Time does not heal all wounds: quality of life and psychological distress of people who survived the holocaust as children 55 years later

The lived experience of surviving from the Islamic State attack and capture in Iraq and Syria: An arts-based qualitative study with Yazidi young women

BACKGROUND

In August 2014, the Islamic State in Iraq and Syria (ISIS) attacked the Sinjar district and destroyed several villages and towns and killed several individuals.

AIM

In this study, the Yazidi young women who survived the ISIS attack were encouraged to express their lived experiences through paintings following participation in a 6-month art-based intervention program.

METHODS

A total of 13 Yazidi Kurdish females aged 18 to 25 years (Mean: 21.7 years) were invited to participate in an art-based (drawing and painting) course for 6 months in 2018. They were invited to draw or paint images that portrayed their lived experiences of attack and capture by the ISIS. Qualitative research situated within feminist methodology was used with the young women in this study. The interviews were analyzed using the descriptive content analysis method.

RESULTS

The paintings and narratives of the participants were constructed into three main themes: fear and traumatic experiences; feeling of hopelessness; and freedom and hope. During the attack and capture, due to the escape, rape, and horrific treatments by the ISIS fighters, the young women were traumatized severely. They were sold as a sex slave by the ISIS fighters. The participants still had severe anxiety and psychological challenges after being free from the capture. However, despite their traumatic experiences and feeling of hopelessness, most of them were hoping for freedom and a better future.

CONCLUSIONS

This study showed that the Yazidi young females still experienced psychological challenges burdens even 3 years after the traumatic day. However, the participants showed their resilience through feeling hopeful for freedom and a better future.

Examining intergenerational transmission of Holocaust trauma as it relates to Jewish identity, communication type, and mental well-being

A growing body of literature has examined how historical trauma can transmit across generations. Within this literature, one's level of enculturation is thought to impact their awareness of historical losses, which, in turn, is hypothesized to relate to mental well-being. Some studies have suggested that family communication about historical trauma can impact the strength of cultural identity and mental well-being. The current study sampled second- and third-generation Holocaust survivors to examine how family communication about the Holocaust relates to historical loss awareness and the strength of Jewish identity. Adults (N = 98) with relatives who had either been killed in or who survived the Holocaust completed online questionnaires. First, we examined the associations among Jewish identity, historical loss awareness, and family communication about the Holocaust. Next, we examined whether Holocaust-related family communication type predicted mental well-being. Healthy communication was classified as frequent and willing, and unhealthy communication was classified as indirect and guilt-inducing. Multiple linear regression analyses indicated that stronger Jewish identity and more frequent family Holocaust communication predicted more historical loss awareness, R² = .22. Unhealthy communication was related to poorer mental well-being, R² = .09, lending support to the idea that family narratives about trauma impact the next generation. Implications for healing from historical trauma are discussed.

Families With Violence Exposure and the Intergenerational Transmission of Somatization

INTRODUCTION

Adults who have histories of childhood trauma have been noted to display greater somatization, dissociative symptoms and affect dysregulation. What happens in the parent-child relationship when those traumatized children become parents? A potential link to somatization in the child has been suggested by several prior studies. Children who have early attachment disturbances had more physical complaints if their mothers displayed less maternal sensitivity during observed parent-child interactions. Yet, the intergenerational link between maternal and child somatization has not been sufficiently explored in a longitudinal study in order to understand the potential impact of maternal trauma history and related psychopathology on subsequent child somatization and psychopathology.

METHODS

This paper examined prospective, longitudinal data of 64 mother-toddler dyads (mean age = 2.4 years, SD = 0.7) who were later studied when children had a mean age of 7 years. Mothers with and without histories of interpersonal violence (IPV; physical/sexual abuse and/or family violence exposure) were included. Mothers with IPV histories were oversampled. Linear and Poisson regression models were used to test the associations between maternal IPV-related post-traumatic stress disorder (PTSD) with maternal somatization severity when children were toddlers, and between maternal somatization and maternal interactive behaviors with child somatization by maternal report and clinician-rated assessment at school-age.

RESULTS

Maternal PTSD severity was significantly associated with increased maternal somatization severity (p = 0.031). Maternal somatization severity during the child's early childhood predicted both maternal report of child somatization (p = 0.011) as well as child thought problems (p = 0.007) when children were school-aged. No association was found between maternal somatization and child-reported psychopathology. The study did not find that maternal alexithymia, caregiving behaviors or child exposure to violence contributed significantly to the model examining the association between maternal and child somatization.

CONCLUSION

The results are in line with the hypothesis of intergenerational transmission of somatization in the context of IPV and related maternal PTSD during formative early development. We interpret this as an expression of psychological distress from mother to child, as maternal trauma and pathology affect the caregiving environment and, thus, the parent-child relationship. The authors conclude with a discussion of implications for parent-infant and early childhood intervention.

Factors Associated With Health-Related Quality of Life Among Older People Exposed to the Jeju 4·3 Incident

OBJECTIVE

We explored factors associated with health-related quality of life (HRQOL), including socio-demographic and clinical characteristics, in among older people exposed to the Jeju 4·3 incident, and aimed to determine the effects of depression, posttraumatic stress disorder (PTSD) and perceived social support on HRQOL.

METHODS

We obtained data from 110 survivors and 1,011 immediate family members of the victims of the Jeju April 3 incident (mean age, 75.1 years), and evaluated the relationships of HRQOL with sociodemographic and clinical characteristics including posttraumatic and depressive symptoms, and perceived social support.

