Holocaust Survivors in a Primary Care Setting: Fifty Years Later

 

Brian Trappler

 

Jeffrey W. Braunstein

 

George Moskowitz

 

Steven Friedman

 

SUNY Health Science Center at Brooklyn

 

 

Abstract

            Past studies have not assessed the prevalence of emotional disturbances in Holocaust survivors seeking medical treatment in a family practice environment.  The present study examined the prevalence of lifetime (the presence of symptomatology during at any time) and current posttraumatic stress disorder (PTSD) symptoms, general anxiety, and depression in Holocaust survivors seeking medical treatment in a primary care setting.  20 of the 27 Holocaust survivors in our sample received a current diagnosis of PTSD and reported significant symptoms of depression and general anxiety.  Although 74% of the survivors were currently diagnosed with PTSD, participants in this study had reported an overall decline in reexperiencing, hyperarousal, and overall PTSD symptoms but exhibited increased avoidance and numbing symptoms throughout the lifespan.  These preliminary results suggest that removing avoidance as a defense mechanism during the course of psychotherapy may leave these survivors without an adequate way for coping with their trauma, subsequently increasing their vulnerability to psychopathology.  Implications for psychological interventions are provided.

 

KEY WORDS: Holocaust, geriatric, trauma, posttraumatic stress disorder

Holocaust Survivors in a Primary Care Setting: Fifty Years Later

            There is considerable interest in the long-term effects of trauma throughout the lifespan of survivors (Averill & Beck, 2000).  Although numerous studies have examined emotional disturbances in war veteran and civilian populations, few studies have examined the long-term prevalence and symptoms profile of emotional disturbances in Holocaust survivors of Nazi concentration camps.  Kuch & Cox (1992) were the first to apply DSM criteria to the examination of emotional disturbances.  They reported that forty-six percent of their sample of Holocaust survivors (n = 58) met the DSM-III-R criteria for PTSD.  Yehuda, Kahana, Schmeidler, Southwick, Wilson, & Giller (1995) noted that after 50 years, 57% of Holocaust survivors still met criteria for PTSD.  In addition, these investigators concluded that the presence and severity of current PTSD symptoms was related to experiencing additional stressful events throughout life.

            Hyer, Summers, Braswell, & Boyd (1995) compared survivors of World War II with survivors of the Korean and Vietnam wars and found that younger veterans had greater elevations in PTSD symptomatology when compared to older veterans, although older veterans experienced a diminished interest in daily activities.  These older veterans were prone to all PTSD symptoms when exposed to trauma-related triggers.  Yehuda, Kahana, Southwick, & Giller (1994) reported that Holocaust survivors also currently experienced significant depressive symptomatology.  Solomon and Prager (1992) found that Holocaust survivors living in Israel reported greater perceptions of danger, more psychological distress, and higher levels of state and trait anxiety during the SCUD missile attack of the Gulf War than age matched citizens who were not Holocaust survivors.  These findings suggest that in the absence of hyperarousal symptoms and fewer intrusive symptoms, older trauma survivors are more likely to be diagnosed with major depression because of their avoidance and emotional numbing. 

            The purpose of this study was to examine the prevalence of lifetime and current PTSD symptoms, general anxiety, and depression in Holocaust survivors seeking medical treatment in a primary care setting.  Past studies have not assessed the prevalence of emotional disturbances in Holocaust survivors seeking only medical treatment in a family practice environment.  We wished to identify a subgroup of survivors who had not routinely sought mental health services to gain an understanding of how they coped with trauma during their lifetime. 

Method

Participants

            The population for this study was limited to Holocaust survivors seeking medical services in a community-based family medical practice.  Each participant in this study was forced into either labor or concentration camps during their childhood or early adulthood at the time of the Holocaust (1939-1945) and experienced a significant threat to their life.  Twenty-seven patients in this medical practice were identified as Holocaust survivors.  All twenty-seven patients agreed to participate in the study.  The mean age of participants in the study was 75.3 (SD +5.7) ranging from 66 to 91 years old.  Fourteen of the participants were men and thirteen were women.  Regarding marital status, sixteen of the participants were married, eight were widowed, two were divorced, and one was single.  Eight participants were disabled (four medically disabled, three psychiatrically disabled, and one both medically and psychiatrically disabled).  Participants were not seeking mental health treatment at the time of the study.  Ten participants had received past outpatient mental health treatment.  None of the participants reported any past psychiatric hospitalizations.  70.4% of participants (n = 19) were receiving treatment for a variety of chronic medical problems such as diabetes, hypertension, cancer (skin, colon, breast) and emphysema in a community-based family medical office. 

Instruments

            Clinician-Administered PTSD Scale for DSM-IV (CAPS).  This scale (Blake, Weathers, Nagy, Kaloupek, Charney, & Keane, 1998) is a structured clinical diagnostic interview based on DSM-IV criterion for PTSD.  It consists of standard questions and behavioral ratings, evaluating both the frequency and intensity of posttraumatic stress disorder symptoms.  The CAPS assesses current (past week and past month) and lifetime symptoms of PTSD.  Its items are rated for both frequency and intensity on a scale of 0 (never/none) to 4 (daily/extreme).  The interviewer assesses the validity of responses, considering issues such as compliance with the interview mental status, and efforts to exaggerate or minimize symptoms.  The administration time is approximately 90 minutes.

