Mental Illness: Special Considerations in Holocaust Survivors

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Mental IllnessSpecial Considerations in
Holocaust Survivors

• Alessandra Scalmati, MD
• Division of Geriatric Psychiatry
• Montefiore Medical Center
• Bronx, NY

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Goals

• To explore the prevalence of mental illness in
  Holocaust Survivors and the interaction between
  the history of trauma and the specific
  pathologies encountered.
• To suggest some therapeutic strategies to address
  some of the specific needs of Survivors
  sufferings with mental illness.

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Historic Background I

• The immediate post-war period
• The shame of the Victims They went to their
  death like sheep to the slaughter
• The guilt of the Survivors The best died,
  What did you have to do to survive?
• The guilt of the Witnesses We tried to help, we
  did our best, or did we?
• The birth of Israel as a redemptive moment in
  Jewish history, the chance to present the world
  with a new image of the Jewish people.
• In Europe and America the dream for assimilation
  and real social acceptance never had a better
  chance to succeed.

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Historic Background II

• The immediate post-war period
• There was no language in psychiatry to describe
  the suffering of the Survivors, no research or
  clinical work on trauma, and its aftermath.
• There were great internal and external pressures
  that created a culture of silence and pushed the
  Survivors to put the past behind them and move
  on.
• In the following decades, there was also,
  particularly in Israel, a very strong desire to
  avoid viewing the victim of the Holocaust as
  fragile or damaged, or to pathologize them in any
  way. The focus was on their strength and
  resilience.

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Historic Background III

• The 70s and the 80s
• It was not until the work with traumatized
  Viet-Nam veterans became widely available and
  Yael Danieli published her study on Holocaust
  Survivors, that some attention started to be paid
  to the mental health needs of Survivors.
• Meanwhile the Survivors had struggled alone for
  30 to 40 years, often without treatment, or
  receiving treatment by well meaning doctors and
  therapists who were not trained to understand, or
  incorporate the patients experience in the
  treatment plan. Often the Survivors would not
  talk of it.

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What do we know now about the effects of severe
trauma?

• Everybody is affected differently
• When the trauma is as extensive as the Holocaust
  everybody suffers some sequelae
• Predisposing and protective factors to more
  troubling consequences include
• age at time of exposure,
• type of trauma,
• ego function/resilience,
• social support,
• number of traumatic events/length of exposure,
• history of/predisposition to mental illness

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Did Holocaust Survivors Develop Mental Illnesses
after the War?

• For some Survivors the Holocaust was a severe
  life stressor, that acted like a trigger for the
  development of a major mental disorder, that they
  would probably have developed at some point in
  their life. Of course it is impossible to be
  completely sure, but it is a fair assumption.
  However, this accounts only for a small minority
  of cases, some of whom have spend many decades in
  institutions since the war.
• For the majority of survivors there is an
  increased incidence of anxiety and depressive
  symptoms common in people with a history of
  trauma, that at critical points in their life can
  reach clinical significance.

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Do All Survivors Suffer from PTSD?

• Most have at least some symptoms.
• PTSD symptoms are divided in three groups
• Re-experiencing nightmares, intrusive and
  dissociative recollections and flashbacks.
• Avoidance Numbing, emotional detachment and
  estrangement from others, decreased range of
  affect, sense of foreshortened future, decreased
  interest and participation in activities.
• Hyperarousal increased startle reaction,
  irritability, angry outbursts, sleep disturbance,
  hypervigilance, and difficulties concentrating.

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What is Complex PTSD?

• Its a controversial diagnosis, not currently
  recognized, advocated by some mental health
  professionals who specialize in working with
  survivors of severe trauma.
• Patients suffering from this disorder have all
  the symptoms of PTSD, and present as highly
  dysfunctional. They are incapable of intimate
  relationships, they often engage in self
  destructive behaviors, and they make abundant use
  of dissociation as a defense mechanism.
• Many more conservative clinicians feel that these
  patients meet criteria for Personality D/O, and
  PTSD.

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What do Survivors Suffer From?

• According to most studies the prevalence of most
  major mental illnesses is similar to that
  encountered in the general population with the
  exception of a significant increase in the
  incidence of PTSD, and, in the one study that use
  this Dx, Complex PTSD (in Survivors that were
  children or adolescent at the time of the war).
• However, most studies agree that there is an
  increase of subclinical syndromes, meaning that
  Survivors complain more of feeling anxious or
  depressed, or generally distressed.

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Review of Major Mental Illnesses I

• Schizophrenia and Other Psychotic D/O fairly
  rare, about 1-2 of population, very disabling,
  chronic.
• Mood D/O quite common, Unipolar Depression close
  to 20 of certain subgroups, Bipolar probably
  around 5. Compatible with high functioning, but
  associated with a lot of suffering, very
  significant increase in the risk of suicide. High
  familial association.
• Anxiety D/O quite common, 8-15 of population
  depending on sample, higher in Survivors b/o
  PTSD. Can be associated with increased risk of
  suicide.