RESULTS

Poorer physical health, psychological health, social relationships, and environment HRQOL domain scores were strongly associated with older age, being a woman, poor socioeconomic status, and symptoms of depression and PTSD. The regression analyses indicated that, when relevant factors were controlled for, perceived social support moderated the negative association between HRQOL and psychiatric symptoms.

CONCLUSION

Our results suggest the importance of sociodemographic characteristics, in addition to psychiatric symptoms, for understanding HRQOL in older people exposed to the Jeju 4·3 incident. These results have important implications for interventions aiming to improve the HRQOL of the victims of the Jeju 4·3 incident.

The Relationship of Race, Psychosocial Stress and Resiliency Indicators to Neurocognitive Impairment among Older Americans Enrolled in the Health and Retirement Survey: A Cross-Sectional Study

Background: Race/ethnicity, toxic stress (TS), resilience-promoting factors (RPFs), and their interactions were investigated in relationship to neurocognitive impairment (NI) in a nationally representative sample of adult Americans ≥50 years enrolled in the Health and Retirement Study (HRS) between 2012 and 2014. Methods: NI was defined as physician diagnosis of Alzheimer’s disease/dementia or HRS total cognition score ≤ 10. Race/ethnicity (i.e., African American, White, or Other), TS (i.e., everyday discrimination and chronic stressors), and mastery (as indicator of RPF) were self-reported. Multivariable logistic regression models estimated race-, TS-, RPF-associated odds ratios (ORs), and 95% confidence intervals (CI) for NI adjusting for socio-demographic confounders. Results: 6317 respondents interviewed between the years 2012 and 2014, age range 55–104 years old, 83% White, 13% Black and 4% Other race were included in the study. Chronic stress (OR = 1.88, 95% CI: 1.42–2.48), discrimination (OR = 3.31, 95% CI: 2.12–5.19) and low mastery (OR = 1.85, 95% CI: 1.38–2.48) were each associated with higher NI risk while low mastery was associated with higher NI risk in discrimination and race/ethnicity dependent manner. Specifically, low mastery-associated risk for NI was evident among adults that denied experiencing discrimination (OR = 2.01, 95% CI: 1.51–2.68), but absent among those that experienced discrimination (OR = 0.72, 95% CI: 0.32–1.62). Further, AA race was associated with NI risk but only among adults with high mastery (OR = 2.00, 95% CI: 1.20–3.35). Conclusions: Discrimination, chronic stress, and low mastery were associated with worse cognition. Persisting cognitive disadvantage for AA vs. White/Other race only among high mastery adults suggests that adverse social experiences may counteract mastery-associated cognitive benefits among AA population. TS reduction through policies that promote equal treatment by race/ethnicity in social life, health, justice, and economic systems may promote successful cognitive aging.

The long-term effects of early-life trauma on psychological, physical and physiological health among the elderly: the study of Holocaust survivors

Objectives: To study post-traumatic stress symptoms and post-traumatic growth and heart rate variability among elderly Holocaust survivors and a matched comparison group and the mediational effect of post-traumatic stress symptoms and post-traumatic growth on the association between Holocaust experience and heart rate variability. Method: 159 Holocaust survivors and 87 matched participants without Holocaust experience answered post-traumatic stress symptoms and post-traumatic growth questionnaires. Heart rate variability time and frequency parameters were measured for a subsample of N = 133. Results: Holocaust survivors reported higher levels of post-traumatic stress symptoms and post-traumatic growth. Most heart rate variability measures were similar in the two groups, except for better heart rate variability measured by the ratio of low frequency/high frequency among Holocaust survivors. Structural equation modeling showed that belonging to the Holocaust survivor group was associated with higher post-traumatic stress symptoms and higher post-traumatic growth, as well as better heart rate variability scores (standard deviation of normal to normal R-R intervals, high frequency and the ratio of low frequency/high frequency) through the mediation of post-traumatic stress symptoms and post-traumatic growth. Conclusions: The study emphasized the duality of the association between post-traumatic stress symptoms and post-traumatic growth and their integrated effect on heart rate variability.

Caring for older people with dementia reliving past trauma

BACKGROUND

The occurrence of behavioural changes and problems, and degree of paranoid thoughts, are significantly higher among people who have experienced extreme trauma such as during the Holocaust. People with dementia and traumatic past experiences may have flashbacks reminding them of these experiences, which is of relevance in caring situations. In nursing homes for people with dementia, nursing assistants are often the group of staff who provide help with personal needs. They have firsthand experience of care and managing the devastating outcomes of inadequate understanding of a person's past experiences.

AIM

The aim was to describe nursing assistants' experiences of caring for older people with dementia who have experienced Holocaust trauma.

RESEARCH DESIGN

A qualitative descriptive and inductive approach was used, including qualitative interviews and content analysis.

PARTICIPANTS AND RESEARCH CONTEXT

Nine nursing assistants from a Jewish nursing home were interviewed.

ETHICAL CONSIDERATIONS

The study was approved by the Regional Ethical Review Board, Stockholm.

FINDINGS

The theme 'Adapting and following the survivors' expression of their situation' was built on two categories: Knowing the life story enables adjustments in the care and Need for flexibility in managing emotional expressions.