            An earlier version of the scale, the CAPS-1, (Blake, Weathers, Nagy, Kaloupek, Klauminzer, Charney, & Keane, 1990; Blake, Weathers, Nagy, Kaloupek, Gusman, Charney, & Keane 1995), was based on DSM-IIIR criterion and has been replaced by the current version, updated for DSM-IV.  The CAPS-1 has demonstrated excellent test-retest reliability (.90 to .98 for the total score) and above average internal consistency (alpha = .94) in a study of combat veterans (Weathers, Blake, & Litz, 1991; Weathers, Blake, Krinsley, Haddad, Huska, & Keane, 1992).  The CAPS-1 has also demonstrated excellent convergent validity with other diagnostic measures.

            Impact of Event Scale (IES).  The IES is a 15-item self-report instrument designed to measure current posttraumatic stress disorder symptoms associated with a specific traumatic life event.  The instrument provides a total score and subscales measuring reexperiencing and avoidance symptoms related to PTSD (Horowitz, Wilner, & Alvarez, 1979).  Seven items load on the Intrusion subscale and eight on the Avoidance subscale.  Participants rate items on a 4-point scale measuring the frequency of symptoms during the last week from 0 (not at all) to 5 (often).  Zilberg, Weiss, & Horowitz (1982) have reported the Intrusion and Avoidance subscales to have adequate internal consistency (.79 to .91 and .82 to .91) and test-retest reliability (.86 to .89 and .88 to .90).

            Beck Depression Inventory (BDI).  The BDI (Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961) is a 21-item self-report instrument measuring symptoms of depression during the last 7 days.  Participants rate symptom severity on a 4-point scale ranging from 0 to 3.  Total scores range from a minimum of 0 to a maximum of 63.  Beck, Steer, & Garbin (1988) reviewed twenty-five years of research on the inventory, providing evidence that it has excellent reliability and validity.

            Beck Anxiety Inventory (BAI).  The BAI (Beck, Epstein, Brown, & Steer, 1988; Wilson, de Beure, Palmer, & Chambless, 1999) is a 21-item self-report instrument measuring symptoms of anxiety during the last 7 days.  Participants rate symptom severity on a 4-point scale ranging from 0 to 3.  Total scores range from a minimum of 0 to a maximum of 63.  It has high internal consistency and above average test-retest reliability over the course of one week (Beck, Epstein, Brown, & Steer, 1988).  In addition, it has adequate concurrent, convergent, and discriminant validity (Beck & Steer, 1991; Fydrich, Dowdall, & Chambless, 1992).  Gillis, Hagga, and Ford (1995) conducted extensive normative research with the BAI, closely matching the demographic information of the normative sample with the U.S. national census of 1990.

Procedure

            A board certified psychiatrist and family practice physician evaluated the participants within a community-based, primary care medical office.  A general psychiatric interview, structured diagnostic clinical interview (CAPS) and self-report instruments (BDI, BAI, and IES) were completed during the evaluation.  Participants were informed of the purpose for the evaluation before consenting to the study.  They received instructions for completing all self-report instruments and were offered psychiatric and psychological treatment upon the completion of the evaluation.  Participants were instructed to complete the self-report instruments without assistance.

Results

            The CAPS Past Week Total Score, measuring DSM-IV PTSD diagnostic criterion, indicated that 20 of 27 participants met current and lifetime diagnostic criterion for PTSD.  The seven participants without PTSD did not meet the criterion for PTSD at anytime in their lives as assessed on the CAPS.  Four participants not diagnosed with PTSD received primary diagnoses of psychosis (n=1), intermittent explosive disorder (n=1), and other non-PTSD anxiety disorders (n=2) as determined by both a general psychiatric evaluation and psychometric testing used in the study.  Only, three participants were not diagnosed with a current DSM-IV psychiatric disorder.

            Table 1 presents the means and standard deviations of the total scores on the BDI, BAI, IES total score, IES intrusion subscale, IES avoidance subscale, and CAPS total score as a function of PTSD status.  The diagnosis of PTSD and subsequent group designation for the analysis was determined by positive findings from the general psychiatric evaluation and the CAPS.  Six Mann-Whitney Tests were conducted to analyze the effects of PTSD on participants’ scores for the BDI, BAI, IES total score, IES Intrusion subscale, IES Avoidance subscale and the CAPS total score (see Table 1).  There was a significant difference between PTSD (n = 20) and non-PTSD (n = 7) participants on all measures with participants in the PTSD group exhibiting significantly greater symptoms of depression, general anxiety, intrusive thought, avoidance, and overall PTSD symptomatology when compared to the non-PTSD group (BDI, U = 4.0, p < .001; BAI, U = 1.0, p < .001; IES total score, U = 1.0, p < .001; IES Intrusion subscale, U = 0.0; IES Avoidance subscale, U = 0.0; and CAPS total score, U = 0.0, p < .001).

