Chronic pain in Holocaust survivors

[Long-term medical complications of Holocaust trauma]

Holocaust survivors are currently confronted with the problems inherent to ageing such as illness, frailty, dependency and isolation. A study was carried out to assess the long-term medical consequences of the Holocaust trauma.

Activity engagement and psychological distress among Holocaust survivors during the COVID-19 pandemic

OBJECTIVES

The COVID-19 pandemic may pose a specific threat for Holocaust survivors, as such threats may be linked with increased psychological distress. Moreover, research has demonstrated that engaging in planful problem-solving activities is associated with reduced distress. Accordingly, we aimed to examine the link between engaging in activities during COVID-19 and psychological distress among Holocaust survivors with varying levels of post-traumatic symptoms (PTS) and comparisons (not directly exposed to the Holocaust).

DESIGN

A cross-sectional design composed of Holocaust survivors and a comparison group.

SETTING

Participants were interviewed face-to-face, over the telephone, or filled the scales online at their leisure.

PARTICIPANTS

Data were collected from 131 older Jewish Israelis (age range 76-94, M = 82.73, SD = 4.09), who were divided into three groups (comparisons; low-PTS survivors; high-PTS survivors).

MEASUREMENTS

Participants completed scales assessing PTS, activity engagement, and psychological distress and provided additional sociodemographic, medical, and COVID-19-related information.

RESULTS

When activity engagement was low, high-PTS survivors reported extremely high levels of psychological distress relative to low-PTS survivors and comparisons. However, when activity engagement was high, these group differences were considerably reduced, as the psychological distress of high-PTS survivors was significantly lower.

CONCLUSIONS

The study highlights the importance of daily planning and activity engagement for Holocaust survivors with high PTS levels in reducing psychological distress. Clinicians are urged to take this factor into account when dealing with the psychological effects of COVID-19 on survivors and on traumatized older adults in general.

The impact of poverty and deprivation at the end of life: a critical review

This critical review interrogates what we know about how poverty and deprivation impact people at the end of life and what more we need to uncover. While we know that people in economically resource-rich countries who experience poverty and deprivation over the life course are likely to die younger, with increased co-morbidities, palliative care researchers are beginning to establish a full picture of the disproportionate impact of poverty on how, when and where we die. This is something the Covid-19 pandemic has further illustrated. Our article uses a critical social science lens to investigate an eclectic range of literature addressing health inequities and is focused on poverty and deprivation at the end of life. Our aim was to see if we could shed new light on the myriad ways in which experiences of poverty shape the end of people's lives. We start by exploring the definitions and language of poverty while acknowledging the multiple intersecting identities that produce privilege. We then discuss poverty and deprivation as a context for the nature of palliative care need and overall end-of-life circumstances. In particular, we explore: total pain; choice at the end of life; access to palliative care; and family caregiving. Overall, we argue that in addressing the effects of poverty and deprivation on end-of-life experiences, there is a need to recognise not just socio-economic injustice but also cultural and symbolic injustice. Too often, a deficit-based approach is adopted which both 'Others' those living with poverty and renders invisible the strategies and resilience they develop to support themselves, their families and communities. We conclude with some recommendations for future research, highlighting in particular the need to amplify the voices of people with lived experience of poverty regarding palliative and end-of-life care.

Impact of the Holocaust on the outcomes of elderly patients sustaining a fragility hip fracture

INTRODUCTION

Holocaust survivors (HS) were under an immense continues physical and mental stressors in their younger years, putting them at increased risk for both fragility hip fractures and worse medical and functional outcomes. We aimed to evaluate whether being a HS could affect the functional outcomes of fragility hip fractures in patients 80 years of age and older following surgery.

MATERIALS AND METHODS

A retrospective study comparing consecutive patients, 80 years and older, who were operated for fragility hip fractures between 2011 and 2016. HS survival status was self-defined by survivors who were born in European and northern African countries that were later occupied by the Nazi regime during World War II and experienced incarceration in concentration camps, forced labor camps and mass transport. Primary outcomes were mortality either within hospital or in the post-operative year. Secondary outcomes were in-hospital complications, recurrent hospitalizations and orthopedic complications within the post-operative year.