DISCUSSION AND CONCLUSION

The world still witnesses genocidal violence and such traumatic experiences will therefore be reflected in different ways when caring for survivors with dementia in the future. Person-centred care and an awareness of the meaning of being a survivor of severe trauma make it possible to avoid negative triggers, and confirm emotions and comfort people during negative flashbacks in caring situations and environments. Nursing assistants' patience and empathy were supported by a wider understanding of the behaviour of people with dementia who have survived trauma.

Psychopathology and Quality of Life in Traumatized or Victimized Underage Individuals as Factors for Forensic Multilevel Assessment-A Pilot Investigation

Background: Psychological sequels to criminal violence can be long lasting and severe. They are in many countries not sufficiently considered in court cases as an important circumstance that could be used to assess the severity of the crime, also guiding redress, compensation, and rehabilitation of the victim, and-in children-child custody considerations. So far, the focus of forensic assessment has often been limited to diagnostic categories, especially "posttraumatic stress disorder" (PTSD), a diagnosis that presently is subjected to rapidly changing definitions both in and between diagnostic systems. Other indicators such as quality of life (QoL) might be of equal importance as compared to clinical or research diagnostic categories to understand and evaluate the impact of a crime and the amount of help needed and, in the legal context, redress to be asked. Symptoms might differ depending on the crime encountered. Objective and Methods: QoL and general symptom patterns including a PTSD diagnosis were assessed in a group of 10- to 17-year-old minors with (n = 33) and without (n = 49) PTSD diagnosis who all had experienced sexual abuse, physical abuse, death of a parent, or their parents' divorce, using standardized diagnostic instruments. Results: PTSD patients reported a significantly lower QoL than non-PTSD controls. Reported symptom patterns with potential impact on life, such as intrusive thoughts, differed between the victims of different crime types, with the highest rates of both intrusive symptoms and combined symptom profile in victims of sexual abuse. Data indicate that the changes between older and present criteria and between DSM and recently published ICD 11 might help identify different groups and symptom profiles. Conclusion: Specific trauma-related symptom profiles integrating the type of crime encountered and its individual impact on QoL may help improve future forensic assessment and guide compensation and rehabilitation plans. Carefully designed studies are now needed to further explore the use and forensic usability of complex indicators and the impact of violence in different forensic settings.

Rehabilitation for Survivors of the 1994 Genocide in Rwanda: What Are the Lessons Learned?

Rehabilitation remains a significant concern among survivors of the 1994 genocide in Rwanda. Rehabilitation falls under tertiary prevention, which is a core function of public health. Despite efforts to introduce various rehabilitation programmes for genocide survivors in Rwanda, these initiatives have often proved inadequate in meeting their long-term needs. The failure of the Rwandan Government, international community, United Nations, and other Non-Government Organisations (NGOs) calls into serious question their commitment to international human rights laws. Rehabilitation should be regarded as a free-standing human right for genocide survivors and a human rights-based approach to the rehabilitative process should incorporate measurable outcomes based on an agreed ethical framework. The author calls upon the international community to reiterate its concerns about genocide survivors and reaffirm its commitments to human rights. The main issues discussed in this article are: the long-term needs of survivors of the 1994 genocide; what is already provided, and the gaps; how Stucki's Rehabilitation Cycle framework (a problem-solving tool) can help improve current provision; the role of the international community, NGOs, and genocide survivors' organisations in advancing rehabilitation; and the need for a human rights-based approach to rehabilitation. A strong recognition of the right to rehabilitation is crucial. An ethical framework related to the human rights-based approach should also assist in setting outcomes that can be measured against agreed standards, ensuring: rights that have been violated are identified; the accountability of each service provider in promoting rehabilitation; rehabilitation which is inclusive and non-discriminatory; participation by encouraging collaboration with survivors rather than doing things for them; and empowerment by enabling survivors to understand their rights and have the confidence to challenge or question when their rights have been violated.

Childhood trauma and resilience in old age: applying a context model of resilience to a sample of former indentured child laborers

OBJECTIVES

Psychological resilience has been rarely investigated in elderly populations. We applied a more comprehensive model of trauma-specific coping and resilience, which included Ungar's context model and included decentral factors of resilience (i.e., environments that provide resources to build resilience).

METHOD

We assessed resilience in a cohort of former Swiss indentured child laborers (N = 74; 59% males) at two time points; first at the mean age of 80 years and then again 20 months later. At each time point, the following measures of resilience were assessed: resilience indicators of life satisfaction and lack of depression. In addition, resilience predictors of trauma exposure, perceived social support, dysfunctional disclosure of traumatic experiences, social acknowledgment as a victim, and self-efficacy; and decentral resilience factors of education, income, number of children, and physical health were measured.

RESULTS

Using path-analysis, we found that life satisfaction and lack of depression were predicted by dysfunctional disclosure, social support, and self-efficacy at various significance levels. Change scores of resilience were predicted by higher trauma exposure, social acknowledgment as a victim, and an interaction between the two. The model for decentral factors also fitted, with physical health and income predicting the resilience indicators.

CONCLUSION

Applying this comprehensive resilience model in a sample of older adults revealed meaningful findings in predicting resilience at a single time point and over time. Atypical coping strategies, such as perceived social acknowledgment as a victim and disclosure, may be particularly important for former victims who have suffered institutional abuse.

