution chronique et débilitante de la pathologie psychiatrique. Cependant, bien que l'on observe une réactivation des symptômes de l'état de stress post-traumatique chez les sujets âgés et alors que leur souffrance mentale est toujours présente, la majorité des survivants de l'Holocauste témoigne d'une bonne fauclté d'adaptation aux contraintes matérielles et psychologiques de la vie quotidienne.

Keywords:

• PTSD
• Holocaust
• aging
• reactivation
• chronicity

Research into posttraumatic psychiatric morbidity has a long history. Since the first descriptions of “soldiers' heart” syndrome in the American Civil War, wars, natural catastrophes, mass fires and accidents, rape abuse, and torture have all added to our understanding of the effects of trauma on the human psyche.^1-4 Despite the accumulating data and the magnitude of human suffering, the unique diagnostic categorization of posttraumatic stress disorder (PTSD) is a “latecomer” in formal psychiatric classification systems.

Two factors have delayed the progress in diagnosis and understanding of PTSD: (i) the attribution of this disorder to combat-related events; and (ii) the tendency to view the symptoms developing after a trauma as “normal response.” Thus, in the first half of this century, the psychiatric approach to trauma has varied widely⁵ After World War II (WWII), the American Psychiatric Association included “gross stress reaction” in the first edition of the Diagnostic and Statistical Manual (DSM). Surprisingly, this entity was dropped from DSM-II and only the advent of DSM.-IV in 1994 separated acute stress disorder from PTSD. In addition, DSM-IV offers as specifiers the definitions of “acute” or “chronic” to describe the course of the disorder, as well “with delayed onset” to acknowledge appearance of the disorder 6 months (or later) after exposure to the trauma. It is important to note that the current classification also relinquishes the emphasis of the uniqueness of the traumatic event and conceptualizes PTSD as common to many different types of events. In these events, the individual experiences, witnesses, or is confronted with death or serious injury, and responds with intense fear, helplessness, or horror.^3,6

Despite the refinement and opcrationalization of diagnostic criteria for PTSD, relatively little is known about the course of the disorder. In the March 1999 issue of the American Journal of Psychiatry, three published studies used longitudinal designs to address both the acute and chronic effects of trauma.^7-9 The study by Koren and colleagues,⁹ in conjunction with retrospective studies of the natural history of PTSD¹⁰ seem to emphasize that the course of PTSD is one of an increase in symptoms in the early phase (1 to 3 months after trauma), followed by a plateau. Is this “plateau” phase lifelong? Do PTSD symptoms remain severe and disabling throughout the life cycle? Are maturation, aging, and reintegration into society factors that affect the course of PTSD?

Veterans of WWII and Holocaust survivors offer a unique opportunity to evaluate the course of PTSD through the life cycle of people who have been subjected to extreme and massive psychic trauma in their youth. The majority of Holocaust survivors and more than half of WWII veterans interviewed 50 years after the war spontaneously listed it as the “most significant stressor” of their life.¹¹ With the aging of veterans and survivors, reports of reactivation of PTSD have been published.¹² Physical ill health, retirement, loneliness, comorbid psychiatric illness, anniversaries, reunions, and use of alcohol and psychotropic medication are all factors implicated in the exacerbation of both arousal and reexperiencing symptoms of PTSD.^12-15 For many WWII veterans, PTSD has lasted 50 years,¹⁵ although masking of intrusive symptoms in midlife was usual.¹² The rates of active PTSD reported among the veterans range from 12.4%¹⁴ to 45%. ¹³ It is noteworthy that veterans who suffer from comorbid psychiatric conditions report no significant reduction in symptoms over the preceding 10 years.¹³

The Holocaust was the most traumatic experience to occur in the 20th century. Most of the survivors are now elderly and for them, aging is a phase of severe crisis.¹⁶

Psychiatrists and other health professionals can facilitate the voicing of the suffering of people who spent their lives in the persistent shadows of the Holocaust. Indeed, in the last decade, many studies have focused on the long-term consequences of this massive traumatization. ¹⁷ Among the particularities of survivor suffering were: being outlawed, discrimination, defamation, total absence of rights, loss of individuality, life-threatening ewer a long period of time, torture, physical hardships, ill health, being uprooted, few or no survivors in the family and elsewhere, lack of graves for victims, and the realization at the end of WWII that language, culture, and home are lost forever.¹⁸ In later life, when friends are gone, the need to share with others becomes urgent; to bear witness is vital.¹⁹