RESULTS

Two hundred thirty-one HS and 339 controls, ages 86.4 ± 4.4 years who were operated for fragility hip fracture between January 2011 to June of 2016 were included in the study. Patients from both groups were of similar age, Carlson's co-morbidity index score, leaving arrangement and pre-fracture mobility. Among HS there were more women (p = 0.029). HS did not have lower survival rates either within hospital or in the post- operative year. Both length of stay and in-hospital complication rates were similar between groups. In the post-operative year, HS were less likely to be hospitalized than controls (p = 0.021). The rate of orthopedic complications was also similar.

CONCLUSIONS

Holocaust survivors patients do not achieve worse outcome following fragility hip fracture surgery and present distinctive resilience.

Consequences of holocaust on physical health of survivors: bibliography review

OBJECTIVE

Period of elderly age preordains the occurrence of many health issues. People deported during World War II to concentration camps suffered from malnutrition, lack of sleep, physical and mental exhaustion. Recently, the health condition of Holocaust survivors is often complicated as a result of physical punishments and different torture methods as well as mental hardships which they had suffered during deportation. The consequences often have psychosomatic nature thus the survivors are often receivers of health care. The topic of bibliography review is based on the need to objectivize and systematically evaluate subjective health issues of Holocaust survivors in connection with trauma related to the stay in a concentration camp. The aim is to offer a review of effects of the Holocaust on health of different body systems for survivors in concentration camps and Jewish ghettos in the course of World War II.

METHODS

To map the subjective problems of Holocaust survivors, evidence-based medicine (EBM) method has been used with the help of scientific database PubMed, CINAHL Plus with full text, ProQuest and other sources with specific key words and Boole operators. Prognostic type of clinical/review questions has been selected for the bibliography review, which is trying to predict the probability of relation or output of illness/condition and based on diseases or symptoms seriousness to find out expectancy for treatment/improvement of care.

RESULTS

175 studies have been found in basic search with the use of key words both in English and in Czech language. The search has not been time-limited. The advanced search has focused on different body systems and health damage due to Nazi experiments. Fourteen studies have been used to complete the study. The research results have confirmed the significant effect of Holocaust trauma on body condition of the survivors. The reasons of this condition were insufficient nutrition, unsuitable and harmful hygienic, living and working conditions and brutality of the guards. According to the research, these factors have impacted all organ systems, mainly locomotion and cardiovascular ones. The results have shown a more frequent occurrence of osteoporosis, fractures of long bones and corresponding chronical pain of people of Jewish origin who had gone through different forms of torture during World War II. Other present symptoms include gastrointestinal problems, tumors mainly in the area of colorectum and lungs. Moreover, the stay in concentration camps had influence on women's menstrual cycle.

CONCLUSION

The studies of Holocaust effects are an example of the influence of an extreme mental and physical burden on the body condition of the survivors' health. The results of the studies have shown a wide range of the effects also in mental and social areas.

Mental Health Comorbidities in Pediatric Chronic Pain: A Narrative Review of Epidemiology, Models, Neurobiological Mechanisms and Treatment

Chronic pain during childhood and adolescence can lead to persistent pain problems and mental health disorders into adulthood. Posttraumatic stress disorders and depressive and anxiety disorders are mental health conditions that co-occur at high rates in both adolescent and adult samples, and are linked to heightened impairment and disability. Comorbid chronic pain and psychopathology has been explained by the presence of shared neurobiology and mutually maintaining cognitive-affective and behavioral factors that lead to the development and/or maintenance of both conditions. Particularly within the pediatric chronic pain population, these factors are embedded within the broader context of the parent-child relationship. In this review, we will explore the epidemiology of, and current working models explaining, these comorbidities. Particular emphasis will be made on shared neurobiological mechanisms, given that the majority of previous research to date has centered on cognitive, affective, and behavioral mechanisms. Parental contributions to co-occurring chronic pain and psychopathology in childhood and adolescence will be discussed. Moreover, we will review current treatment recommendations and future directions for both research and practice. We argue that the integration of biological and behavioral approaches will be critical to sufficiently address why these comorbidities exist and how they can best be targeted in treatment.

World War II-related post-traumatic stress disorder and breast cancer risk among Israeli women: a case-control study

BACKGROUND

Several studies have suggested that post-traumatic stress disorder (PTSD) is related to adverse health outcomes. There are limited data on PTSD and cancer, which has a long latency period. We investigated the association between World War II (WWII)-related PTSD and subsequent breast cancer (BC) risk among Jewish WWII survivors and examined whether this association was modified by exposure to hunger during WWII.