Lifetime history of traumatic events in a young adult Mexican American sample: Relation to substance dependence, affective disorder, acculturation stress, and PTSD

Mexican Americans comprise one of the most rapidly growing populations in the United States, and within this population, trauma and post-traumatic stress disorder (PTSD) are associated with physical and mental health problems. Therefore, efforts to delineate factors that may uniquely contribute to increased likelihood of trauma, PTSD, and substance use disorders over the lifetime in Mexican Americans are important to address health disparities and to develop treatment and prevention programs. Six hundred fourteen young adults (age 18-30 yrs) of Mexican American heritage, largely second generation, were recruited from the community and assessed with the Semi-Structured Assessment for the Genetics of Alcoholism and an acculturation stress scale. More males (51.2%) reported experiencing traumas than females (41.1%), however, a larger proportion of females received a PTSD diagnosis (15%) than males (8%). Alcohol dependence and affective disorders, but not anxiety disorders, antisocial disorders, nicotine, marijuana, or stimulant dependence, were significantly comorbid with PTSD. Endorsing higher levels of acculturation stress was also significantly associated with both trauma exposure and a diagnosis of PTSD. Logistic regression revealed that female gender, having an affective disorder, alcohol dependence, higher levels of acculturation stress, and lower levels of education were all predictors of PTSD status. Additionally, alcohol dependence generally occurred after the PTSD diagnosis in early adulthood in this high-risk population. These studies suggest that treatment and prevention efforts should particularly focus on young adult second generation Mexican American women with higher levels of acculturation stress, who may be at higher risk for PTSD, affective disorder, and alcohol dependence following trauma exposure.

Developmental Origins of Health and Disease - from a small body size at birth to epigenetics

The Developmental Origins of Health and Disease (DOHaD) hypothesis proposes that several non-communicable diseases have their origins in prenatal life and in early childhood. This is believed to work through programming, an insult, taking place at a sensitive period of development, may have lifelong consequences, increasing and programming disease risk later in life. The Helsinki Birth Cohort Study (HBCS) has been focusing upon the importance of factors active during periods in early life and their influence on later health in 20,431 people born 1924-44. This review will focus upon findings from the HBCS over the past 20 years. Early growth patterns associated with coronary heart disease, type 2 diabetes and other health outcomes are described. The long-term health impact of maternal adiposity is also discussed. Potential underlying mechanisms explaining the associations are discussed including epigenetic factors. Key messages Several non-communicable diseases - including coronary heart disease and type 2 diabetes - have their origins in early life. Early life programming during sensitive periods of development may permanently program future health and disease risk. Optimizing the health and lifestyle of women of reproductive age will have positive health consequences for their offspring.

Exploring communication of traumatic experiences from Khmer Rouge genocide survivors to their offspring: In-depth interviews with both generations

BACKGROUND

Traumatic events experienced by parents who have survived genocide influence mental health among their offspring. This study aims at exploring how the communication of traumatic events between Khmer Rouge survivors and their offspring was perceived by both generations.

METHODS

Qualitative interviews were performed with six Khmer Rouge survivors and with six young people representing the second generation and were analysed using a content analysis approach.

DISCUSSION

Parents felt that informing their children was important to instill gratitude for living a better life and to empower them. Among children, this was met with empathy but sometimes also disbelief and at times they blamed their parents for being too submissive.

CONCLUSION

The study discloses the complexity, pros and cons of intergenerational sharing of trauma.

Enhancing the lives of older refugees: an evaluation of a training resource

BACKGROUND

Resources and training for aged care workers who are working with older people from refugee backgrounds are limited. Thus, a resource titled 'Enhancing the Lives of Older Refugees: A self-Improvement Resource for Community Service Providers' was developed in 2011, and later accompanied by a training program developed in 2012. The aim of the resource and accompanying training was to assist community aged care service providers, based in South Western Sydney and surrounding areas, to recognise an older refugee, increase their knowledge and skills in working with older refugees, have a greater understanding of older refugees' life experiences, and provide additional information that would allow them to offer appropriate services to those in their care. This paper reports on the evaluation of the training package provided to community aged care personnel.

METHODS

Eleven training sessions were conducted with all participants invited to take part in the research. One hundred and twenty-eight consenting participants completed a pre and post training evaluation questionnaire.

RESULTS

Analysis of the data indicated a positive change in participant's ability to define an older refugee, understanding older refugee's life experiences, loss and grief, the impact of the refugees' experience in old age and the capacity to locate and access information to support the care of older refugees.

CONCLUSIONS

The findings lend support that this mode of training can provide information and resources to increase the capacity of aged care workers to better meet the needs of older people from a refugee background.

Young adults with developmental coordination disorder: a longitudinal study

We conducted a longitudinal study to assess the continuing influence of developmental coordination disorder (DCD) on quality of life and participation. Ninety-six participants (25 in the DCD group, 30 in the borderline group, and 41 in the control group) ages 22-29 yr who had been screened for DCD 3-4 yr previously completed the Participation in Every Day Activities of Life, the Life-Satisfaction Questionnaire, and the World Health Organization Quality of Life (WHOQOL-BREF) instrument. Multivariate analysis of variance revealed a significant between-groups difference, F(7, 95) = 2.89, p = .001, η = 0.173, and post hoc analyses revealed that participants in the DCD and borderline groups scored lower overall on participation, quality of life, and life satisfaction. Linear regression found the Psychological Health domain of the WHOQOL-BREF to be a significant predictor of life satisfaction (B = 0.533; p = .001).

Effects of evacuation in late adulthood: analyzing psychosocial well-being in three cluster groups of Finnish evacuees and non-evacuees

OBJECTIVES

We studied the long-term effects of early separation among aging Finnish evacuees and non-evacuees. A broad set of outcome variables reflecting the psychosocial well-being of both groups in 2005 was analyzed. The role of resilience was also analyzed.

