Symptoms
Objective: disorder
of PTSD
in 124
Klaus
M.D.,
Survivors (PTSD),
of the
butfew
of 1 24 Jewish
with
Holocaust
med
for explicit
tic criteria. also
German
compared
with percent
average
of
and
78%
organic
the of the
PTSD
Auschwitz
45
of their
brain boards.
survivors total
who
sample
first-degree
had
had
relatives
were
percent ofthe totalsample met the DSM-III-R were sleep disturbance, recurrent nightmares, Auschwitz survivors had significantly more meet
diagnostic
Conclusions: to atrocities.
J
(Am
criteria
for PTSD
The results
suggest
Most
survivors
Psychiatry
1992;
than not
risk
Documentation
is important
A description
of
to our understanding to the care of other
Received
April
25,
late
Psychiatry.
Address
Psychiatry, 1R8, Ont.,
University Canada.
The ported
for
effects
may
received
historical also
of the clinical course persecuted minorities.
1991;
revision
Oct. 10, 1 991 . From the Anxiety reprint
received
Sept.
Disorders
requests
of Toronto,
to Dr.
250
rea-
contribute
of PTSD
I 8, 1991;
and
accepted
Clinic,
Clarke
Institute
of
Kuch,
Clarke
Institute
of
College
psychiatric assessments of the Holocaust by the Consulate General ofthe Federal
St., Toronto
MSP
survivors were supRepublic of Germany,
Toronto.
The
authors thank Dr. Paul of the manuscript.
version
Copyright
Am
J
© 1992
Psychiatry
American
1 49:3,
Garfinkel
Psychiatric
March
to trauma.
syndrome The
according
with not
were
psychiatric tattooed been
detained reported
posttraumatic PTSD
Method:
The
bipolar
from
assessments
files
disorder, those
were
DSM-III-R
identification
in concentration
German
affective
selected to the
stress symptoms
numbers camps.
of 145 reexamdiagnoswere Results:
in concentration camps, and an killed in the Holocaust. Forty-six
who
had
not been
ofchronic
PTSD
adequate
psychiatric
in concentration
in survivors
who
were
camps. exposed
care.
149:337-340)
any survivors of the World War II Nazi concentration camps suffer from chronic psychiatric symptoms (1-8). However, in comparison to Vietnam war veterans, Jewish Holocaust survivors have been virtually neglected by the empirical literature on posttraumatic stress disorder (PTSD). No recent study has explored the full spectrum of their symptoms. The purpose of this study was to describe symptoms of PTSD (DSM-III-R, p. 250) and related phenomena as systematically as possible in a relatively large sample of Jewish Holocaust survivors and to gain an impression of the long-term effects of the concentration sons.
for
investigated
criteria for PTSD. The most common symptoms and intense distress over reminders. The tattooed symptoms and were three times more likely to
M
camps.
M.A.
to be free from
the survivors
a greater
had
been
Cox,
study
symptoms
survivors
of the Holocaust
to be at risk This
judged
were
ofcurrent of2O
expected exposure
who
compensation
descriptions
A subgroup
Sixty-three
well-documented
disorder,
to West
are
J.
Brian
are available.
survivors
obsessive-compulsive applicants
and
Holocaust
empiricaldata
survivors
in Holocaust
Kuch,
Survivors
for his comments
Association.
1992
on an earlier
METHOD The subjects for this study were 124 Jewish survivors of the Holocaust (58 male and 66 female) whose mean age was 62.0 years (SD=9.4, range=39-86). The minimum entrance criterion for the study, criterion A for PTSD in DSM-III-R, was having witnessed atrocities while personally at risk. The subjects were selected out of 145 applicants for German compensation. Because this study was aimed at the symptoms of PTSD, potential subjects with confirmed or suspected organic brain syndrome (N=19), bipolar affective disorder (N=1), and obsessive-compulsive disorder (N=1 ) were excluded. One subject was included in the total sample but excluded from consideration in the subgroups we describe because of a stay in Auschwitz of less than 1 month. The remaining 123 subjects were divided into three groups. 1) One group (N=78) had been detained in various concentration camps for 1 month or more. 2) A subgroup (N=20) ofthe concentration camp group had been detained in one extermination camp (Auschwitz) and had been tattooed on the volar side of their left forearms with identification numbers beginning with the letter A. This subgroup had had particularly well-documented exposure to extreme atrocities and threat of death. 3) A third group (N=4S) had not been in concentration camps. These subjects had been in labor camps and ghettos or had hidden in the illegal un-
337
PTSD
IN SURVIVORS
OF THE
TABLE 1. Frequency
HOLOCAUST
of the DSM-III-R
Symptoms
of PTSD in 124 Holocaust
Survivors Tattooed
Concentration Camp Survivors (N=78)
Total Sample (N=124) Symptom B(1) Intrusive
recollections
B(2) Recurrent
nightmares B(3) Feelings of recurrence B(4) Intense distress over reminders
C(1)
Avoidance
of thoughts
and
C(2) Avoidance ofactivities C(3) Psychogenic amnesia C(4) Diminished
C(S)
interest
Detachment
future