METHODS

We compared 65 BC patients diagnosed in 2005 through 2010 to 200 population-based controls who were members of various organizations for Jewish WWII survivors in Israel. All participants were born in Europe, lived at least six months under Nazi rule during WWII, and immigrated to Israel after the war. We estimated PTSD using the PTSD Inventory and applied logistic regression models to estimate the association between WWII-related PTSD and BC, adjusting for potential confounders.

RESULTS

We observed a linear association between WWII-related PTSD and BC risk. This association remained significant following adjustment for potential confounders, including obesity, alcohol consumption, smoking, age during WWII, hunger exposure during WWII, and total number of traumatic life events (OR = 2.89, 95% CI = 1.14-7.31). However, the level of hunger exposure during WWII modified this effect significantly.

CONCLUSIONS

These findings suggest an independent association between WWII-related PTSD and subsequent BC risk in Jewish WWII survivors that is modified by hunger, a novel finding. Future research is needed to further explore these findings.

Low preparedness before the loss of a wife to cancer and the widower's chronic pain 4-5 years later-a population-based study

OBJECTIVE

The focus of this study was on the impact of spousal loss on the development of chronic pain thereafter. More specifically, the aim was to investigate the effect of experiencing low preparedness before a wife's death and the widower's chronic pain 4-5 years after loss.

METHODS

In a population-based study in the years 2004-2005, anonymous questionnaires were sent out to 907 men in Sweden who had lost a wife to cancer in 2000 and 2001. The questionnaires contained questions on the man's preparedness for his wife's death and his physical and psychological health at follow-up.

RESULTS

Altogether, 691 out of 907 questionnaires were retrieved (76%). Younger widowers (38-61 years old) with a low degree of preparedness for their wife's death had an increased risk of experiencing symptoms of chronic pain (odds ratio 6.67; 2.49-17.82) 4-5 years after loss. The same results did not apply for older widowers (62-80 years old) (odds ratio 0.81; 0.32-2.05). Widowers who experienced chronic pain were at an increased risk for psychological morbidity, depression (relative risk [RR] 2.21; 1.31-3.74), anxiety (RR 2.11; 1.33-3.37), and sleep disorders (RR 2.19; 1.30-3.69).

CONCLUSION

Our data suggest that low preparedness for a wife's death may increase risk of chronic pain among younger widowers 4-5 years after loss. In addition, we found comorbidity between psychological symptoms and chronic pain among widowers. These findings call for studies on possible mechanisms in the association between low preparedness and morbidity and on how to increase preparedness for a wife's death to cancer.

Co-morbidity and pain sites in long-term gynecological cancer survivors and women in the general population

OBJECTIVE

Pain is associated with cancer, cancer treatment, co-morbidity and socioeconomic conditions. The aim of this cross-sectional study was to explore the relationship between co-morbidity and number of pain sites (NPS) in long-term survivors of gynecological cancer and a representative sample of women from the general population. Study population comprised recurrence-free long-term gynecological cancer survivors (n=160) and women selected at random from the general population (n=493) in Mid-Norway. Mean age was 58 and 57 (range 32-75), respectively. Mean follow-up time after treatment for gynecological cancer was 12 years (SD 2.6; range 8-17).

METHODS

Co-morbidity was assessed as conditions/diseases over the past 12 months. NPS was recorded using a body outline diagram indicating where the respondents had experienced pain during the past week. Socioeconomic conditions were measured by Socioeconomic Condition Index (SCI). All assessments were self-reported. We tested three models of covariates with NPS as outcome: 1-2/0 (A), 3/0 (B) and 4-7/0 (C) pain sites in forward stepwise logistic regression. Outcome measure was adjusted odds ratio (aOR) with 95% confidence intervals (CI).

RESULTS

There were no differences in co-morbidity and NPS between gynecological cancer survivors and women from the general population. After adjustment for SCI, age and BMI, musculoskeletal disorders were the strongest predictor of NPS in all models, whereas migraine/headache, sleeping and psychiatric disorders were significantly associated with NPS in model A/B/C, B/C, and C, respectively.

CONCLUSIONS

Gynecological cancer survivors are as healthy, and carry as much co-morbid conditions as women from the general population assessed through associations with NPS.

Socioeconomic conditions and number of pain sites in women

Background

Women in deprived socioeconomic situations run a high pain risk. Although number of pain sites (NPS) is considered highly relevant in pain assessment, little is known regarding the relationship between socioeconomic conditions and NPS.