METHOD

To identify persons with similar patterns of psychosocial well-being among both evacuated (n = 887) and non-evacuated persons (n = 1748), a cluster analysis was conducted, using the mixture model of latent class analysis/latent profile analysis method. The psychosocial well-being of the evacuees and non-evacuees in 2005 was predicted by multinomial logistic regression analysis, with the nominal cluster variable as the dependent variable.

RESULTS

Although the evacuees had experienced early separation trauma, they were not faring worse than the non-evacuees regarding psychosocial well-being in 2005. Favorable rearing home circumstances are a protective factor during the entire life span, when the psychosocial well-being of both groups was predicted in 2005. Sense of coherence was a significant predictor of psychosocial well-being. To rejoin the rearing family was stressful for many evacuees.

CONCLUSION

The results show that even long-term separation from one's parents during childhood must be understood as representing a developmental context which makes the emergence of problems either less likely or more likely, depending on other risk and protective factors in both the rearing home and the foster family. After the war, when the evacuees returned home the families should have received help and support to amend the reunion.

Integrative testimonial therapy: an Internet-based, therapist-assisted therapy for German elderly survivors of the World War II with posttraumatic stress symptoms

Trauma-focused cognitive behavioral treatments are known to be effective for posttraumatic stress disorder (PTSD) in adults. However, evidence for effective treatments for older persons with PTSD, particularly elderly war trauma survivors, is scarce. In an open trial, 30 survivors of World War II aged 65 to 85 years (mean, 71.73 years; SD, 4.8; n = 17 women) with PTSD symptoms were treated with a Web-based, therapist-assisted cognitive-behavioral/narrative therapy for 6 weeks. Intent-to-treat analyses revealed a significant decrease in PTSD severity scores (Cohen's d = 0.43) and significant improvements on secondary clinical outcomes of quality of life, self-efficacy, and posttraumatic growth from pretreatment to posttreatment. All improvements were maintained at a 3-month follow-up. The attrition rate was low (13.3%), with participants who completed the trial reporting high working alliance and treatment satisfaction. Results of this study suggest that integrative testimonial therapy is a well accepted and potentially effective treatment for older war trauma survivors experiencing PTSD symptoms.

Lifetime history of traumatic events in an American Indian community sample: heritability and relation to substance dependence, affective disorder, conduct disorder and PTSD

American Indians appear to experience a higher rate of traumatic events than what has been reported in general population surveys. American Indians also suffer higher alcohol related death rates than any other ethnic group in the U.S. population. Therefore efforts to delineate factors which may uniquely contribute to increased likelihood of trauma, post traumatic stress disorder (PTSD), and substance use disorders (SUD) over the lifetime in American Indians are important because of the high burden of morbidity and mortality that they pose to American Indian communities. Participants were American Indians recruited from reservations that were assessed with the Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA), family history assessment and the stressful-life-events scale. Of the 309 participants, equivalent numbers of men and women (94%) reported experiencing traumas; however, a larger proportion of women received a PTSD diagnosis (38%) than men (29%). Having experienced multiple trauma and sexual abuse were most highly associated with PTSD. Having experienced assaultive trauma and having PTSD symptoms were both found to be moderately heritable (30-50%). Logistic regression revealed that having an anxiety and/or affective disorder and having a substance dependent diagnosis, but not having antisocial personality disorder/conduct disorder, were significantly correlated with having a diagnosis of PTSD. These studies suggest that trauma is highly prevalent in this American Indian community, it is heritable, is associated with PTSD, affective/anxiety disorders and substance dependence. Additionally, trauma, PTSD and substance dependence appear to all co-emerge in early adulthood in this high-risk population.

Experiences of ageing and aged care in Australia of older survivors of genocide

This qualitative study investigated the ageing and aged care experiences in Australia of two cohorts of older survivors of genocide: Jewish Holocaust survivors and older Cambodian genocide survivors. It was carried out in response to an identified need to better train aged care workers who are in contact with these groups. In-depth interviews were conducted with 21 community-dwelling survivors aged 65 and over. Credibility was ensured by methodological triangulation and peer debriefing. The study highlighted the importance of understanding older survivors’ ageing and aged care experiences in the context of their entire lifecourse and in terms of both vulnerability and resilience. It showed that trauma history can heighten older survivors’ sensitivity to many aspects of the social and physical environments in residential, community and home-based aged care settings. The study also uncovered the potential for aged care services to help older survivors cope with the psycho-social and emotional effects of resurfacing post-traumatic stress symptoms. The implications of the study findings for care practice include the importance of recognising older survivors of genocide as a distinct group of clients and the need to distinguish staff training for caring for this client group from general cultural awareness training.

Somatic diseases in child survivors of the Holocaust with posttraumatic stress disorder: a comparative study

The incidence of mental and somatic sequelae has been shown to be very high in people who survived the Holocaust. In the current study, 80 Holocaust survivors with posttraumatic stress disorder were examined based on evaluation of their complete record (medical reports, clinical history, medical statements, and handwritten declarations of patients under oath). These survivors were compared with subjects with posttraumatic stress disorder caused by traumata other than the Holocaust. The data were analyzed for the presence of cardiovascular, gastrointestinal, and orthopedic diseases that developed in the time between the earliest medical report (expert opinion) and the latest expert opinion. Analysis revealed an increase in myocardial infarction, chronic degenerative diseases, and cancerous changes in the second expert opinion. No differences between the groups were seen with regard to sex, age at traumatization, or age at examination. Several implications of the data are discussed, including the implication that the survivors examined in this study may comprise a highly resilient group, inasmuch as they had reached an advanced age.