startle response reactivity
D(6) Physiologic
derground. parison
They represented
group
with
%
N
%
69
55.6 83.1 2.4
51
65.4
16
80.0
68 1
87.2 1 .3
18 1
90.0 5.0
48
75.0 38.7
62 38
79.5 48.7
15 9
75.0 45.0
62
50.0
50
64.1
14
70.0
4
3.2
3
3.8
2
10.0
80
64.5
52
66.7
13
65.0
39
31.5
29
37.2
7
35.0
35 33 119 64
28.2 26.6 96.0 51.6 66.9
26 22 77 40 53
33.3 28.2 98.7 51.3
7
35.0
7
35.0
20 10
100.0 50.0
53.2
48
67.9 61.5
15 14
75.0 70.0
13.7 60.5
11 54
14.1 69.2
S 15
25.0 75.0
relatively
17 75
a well-documented less exposure
than the tattooed concentration camp three groups did not differ significantly date of assessment. All
N
83 66
D(4)Hypervigilance
D(S) Exaggerated
%
3 93
and situations
C(6) Restricted affect C(7) Sense of foreshortened D(1) Sleep disturbance D(2) Irritability/anger D(3) Difficulty concentrating
N
103
feelings
com-
to atrocities survivors. The in age, sex, or
124
subjects were seen by the first author for inpsychiatric examinations requested by Gercompensation boards. The examination included
dependent man
a 1-2-hour
psychiatric
compensation psychiatrist
board to record
interview
and
a review
of the
files. It had been the practice of the current symptoms with the assis-
tance
of checklists. He was directed by the guidelines German compensation law (9) to examine exposure to “abuse, characterological sensitization
the West chronic
non-phasic
Concentration Camp Survivors (N=20)
depression. The compensation board files included an affidavit and other documentation of the applicant’s persecution and symptoms well as medical reports submitted by the applicant.
of for and
(SD=1 1 .7, range=1-60). Sixty-seven subjects (54.0%) had been in labor camps (mean=26.S months, SD=14.S, range=2-62); 46 (37.1%) had been in ghettos (mean= 25.7months, SD=12.7, range=2-S2); and 28 (22.6%) had been in hiding (mean=16.6 months, SD=1S.7, range=151 ). These figures are not exclusive, in the sense that concentration camp subjects had also spent time in ghettos and labor camps. On average, 78% of the first-degree relatives ofeach subject were reported killed in the Holocaust. A higher percentage of the first-degree relatives of the tattooed subjects (87.7%) than of the subjects who had not been in concentration camps (76.9%) had been killed (t=1.68, df=58, p
Objective: disorder
of PTSD
in 124
Klaus
M.D.,
Survivors (PTSD),
of the
butfew
of 1 24 Jewish
with
Holocaust
med
for explicit
tic criteria. also
German
compared
with percent
average
of
and
78%
organic
the of the
PTSD
Auschwitz
45
of their
brain boards.
survivors total
who
sample
first-degree
had
had
relatives
were
percent ofthe totalsample met the DSM-III-R were sleep disturbance, recurrent nightmares, Auschwitz survivors had significantly more meet
diagnostic
Conclusions: to atrocities.
J
(Am
criteria
for PTSD
The results
suggest
Most
survivors
Psychiatry
1992;
than not
risk
Documentation
is important
A description
of
to our understanding to the care of other
Received
April
25,
late
Psychiatry.
Address
Psychiatry, 1R8, Ont.,
University Canada.
The ported
for
effects
may
received
historical also
of the clinical course persecuted minorities.
1991;
revision
Oct. 10, 1 991 . From the Anxiety reprint
received
Sept.
Disorders
requests
of Toronto,
to Dr.
250
rea-
contribute
of PTSD
I 8, 1991;
and
accepted
Clinic,
Clarke
Institute
of
Kuch,
Clarke
Institute
of
College
psychiatric assessments of the Holocaust by the Consulate General ofthe Federal
St., Toronto
MSP
survivors were supRepublic of Germany,
Toronto.
The
authors thank Dr. Paul of the manuscript.
version
Copyright
Am
J
© 1992
Psychiatry
American
1 49:3,
Garfinkel
Psychiatric
March
to trauma.
syndrome The
according
with not
were
psychiatric tattooed been
detained reported
posttraumatic PTSD
Method:
The
bipolar
from
assessments
files
disorder, those
were
DSM-III-R
identification
in concentration
German
affective
selected to the
stress symptoms
numbers camps.
of 145 reexamdiagnoswere Results:
in concentration camps, and an killed in the Holocaust. Forty-six
who
had
not been
ofchronic
PTSD
adequate
psychiatric
in concentration
in survivors
who
were
camps. exposed
care.
149:337-340)
any survivors of the World War II Nazi concentration camps suffer from chronic psychiatric symptoms (1-8). However, in comparison to Vietnam war veterans, Jewish Holocaust survivors have been virtually neglected by the empirical literature on posttraumatic stress disorder (PTSD). No recent study has explored the full spectrum of their symptoms. The purpose of this study was to describe symptoms of PTSD (DSM-III-R, p. 250) and related phenomena as systematically as possible in a relatively large sample of Jewish Holocaust survivors and to gain an impression of the long-term effects of the concentration sons.
for
investigated
criteria for PTSD. The most common symptoms and intense distress over reminders. The tattooed symptoms and were three times more likely to
M
camps.