Methods

The study population comprised 653 women; 160 recurrence-free long-term gynecological cancer survivors, and 493 women selected at random from the general population. Demographic characteristics and co-morbidity over the past 12 months were assessed. Socioeconomic conditions were measured by Socioeconomic Condition Index (SCI), comprising education, employment status, income, ability to pay bills, self-perceived health, and satisfaction with number of close friends. Main outcome measure NPS was recorded using a body outline diagram indicating where the respondents had experienced pain during the past week. Chi-square test and forward stepwise logistic regression were applied.

Results and Conclusion

There were only minor differences in SCI scores between women with 0, 1-2 or 3 NPS. Four or more NPS was associated with younger age, higher BMI and low SCI. After adjustment for age, BMI and co-morbidity, we found a strong association between low SCI scores and four or more NPS, indicating that there is a threshold in the NPS count for when socioeconomic determinants are associated to NPS in women.

Coping and emotional distress during acute hospitalization in older persons with earlier trauma: the case of Holocaust survivors

BACKGROUND

Older persons with earlier trauma are often more vulnerable to stresses of old age.

AIMS

To examine the levels of emotional distress in relation to cognitive appraisal of acute hospitalization and coping strategies in Holocaust survivors compared with an age- and education-matched group of elderly persons without Holocaust experience.

METHODS

This is a cross-sectional study of 63 Holocaust survivors, 65 years and older, hospitalized for an acute illness, and 57 age-, education- and hospital unit-matched people without Holocaust experience. Participants completed appraisal and coping strategies (COPE) questionnaires, and the brief symptoms inventory (BSI-18).

RESULTS

Holocaust survivors reported higher levels of emotional distress, appraised the hospitalization higher as a threat and lower as a challenge, and used more emotion-focused and less problem-focused or support-seeking coping strategies than the comparison group. Study variables explained 65% of the variance of emotional distress; significant predictors of emotional distress in the final regression model were not having a partner and more use of emotion-focused coping. The latter mediated the relation of group variable and challenge appraisal to emotional distress.

CONCLUSIONS

Health professionals must be aware of the potential impact of the hospital environment on the survivors of Holocaust as well as survivors of other trauma. Being sensitive to their specific needs may reduce the negative impact of hospitalization.

Ageing Holocaust survivors in Australia

In recent years, a phenomenon of "late effects of the Holocaust" has emerged, with impacts on the psychological and physical health of ageing Holocaust survivors. As Holocaust survivors age, they may experience heightened anxiety around normal processes of ageing, worsened post-traumatic stress disorder with cognitive decline, and fear of the medical system. Holocaust survivors are at increased risk of osteoporosis, cardiometabolic disease due to hypothalamic-pituitary-adrenal axis dysfunction, cancer, and sequelae of Nazi medical experiments. From existing medical literature on this topic, practical principles of management are derived to create a framework for sensitive medical management of Holocaust survivors in Australia. The issues discussed are also relevant to the wider geriatric refugee or prisoner-of-war experience.

Health and functional status and utilization of health care services among holocaust survivors and their counterparts in Israel

To examine differences in health and functional status and in utilization of health services between holocaust survivors and their counterparts; and (b) to investigate if holocaust survivor status is a significant predictor of health status, functional status, and utilization of health services. The study included 1255 respondents of whom 272 were holocaust survivors. Interviews were conducted face-to-face at the respondents' homes. Participants were asked about their health (self-rated health and comorbidity) and functional (ADL and IADL) status, utilization of inpatient and outpatient health care services, age, gender, education, marital status, length of residence in Israel, and if they were holocaust survivors. Holocaust survivors, who were frailer and more chronically ill compared to their counterparts, visited their family physician and the nurse at the health care clinic more often than their counterparts did, and received more homecare services. Yet, there were no differences between them in the utilization of other health care services such as visits to specialists, emergency department, and hospitalizations. Holocaust survivors are more homebound due to more morbidity and functional limitations and therefore receive more health home care services that offset the utilization of other health services.

Holocaust survivors in old age: the Jerusalem Longitudinal Study

OBJECTIVES

To examine the hypothesis that Holocaust exposure during young adulthood negatively affects physical aging, causing greater morbidity, faster deterioration in health parameters, and shorter survival.

DESIGN

A longitudinal cohort study of the natural history of an age-homogenous representative sample born in 1920/21 and living in Jerusalem.

SETTING

Community-based home assessments.

PARTICIPANTS

Four hundred fifty-eight subjects of European origin aged 70 at baseline and 77 at follow-up.