Attachment and coping as facilitators of posttraumatic growth in Turkish university students experiencing traumatic events

This study was designed to explore the role of attachment and coping as facilitators of posttraumatic growth (PTG) in a sample of Turkish university students who experienced traumatic life events. Participants who reported a traumatic event from a list were asked to choose the most distressing one; to answer questions related to the impact of the trauma; and to fill out measures of attachment styles, ways of coping, and PTG. PTG was regressed on gender, trauma-related factors, attachment styles, and coping styles in order to examine the associations with PTG. Felt helplessness and horror, fatalistic coping, and optimistic coping were significant predictors of PTG. Fatalistic coping partially mediated the relationship between attachment anxiety and PTG.

Disaster survivors in their third decade: trajectories of initial stress responses and long-term course of mental health

This study analyzed trajectories of initial stress and long-term mental health after the 1980 North Sea oil rig disaster. A growth-mixture model of the survivors' stress manifestations in the first 8 weeks (Posttraumatic Stress Scale, [PTSS-10]) and general mental health in 1980, 1981, 1985, and 2007 (General Health Questionnaire, [GHQ-20]) was estimated. Survivors' GHQ-scores in 1985 and 2007 were contrasted to those of a comparison group. Four trajectories were identified among survivors. The resilient (n = 43) displayed initially moderate stress that rapidly declined. The recovery (n = 10), chronic (n = 8), and relapse (n = 9) showed initially stable high stress scores, but the long-term mental health differed. Early screening may identify those at long-term risk.

Expecting a good quality of life in health: assessing people with diverse diseases and conditions using the WHOQOL-BREF

BACKGROUND AND OBJECTIVES

Fulfilling patient expectations is central to defining a good quality of life (QoL) in health. The WHOQOL-BREF was developed using novel, person-centred methods and is a generic patient-reported outcomes measure (PROM). However, without robust psychometric performance, PROMs cannot be relied upon to assess individuals. This study investigated the WHOQOL-BREF (UK), with this use in mind.

DESIGN

Cross sectional with nested repeated measures.

SETTING AND PARTICIPANTS

Twenty-seven disease groups or health conditions and healthy people were recruited at 38 UK sites, in a wide range of settings (n = 4628).

INTERVENTIONS

'Treatment as usual'; new and alternative interventions.

OUTCOME MEASURES

WHOQOL-BREF (UK); SF-36.

RESULTS

Respondent burden was low, as acceptability and feasibility were high. Internal consistency was excellent (0.92) and test-retest reliability good. Distinctive QoL profiles were found for diverse conditions. Musculoskeletal, psychiatric and cardiovascular patients reported the poorest QoL and also improved most during treatment. Overall, QoL was good, and best for healthy groups, supporting discriminant validity. Compared with the SF-36, WHOQOL physical and psychological domains showed good concurrent validity, although social was weak. Small or moderate effect sizes confirmed responsiveness to change in specified domains for certain conditions and interventions. Age had a small impact on reporting QoL.

DISCUSSION AND CONCLUSION

The WHOQOL-BREF is found to be a high quality patient-centred generic tool suited to individual assessment in clinics, for research, and audit.

Rates of trauma spectrum disorders and risks of posttraumatic stress disorder in a sample of orphaned and widowed genocide survivors

BACKGROUND

During the Rwandan genocide of 1994, nearly one million people were killed within a period of 3 months.

OBJECTIVE

The objectives of this study were to investigate the levels of trauma exposure and the rates of mental health disorders and to describe risk factors of posttraumatic stress reactions in Rwandan widows and orphans who had been exposed to the genocide.

DESIGN

Trained local psychologists interviewed orphans (n=206) and widows (n=194). We used the PSS-I to assess posttraumatic stress disorder (PTSD), the Hopkins Symptom Checklist to assess depression and anxiety symptoms, and the M.I.N.I. to assess risk of suicidality.

RESULTS

Subjects reported having been exposed to a high number of different types of traumatic events with a mean of 11 for both groups. Widows displayed more severe mental health problems than orphans: 41% of the widows (compared to 29% of the orphans) met symptom criteria for PTSD and a substantial proportion of widows suffered from clinically significant depression (48% versus 34%) and anxiety symptoms (59% versus 42%) even 13 years after the genocide. Over one-third of respondents of both groups were classified as suicidal (38% versus 39%). Regression analysis indicated that PTSD severity was predicted mainly by cumulative exposure to traumatic stressors and by poor physical health status. In contrast, the importance given to religious/spiritual beliefs and economic variables did not correlate with symptoms of PTSD.

CONCLUSIONS

While a significant portion of widows and orphans continues to display severe posttraumatic stress reactions, widows seem to constitute a particularly vulnerable survivor group. Our results point to the chronicity of mental health problems in this population and show that PTSD may endure over time if not addressed by clinical intervention. Possible implications of poor mental health and the need for psychological intervention are discussed.

Psychiatric disorders and other health dimensions among Holocaust survivors 6 decades later

BACKGROUND

No previous community-based epidemiological study has explored psychiatric disorders among those who survived the Holocaust.

AIMS

To examine anxiety and depressive disorders, sleep disturbances, other health problems and use of services among individuals exposed and unexposed to the Holocaust.