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Review of Major Mental Illnesses II

• Substance Abuse 10-15 of general population.
  Alcohol is the most common substance of abuse in
  male Survivors, prescription drugs (pain killer,
  and tranquillizers) are the most common in
  female.
• Dementia and Cognitive Impairment Age is the
  most important risk factor. 50 incidence after
  the age of 85.
• Personality D/O Stable pattern of inner
  experiences and behaviors, that are quite
  inflexible and the patient perceives as
  ego-syntonic. Very poor data on incidence.

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Are Survivors at Greater Risk for Suicide?

• We are not very good at predicting suicide.
• What we know is that Survivors have an increased
  incidence of Suicidal Ideations and Suicide
  Attempts (a few small studies, but worth paying
  attention to).
• The risk factors for Completed Suicide are
• Mental Illness
• Old Age
• Male Gender
• Social isolation
• Access to lethal means
• Substance Abuse, or other disinhibiting factors

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Mr. A Is This Depression?

• Mr A is an 87 y old widowed Survivors, he fought
  with the partisans during the war, after escaping
  from the ghetto at age 17 in 1940, but was unable
  to convince his parents and sisters to follow him
  in the woods. They all perished. The 16 y old
  girl he was in love with was also killed in the
  camps. He spent years after the war looking for
  his loved ones. He finally gave up his search,
  came to the US, married and had 2 children. Now
  he lost his wife and he cannot stop thinking
  about the war. His life feels empty and
  meaningless. He cannot sleep and he is tormented
  by nightmares.

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Mrs. B Irremediable Misery

• Mrs. B is an 85 y old woman who left Germany on a
  Kindertransport in 1938 at the age of 13, she
  never saw her parents, grandparents, or brother
  again. At the end of the war, she came to the US,
  where she met her husband, who was a camp
  survivor. They had 2 children. Mrs. B was
  anxious, sickly, and troubled most of her life,
  but managed to hold a job as a teacher. Since the
  death of her husband, and an increasing number of
  physical ailments have made her more dependent,
  she just sits in her apartment complaining.
  Nothing anybody does, is quite the right thing to
  make her better.

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Mrs. C Paralyzing Anxiety

• Mrs. C is a 86 y old woman, who spent 2 years
  hiding inside a wooden chest as big as a coffin
  in the farm of gentiles. She could come out for a
  few hours at night when they would come to feed
  her. She was the only one to survive in her
  family. When she arrived at the farm she was
  wounded, and for days she was in pain, and
  delirious with fever, waiting to die. After the
  war, she came to the US, married another
  survivor, had a son. She was sickly all her life,
  but managed to marginally function. After the
  death of her husband, she became tormented by a
  paralyzing anxiety.

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Mr D Is it Psychosis?

• Mr. D is a 95 y old camp Survivor, who lost his
  first wife and young child in Auschwitz. After
  the war he remarried another survivor, had 3
  children and came to the US, where he worked as
  a schechter (ritual slaughterer) and had his own
  business. According to his children, he was
  quiet, kept to himself, did not trust anybody,
  and occasionally expressed bizarre believes
  about a conspiracy against the Jews. Now he is
  accusing the neighbors of harassing him and
  sending anti-Semitic messages through the TV.

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Therapeutic Considerations I

• Try to learn the specifics of the trauma that the
  patient suffered.
• Understand the best level of functioning that was
  attained after the war.
• Assess the patients strengths social support,
  ego functioning, coping skills, psychological
  awareness.
• Evaluate the motivation for treatment.
• Set realistic goals, for yourself and for the
  patients. We might be able to offer some relief
  from suffering, but we will never repair the
  past.

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Therapeutic Considerations II

• Often medications are very helpful (Major
  Depression, Psychosis, Severe Anxiety, Severe
  PTSD, Complication of Dementia)
• Psychotherapy is often useful, but only if the
  patient thinks so. Sometimes tolerating the
  intolerable is our best intervention.
• Be careful not to make them talk just because you
  want to find out.
• Take care of yourself this is hard material to
  listen to.
• Beware of rescue fantasies, you will fail.

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Conclusions

• Exposure to the devastating trauma of the
  Holocaust increases the incidence of PTSD and the
  prevalence of anxiety and depressive symptoms in
  Survivors, even thought the incidence of most
  Major Mental D/O is comparable to the general
  population.
• The experience of trauma changes the way in which
  the symptomatology of mental illness is
  expressed in Survivors.
• An understanding of the trauma of the Holocaust
  is essential to devise a sensitive and effective
  treatment plan.