            Four case-controlled paired sample t-tests measuring differences between past week and lifetime symptoms of PTSD on the CAPS were conducted for all participants (see Table 2).  There was a significant decrease in reexperiencing symptoms (t (26) =       -15.65, p < .001), hyperarousal symptoms and overall PTSD symptoms (t (26) = -5.88,    p < .001) throughout the survivors’ lifetime, although a significant increase in avoidance and numbing symptoms was also reported (t (26) = -6.48, p < .001).

Discussion

            Our results suggest that after more than fifty years, Holocaust survivors continue to exhibit symptoms of posttraumatic stress with 74% of our sample of participants attending a primary care family practice receiving a diagnosis of PTSD.  Although our participants reported an overall decline in reexperiencing, hyperarousal, and overall PTSD symptomatology throughout the lifespan, over time there was a trend toward an increase in avoidance and numbing.  This is consistent with another study (McFarlane, 1990) suggesting an increase in avoidance and social estrangement as PTSD survivors’ age.  In addition, these PTSD survivors become more somatically preoccupied and present more frequently in medical settings as they age (Lyons & McClendon, 1990).

            The avoidance exhibited by Holocaust survivors has apparently served as an adaptive function, allowing many of these survivors to control hyperarousal symptoms and maintain an adequate level of functioning.  A supporting clinical observation was that most of our patients never shared the details of their trauma with their children (avoidance), and frequently requested sleep medication and sedatives during periods of hyperarousal. 

Regarding the determination of pharmacotherapy, case-by-case decisions need to be made based on the patients’ chronicity of PTSD symptoms.  Patients without chronic physiological hyperarousal symptoms may benefit from short-term use of benzodiazepines or hypnotics, whereas patients with chronic hyperarousal symptoms might instead benefit from serotonergic antidepressant and mood stabilizing medications given the addiction potential of benzodiazepines. 

Holocaust survivors may have found other adaptive ways to avoid and cope with their trauma, such as actively engaging in work, community and religious activities, and raising children.  In contrast to the theory of thought rebound (Salkovskis & Campbell, 1994; Rutledge, Hancock, & Rutledge, 1996), which hypothesize that the suppression of unwanted ideation leads to increased intrusive ideation, these trauma survivors have effectively used avoidance, suppression, and sublimation (religious, community, family values) to cope with PTSD symptoms.  These findings have direct implications for psychological treatment.

            Cognitive-behavioral interventions have proven to be effective in the treatment of PTSD for other trauma populations (Keane, Fairbank, Caddell, Zimering, & Bender, 1985; Resick, Jordan, Girelli, Hutter, & Marhoefer-Dvorak, 1988), helping patients increase their capacity to tolerate cognitive, affective, and physiological symptoms.  Many cognitive-behavioral interventions for the treatment of PTSD are exposure-based, encouraging survivors to discuss and confront distressing images, places, and situations related to the traumatic event that they avoid.  Although these interventions have proven helpful to alleviate symptoms in sexual assault victims and war veterans, these techniques may be contraindicated for Holocaust survivors who rely heavily on defenses such as suppression and avoidance.  Removing avoidance as a defense mechanism in these victims may leave survivors without an adequate mechanism for coping with their trauma, subsequently increasing their vulnerability to psychopathology.  Cognitive-behavioral coping skills such as relaxation training and rhythmic breathing may be a better choice for treatment if a survivor has partially succeeded in using avoidance to cope.

            Future research could benefit by improving several of the limitations in design and measurement in this study.  Utilizing both a geriatric patient control group and a larger non-PTSD survivor group may allow for increased generalizability of findings.  In addition, although the CAPS assesses for both current and lifetime symptomatology, the instrument does not measure symptomatology from a longitudinal perspective.  Our clinical observations suggest that a subtle bimodal distribution of symptomatology may exist, with the most prominent avoidance symptoms occurring during the initial aftermath (1945-1950) and again later in life (1990-present).

            Assessing the influence of a supportive community and familial environment on the manifestation of symptomatology during the lifespan needs to be more thoroughly assessed.  In addition, examining personality traits as a function of PTSD status may provide insight into predisposing factors for developing emotional disturbances after experiencing traumatic events.  With Holocaust survivors nearing the upper limits of life expectancy, research in this area needs to be conducted as soon as possible.

            Although the generalizability of this study to the population of Holocaust survivors is limited due to a small sample size, these results suggest that a careful assessment of symptomatology throughout the lifespan is needed before treatment is planned or implemented.  In conclusion, the present findings are evidence that Holocaust survivors seeking medical treatment in a family practice setting may experience significant emotional disturbances requiring mental health treatment.  When patients experience a temporary breakdown in their compensatory mechanisms for controlling their PTSD symptoms, targeted mental health treatment may be indicated. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

 

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