M.A.
to be free from
the survivors
a greater
had
been
Cox,
study
symptoms
survivors
of the Holocaust
to be at risk This
judged
were
ofcurrent of2O
expected exposure
who
compensation
descriptions
A subgroup
Sixty-three
well-documented
disorder,
to West
are
J.
Brian
are available.
survivors
obsessive-compulsive applicants
and
Holocaust
empiricaldata
survivors
in Holocaust
Kuch,
Survivors
for his comments
Association.
1992
on an earlier
METHOD The subjects for this study were 124 Jewish survivors of the Holocaust (58 male and 66 female) whose mean age was 62.0 years (SD=9.4, range=39-86). The minimum entrance criterion for the study, criterion A for PTSD in DSM-III-R, was having witnessed atrocities while personally at risk. The subjects were selected out of 145 applicants for German compensation. Because this study was aimed at the symptoms of PTSD, potential subjects with confirmed or suspected organic brain syndrome (N=19), bipolar affective disorder (N=1), and obsessive-compulsive disorder (N=1 ) were excluded. One subject was included in the total sample but excluded from consideration in the subgroups we describe because of a stay in Auschwitz of less than 1 month. The remaining 123 subjects were divided into three groups. 1) One group (N=78) had been detained in various concentration camps for 1 month or more. 2) A subgroup (N=20) ofthe concentration camp group had been detained in one extermination camp (Auschwitz) and had been tattooed on the volar side of their left forearms with identification numbers beginning with the letter A. This subgroup had had particularly well-documented exposure to extreme atrocities and threat of death. 3) A third group (N=4S) had not been in concentration camps. These subjects had been in labor camps and ghettos or had hidden in the illegal un-
337
PTSD
IN SURVIVORS
OF THE
TABLE 1. Frequency
HOLOCAUST
of the DSM-III-R
Symptoms
of PTSD in 124 Holocaust
Survivors Tattooed
Concentration Camp Survivors (N=78)
Total Sample (N=124) Symptom B(1) Intrusive
recollections
B(2) Recurrent
nightmares B(3) Feelings of recurrence B(4) Intense distress over reminders
C(1)
Avoidance
of thoughts
and
C(2) Avoidance ofactivities C(3) Psychogenic amnesia C(4) Diminished
C(S)
interest
Detachment
future
startle response reactivity
D(6) Physiologic
derground. parison
They represented
group
with
%
N
%
69
55.6 83.1 2.4
51
65.4
16
80.0
68 1
87.2 1 .3
18 1
90.0 5.0
48
75.0 38.7
62 38
79.5 48.7
15 9
75.0 45.0
62
50.0
50
64.1
14
70.0
4
3.2
3
3.8
2
10.0
80
64.5
52
66.7
13
65.0
39
31.5
29
37.2
7
35.0
35 33 119 64
28.2 26.6 96.0 51.6 66.9
26 22 77 40 53
33.3 28.2 98.7 51.3
7
35.0
7
35.0
20 10
100.0 50.0
53.2
48
67.9 61.5
15 14
75.0 70.0
13.7 60.5
11 54
14.1 69.2
S 15
25.0 75.0
relatively
17 75
a well-documented less exposure
than the tattooed concentration camp three groups did not differ significantly date of assessment. All
N
83 66
D(4)Hypervigilance
D(S) Exaggerated
%
3 93
and situations
C(6) Restricted affect C(7) Sense of foreshortened D(1) Sleep disturbance D(2) Irritability/anger D(3) Difficulty concentrating
N
103
feelings
com-
to atrocities survivors. The in age, sex, or
124
subjects were seen by the first author for inpsychiatric examinations requested by Gercompensation boards. The examination included
dependent man
a 1-2-hour
psychiatric
compensation psychiatrist
board to record
interview
and
a review
of the
files. It had been the practice of the current symptoms with the assis-
tance
of checklists. He was directed by the guidelines German compensation law (9) to examine exposure to “abuse, characterological sensitization
the West chronic
non-phasic
Concentration Camp Survivors (N=20)
depression. The compensation board files included an affidavit and other documentation of the applicant’s persecution and symptoms well as medical reports submitted by the applicant.
of for and
(SD=1 1 .7, range=1-60). Sixty-seven subjects (54.0%) had been in labor camps (mean=26.S months, SD=14.S, range=2-62); 46 (37.1%) had been in ghettos (mean= 25.7months, SD=12.7, range=2-S2); and 28 (22.6%) had been in hiding (mean=16.6 months, SD=1S.7, range=151 ). These figures are not exclusive, in the sense that concentration camp subjects had also spent time in ghettos and labor camps. On average, 78% of the first-degree relatives ofeach subject were reported killed in the Holocaust. A higher percentage of the first-degree relatives of the tattooed subjects (87.7%) than of the subjects who had not been in concentration camps (76.9%) had been killed (t=1.68, df=58, p