METHOD

The relevant population samples were part of the Israel World Mental Health Survey. The interview schedule included the Composite International Diagnostic Interview and other health-related items.

RESULTS

The Holocaust survivor group had higher lifetime (16.1%; OR = 6.8, 95% CI 1.9-24.2) and 12-month (6.9%; OR = 22.5, 95% CI 2.5-204.8) prevalence rates of anxiety disorders, and more current sleep disturbances (62.4%; OR = 2.5, 95% CI 1.4-4.4) and emotional distress (P<0.001) than their counterparts, but did not have higher rates of depressive disorders or post-traumatic stress disorder.

CONCLUSIONS

Early severe adversity was associated with psychopathological disorder long after the end of the Second World War, but not in all survivors. Age during the Holocaust did not modify the results.

Sense of coherence moderates late effects of early childhood Holocaust exposure

This study evaluated child Holocaust survivors with an emphasis on potential protective factors facilitating participants' adaptation to post-Holocaust life. We examined Antonovsky's (1979, 1987) salutogenic paradigm, testing the mediating and moderating effect of participants' sense of coherence (SOC) on the association between early childhood deprivation due to Holocaust persecution and posttraumatic stress later in life. The nonclinical sample, composed of 203 child Holocaust survivors born between 1935 and 1944 completed questionnaires on Holocaust survival exposure, inventories on current health, posttraumatic stress, and SOC. The results indicated that SOC moderates the association between traumatic experiences during the war and posttraumatic stress, and SOC acts as a protective factor, buffering the impact of traumatic Holocaust experiences on child survivors in old age. Survivors with a less coherent perspective on the meaning of their life showed greater vulnerability for posttraumatic complaints. The moderating role of the SOC may suggest promising avenues of therapeutic interventions for child Holocaust survivors and other adults with early childhood trauma.

Posttraumatic Stress Disorder and Older Women

This article examines the literature related to the identification and treatment of post traumatic stress disorder in older women. From this review, several key findings emerge. Consistent in the research literature is the fact that American women are more at risk for PTSD than are men as a result of the high frequency of sexual and domestic physical abuse that women experience. Studies on older women and PTSD indicate that older women are underdiagnosed and are more typically perceived as suffering from depression, anxiety or poor physical health. It was found consistently that older women who present with age-related stressors may not be asked about earlier trauma history or it may not be understood within the context of trauma related variables. In several research studies, trauma history was often not identified either as a result of current assessment practice or because women from certain age cohorts did not disclose trauma-related data to health professionals. Key researchers emphasize the necessity of clinicians, staff and medical personnel to attend to the historical variables present in trauma histories of older women. Researchers underscore the importance of understanding the impact of early and repeated trauma, especially interpersonal trauma, on the physical health and social functioning of older women- even though a significant amount of time may have elapsed since exposure. These findings indicate that further study of PTSD in older women is warranted. The paper concludes with a discussion of assessment and treatment options.

Understanding Native women's health: historical legacies

PURPOSE

Theoretical underpinnings of two theories are examined for their applicability in guiding practice and research when understanding Native American women's health outcomes.

METHOD

Published studies testing two independent theories, historical trauma and weathering, are reviewed. Key theoretical concepts that are applicable in the study of Native women and understanding their intergenerational heritage of injustice and cultural context are discussed.

RESULTS

The authors infer underlying assumptions and definitions of both theories and present a hypothetical diagram blending both theories.

CONCLUSION

By understanding historical legacies and the surrounding context, researchers and clinicians can develop knowledge to improve and enhance optimal health outcomes and life opportunities for Native women.

Diurnal cortisol patterns and stress reactivity in child Holocaust survivors reaching old age

OBJECTIVES

Late-life implications of early traumatic stress for the adreno-cortical system were examined in a sample of 133 child survivors of the Holocaust, who were subjected to Nazi persecution during infancy.

METHOD

In a non-convenience sample of child survivors, born between 1935 and 1944, basal circadian cortisol release and cortisol reactivity to a stressor were assessed.

RESULTS

Age, parental loss during the Holocaust, current depression, post-traumatic stress disorder (PTSD) and physical illness were not associated with differences in basal diurnal cortisol levels. Neuro-endocrine effects, however, were found in stress reactivity through elevated cortisol levels in male respondents in the youngest age group (born 1941-1945), and in male respondents suffering from PTSD-related functional impairment.

CONCLUSION

The youngest survivors of Nazi persecution show late-life effects of traumatic stress during early childhood, evidenced by the early onset of differential neuroendocrine pathways to stress-regulating strategies.

Life trajectories of female child abuse survivors thriving in adulthood

A narrative study of thriving adult female survivors of childhood maltreatment was undertaken to discover how they had achieved success. Life trajectory patterns, turning points, and setbacks were identified. Data consisted of 81 interview transcripts derived from a series of three interviews, spaced over 6 to 12 months, with 27 survivors. The childhood abuse was intrafamilial, beginning as early as infancy and continuing, in most cases, until participants left home. The onset and pace of the healing trajectory were quite variable, including a roller-coaster pattern as well as patterns of slow, steady progress and continued struggle. Four types of redemption narratives were delineated. Survivors had not been spared depression but had made achievements in work and education and displayed remarkable generativity, parenting their own children well, and mentoring other young girls, especially victims of abuse.

Mental distress in the Danish general population

OBJECTIVE

To present data on mental distress in the Danish general population using recently validated Hopkins symptom checklist (SCL) subscales and compare with data from other countries. To evaluate associations between mental distress and biopsychosocial factors.