In 1997, Sadavoy²⁰ reviewed the late-life effects as reported in studies of Holocaust survivors and WWII veterans. He concluded that survivor syndromes indeed persist into old age, that Holocaust survivors as a group have adapted well to instrumental aspects of life, but that there is a deficiency of treatment studies in this population. The Traumatic Stress Studies Program at the Mount Sinai School of Medicine, New York,^21-24 provides more specific data, as do several research groups in Israel.^16,25-29 Converging lines of research demonstrate that aging Holocaust survivors are in a sense a ”fragile“ group. Cumulative trauma, recent stress, and lack of social support increase the probability of retraumatization in old age.^21,24,29 Nevertheless, it is surprising that using DSM criteria to diagnose present PTSD in aging Holocaust survivors, the reported rates in controlled studies are 46% to 55.5%.^22,30 Major comorbid psychiatric illness was excluded from these studies. This may be a significant drawback, as depressive and dissociative features, as well as markers of the adrenocortical (steroidal) pathway, are notably abnormal in nontreatment-seeking survivors.^23,24 Increased risk of suicide, depression, chronicity of schizophrenia, and development of late-life paranoia have all been reported in aging Holocaust survivors.¹⁶ Thus, there is a need to study the presence of comorbid PTSD in the minority of survivors who suffer from psychiatric disease. This may aid in understanding the complex relationship between massive psychic trauma and the course of PTSD in subjects who have been under close observation by mental health professionals most of their lives.

The present study was conducted to evaluate the presence of ”active“ PTSD in a group of aging Holocaust survivors who were either repeatedly hospitalized, or spent most of their lives in long-stay psychiatric institutions.

Subjects

At the end of WWII, nearly 500 000 Jews survived the Holocaust. Of these, approximately 300 000 immigrated to Israel in two main periods: shortly after the establishment of the State of Israel, and between 1989 and 1992 when large groups of Jews immigrated from the former USSR.²⁸ It is estimated that 200 000 survivors are now living in Israel, most of whom are now elderly. In the 1950s, nearly 2000 Holocaust survivors were repeatedly or chronically hospitalized in psychiatric hospitals in Israel. The most common diagnosis then was that of schizophrenia. In 1998, there were 700 such patients hospitalized in long-stay wards. The Abarbanel Mental Health Center is Israel's largest academic psychiatric center. 'Ihe center's psychogeriatric division consists of three wards encompassing 110 inpatient beds. From January to June 1998, for the purpose of the present study, all aging Holocaust survivors were interviewed.

Holocaust survivors were defined as subjects that were in Eastern or Western Rurope under the Nazi regime during the years 1933 to 1945. Inclusion criteria for the study were: (i) age ≥65 years; (ii) being a Holocaust survivor. Rxclusion criteria were: (i) DSM-IV diagnosis of dementia; (ii) inability (cognitive impairment or language difficulties) to endorse the Impact of Event Scale (IES)³¹; and (iii) patient's refusal to participate in the study.

Methods

All patients had previously been diagnosed according to DSM-IV criteria as part of an ongoing study project (the data relevant to this project are detailed in reference 16). For purposes of the present study, the IES³¹ and revised PTSD inventory (R-PTSD)³² were used.

The IES comprises two subscales describing and quantifying intrusive and avoidance experiences. The RPTSD inventory is based on endorsement (by the interviewing researcher) of DSM criteria for the presence of PTSD. Both these instruments were previously used and validated in studies of Holocaust survivors and trauma victims.^32,33

Data are presented as means ± standard deviation (SD) and ranges. We used these simple statistical measures as the aim of the study was to present a descriptive audit.

Results

During the period January to June 1998, 93 Holocaust survivors were being treated at the Abarbanel Mental Health Center psychogeriatric wards. Of these, 32 did not fulfill the criteria of the study, and were excluded. All 61 participating patients underwent a semistructured interview. After the interview all endorsed the IES.

Our series comprised 41 women and 20 men. Mean age for the group was 77.1 years (± 6.8; range 65-91). Ihe majority of subjects were in Eastern Rurope during the Nazi regime (43 of 61; 70.5%). Axis I (DSM) psychiatric diagnoses for the group were as follows: 32 of 61 (52.5%) schizophrenia, 17 of 61 (27.9%) affective disorders, and 12 of 61 (19.6%) other psychotic disorders.