METHOD

Questionnaires were sent to a gender- and age-stratified random sample comprising 2040 Danes. Mean SCL subscale scores were calculated. Cases were defined in accordance with the traditional criteria, and Danish and US raw score cut-offs were compared. A multiple regression model was developed to describe associations between biopsychosocial factors and SCL scores.

RESULTS

The response rate was 58%. The Danish mean scores were significantly higher than reported for a US non-patient sample, and Danish raw score cut-offs for caseness were higher. The Danish scores were closer to Nordic mean scores. Age, gender, social status, somatic disorder and traumatic life events in the past year in work life as well as personal life were significantly associated with the level of mental distress. SCL scores were compared with scores on the Major Depression Inventory.

CONCLUSION

The SCL mean scores of the Danish general population were relatively high, but similar to data from the Nordic countries. Consequently, interpretation of the Danish SCL requires Danish norms and Danish cut-off scores for caseness.

Flashbulb memories and posttraumatic stress reactions across the life span: age-related effects of the German occupation of Denmark during World War II

A representative sample of older Danes were interviewed about experiences from the German occupation of Denmark in World War II. The number of participants with flashbulb memories for the German invasion (1940) and capitulation (1945) increased with participants' age at the time of the events up to age 8. Among participants under 8 years at the time of their most traumatic event, age at the time correlated positively with the current level of posttraumatic stress reactions and the vividness of stressful memories and their centrality to life story and identity. These findings were replicated in Study 2 for self-nominated stressful events sampled from the entire life span using a representative sample of Danes born after 1945. The results are discussed in relation to posttraumatic stress disorder and childhood amnesia.

Ten years after the genocide: trauma confrontation and posttraumatic stress in Rwandan adolescents

A decade after the 1994 Rwandan genocide, we interviewed a total of 68 Rwandan orphans about their war experiences and posttraumatic stress disorder (PTSD) symptoms. The two samples comprised youth living either in a child-headed household (CHH) or in an orphanage. All had been exposed to extreme levels of violence and 41% had witnessed the murder of their own mother or father. Of the sample, 44% had PTSD. PTSD vulnerability was greater for youth who at the time of the study lived in CHH than those in an orphanage; it was also higher in those aged 8 to 13 during the outbreak of the genocide than those aged 3 to 7 at the time. Furthermore, a significant relationship was found between the number of traumatic experiences and subsequent stress responses.

Disability and quality of life in post-traumatic stress disorder: impact of drug treatment

The degree of functional disability and quality of life (QOL) impairment in patients with post-traumatic stress disorder (PTSD) is at least comparable with, and in many instances greater than, that of patients with other anxiety and mood disorders. Multidimensional QOL assessments in PTSD have utility in capturing aspects of individual patient experience and satisfaction related to health and treatment, and have fairly robust sensitivity to treatment effects. Despite the growing number of epidemiological and clinical studies detailing QOL in PTSD, there are few studies of the impact of pharmacological agents on QOL outcomes, and none that have included an economic component to evaluate the resource consequences of the disorder. To date, the selective serotonin reuptake inhibitors have been shown to confer significant acute (and longer term) QOL and psychosocial benefits. Further investigation of the relationship of QOL to PTSD symptom severity, disability, treatment outcome and cost, among the different drug treatment modalities, is clearly needed.

A follow-up study of mental health and health-related quality of life in tortured refugees in multidisciplinary treatment

Longitudinal studies of traumatized refugees are needed to study changes in mental health over time and to improve health-related and social interventions. The aim of this study was to examine changes in symptoms of PTSD, depression, and anxiety, and in health-related quality of life during treatment in traumatized refugees. The study group comprises 55 persons admitted to the Rehabilitation and Research Centre for Torture Victims in 2001 and 2002. Data on background, trauma, present social situation, mental symptoms (Hopkins Symptom Checklist-25, Hamilton Depression Scale, Harvard Trauma Questionnaire), and health-related quality of life (WHO Quality of Life-Bref) were collected before treatment and after 9 months. No change in mental symptoms or health-related quality of life was observed. In spite of the treatment, emotional distress seems to be chronic for the majority of this population. Future studies are needed to explore which health-related and social interventions are most useful to traumatized refugees.

Seizure disorders, depression, and health-related quality of life

Disease and mood states are important determinants of quality of life (QOL). Low QOL, due to mood states, can be expected especially in psychiatric disorders such as depression. However, patients with seizure disorders may be even more affected because of the combined burden of physical episodes, psychiatric comorbidities, and psychosocial factors (e.g., stigma). In this study, we compare the quality of life in seizure disorders and clinical depression. Based on our earlier findings, we hypothesize that epilepsy patients fare better than patients with psychogenic, nonepileptic seizures (PNES), and we speculate that QOL in PNES is also lower relative to clinical depression. We estimate the relationships between type of seizures (epilepsy vs PNES), depression, and QOL (SF-36) using multiple regression, and we compare the SF-36 scores of patients with epilepsy and PNES (n=194) with the normative data for clinical depression using one-sample t tests. Our findings indicate that depression contributes to the poor QOL in both epilepsy and PNES, but the patients with PNES, even those without depression, have worse QOL compared with both the epilepsy patients and the depression norms. We conclude that evaluating and treating mood states is as important as treating PNES itself when caring for patients with PNES, and it might be the first step toward improving their QOL.