The R-PTSD inventory facilitated diagnosis of comorbid PTSD in 91.8% of patients (56 of 61). As previously shown, the inventory correlated well with the Schizophrenia Clinical Interview for Diagnosis (SCID). Thus, comorbid PTSD can be said to be reliably diagnosed in the overwhelming majority of subjects in the present study. The IES results demonstrated a significant difference between intrusive and avoidance symptoms. While both subscales were scored as significantly higher than the reported means for the normal population, intrusions were scored as notably more prominent than avoidance. Mean intrusion score was 42.7 ±4.1 (range 3651) and mean avoidance score was 29.7±3.4 (range 2731); < 0.01 [paired Student /-test]). The IES scores in the present study are in the range of a previous study of elderly subjects suffering from PTSD reported by our group.³³

Discussion

Our sample represents a unique group of elderly Holocaust survivors who show a high comorbidity of chronic PTSD (91.8%), with psychotic disorders more than 50 years after the experience of the massive psychic trauma of the Holocaust.

The occurrence of chronic PTSD of such magnitude for an extremely prolonged period is striking. It is significantly higher than the rate reported for war veterans, ranging from 12.4%¹⁴ to 45%. ¹³ This difference may be related to the unique nature of the Holocaust trauma, combining dehumanization, confrontation with death, and massive loss for a prolonged period.²¹ Beal¹⁵ demonstrated that the co-occurrence of imprisonment in addition to the experience of combat led to a higher incidence of PTSD and other psychological symptoms, compared to combat experience alone. Furthermore, Kidson ct al¹³ show that the specific nature of the traumatic experience, such as taking of casualties, or the experience of combat stress, resulted in more pronounced severity, and was significantly associated with the occurrence of PTSD in WWII veterans. Thus, the specific nature of the traumatic experience may influence the occurrence of PTSD and its persistence over time. Beyond this aspect, the coexistence of a severe psychotic disorder in our scries of patients seems to bc decisive. As demonstrated by Kidson et al,¹³ even minor pathologies, such as anxiety and depressive disorders, were more common in war veterans with PTSD. Therefore, this seems to suggest that the severity of the coexistent psychiatric morbidity, such as schizophrenia, may explain the high incidence of chronic PTSD present for such a prolonged period.

It is difficult to say whether the occurrence of PTSD in our group represents lifelong suffering, beginning close to the end of the traumatic experience and persisting for more than 50 years, or whether it represents a phase of symptomatic reactivation occurring in WWII veterans in their old age, as demonstrated by Macleod.¹²

The exposure to trauma puts into effect mechanisms of coping (directed towards the environment), as well as defense mechanisms (directed towards traumatic memory and its psychic repercussions). It is generally acknowledged that most Holocaust survivors have succeeded in mobilizing effective skills for coping, manifesting themselves by recreating families and adapting to social roles. However, the impact of the Holocaust on ego functions led to the activation of defense mechanisms, mostly of splitting and ensuing encapsulation, numbing, and avoidance. As in psychosis, the coexistence of psychosis in our patients led to processes of fragmentation of the ego, thus impairing the exercise of these ego functions. Again, this may have been a decisive factor in the occurrence of active PTSD symptomatology. Furthermore, the primary process (psychosis) may have uncovered the core memories of the traumatic experience and prevented the possibility of masking. One of our patients only described a cannibalistic experience during extreme starvation in the Theresienstadt concentration camp when in the manic-psychotic phase of his bipolar disorder. While euthymic or depressed, he was unable to recall or recollect this experience. Our sample demonstrates a relative preponderance of intrusive symptomatology versus avoidant features. This finding may also be related to the disorganizing effect of psychosis on the ego.³⁴

Conclusion

Our findings show that the comorbidity of psychosis and PTSD in Holocaust survivors leads to a lifelong debilitating illness. Nonpsychotic survivors usually succeeded in achieving a sense of integrity through “historicizing” their memories³⁵ (establishing a continuity between early, positive pre-Holocaust memories, through traumatic memories during the Holocaust and memories of reestablishing the fabric of life in the post-Holocaust period). In contrast, the psychotic survivors were unable to reach this equilibrium and, for them, memory is a lifelong burden.

Selected abbreviations and acronyms

IES	=	Impact of Event Scale
PTSD	=	posttraumatic stress disorder
R-PTSD	=	Revised Posttraumatic Stress Disorder (inventory)
SCID	=	Schizophrenia Clinical Interview for Diagnosis
WWII	=	World War II