MEASUREMENTS

Comprehensive assessment of physical, functional, and psychosocial domains; biographical history of concentration camp internment (Camp), exposure to Nazi occupation during World War II (Exposure), or lack thereof (Controls); and 7-year mortality data from the National Death Registry.

RESULTS

Holocaust survivors of the Camp (n=93) and Exposure (n=129) groups were more likely than Controls (n=236) to be male and less educated and have less social support (P=.01), less physical activity (P=.03), greater difficulty in basic activities of daily living (P=.009), poorer self-rated health (P=.04), and greater usage of psychiatric medication (P=.008). No other differences in health parameters or physical illnesses were found. Holocaust survivors had similar rates of deterioration in health and illness parameters over the follow-up period, and 7-year mortality rates were identical. Proportional hazard models showed that being an elderly Holocaust survivor was not predictive of greater 7-year mortality.

CONCLUSION

Fifty years after their Holocaust trauma, survivors still displayed significant psychosocial and functional impairment, although no evidence was found to support the hypothesis that the delayed effects of the trauma of the Holocaust negatively influence physical health, health trajectories, or mortality.

Transition from acute to chronic pain and disability: A model including cognitive, affective, and trauma factors

This study evaluated a theoretically and empirically based model of the progression of acute neck and back pain to chronic pain and disability, developed from the literature in chronic pain, cognition, and stress and trauma. Clinical information and standardized psychosocial measures of cumulative traumatic events exposure (TLEQ), depressed mood (CES-D), pain (DDS), physical disability (PDI), and pain beliefs (PBPI) were collected at baseline from 84 acute back pain patients followed at an Acute Back Clinic over 3 months. Path analysis was used for the longitudinal prediction of perceived pain and disability. The predictive model accounted for 26% of the variance in persistent pain intensity and 58% of the variance in perceived physical disability at 3 months. Greater exposure to past traumatic life events and depressed mood were most predictive of chronic pain; depressed mood and negative pain beliefs were most predictive of chronic disability. More cumulative traumatic life events, higher levels of depression in the early stages of a new pain episode, and early beliefs that pain may be permanent significantly contribute to increased severity of subsequent pain and disability. Replication in a larger sample is desirable to confirm these paths. Early detection of elevated depressive symptoms and high trauma exposure may identify individuals at greater risk for developing chronic pain syndromes who may benefit from early multidisciplinary intervention.

Subgrouping outpatients of an environmental medicine unit using SCL-90-R and cluster analysis

Between 1999 and 2003 all consecutive outpatients of the environmental medicine unit of the Charité hospital in Berlin were invited to participate in a study on environmentally related disorders. One hundred and sixty-nine of the patients completed a psychosocial questionnaire which comprised SCL-90-R and 14 other tests. When compared with clinical controls, SCL-90-R mean scores of the environmental patients (EP) were found to lie in between those of inpatients of a psychosomatic clinic and melanoma aftercare patients; but they were, with exception of the somatisation dimension, much closer to the latter. Application of the TwoStep Cluster component of SPSS resulted in three subgroups with high, moderate and low scores which were significantly different (p<0.001) although separation was incomplete (87% correct identification; cross-validated discriminant analysis). With all subgroups, scores for somatisation, depression and obsessive compulsion were highest and those for phobic anxiety and psychoticism were lowest. SCL-90-R scores correlated well with results of the Freiburg Personality Inventory, Whiteley Index of hypochondriasis, the short form health questionnaire (SF-36), and the Composite International Diagnostic Interview (CIDI). Hierarchical grouping (average linkage between groups), performed with involvement of SCL-90-R data from literature, resulted in a dendrogram with three distinct groups and three outliers. EP with low SCL-90-R scores were assigned to a group which comprised also general populations (USA, Germany), allergy patients, and melanoma controls. Those with moderate SCL-90-R scores were placed in a group together with chronic pain patients, and 26 'environmentally ill' subjects. The third subgroup of EP formed a cluster with our psychosomatic controls, psychosomatic patients from another study, depressed people, and patients undergoing psychotherapy. The three outliers of the dendrogram, however, were SCL-90-R profiles obtained from persons with toxic waste exposure, neurotoxic workplace exposure or with solvent-induced chronic toxic encephalopathy.

Symptomatology of recurrent low back pain in nursing and administrative professions

The aim of the present study was to explore if (a) recurrent low back pain (LBP) has different symptomatologies in cases from occupations with predominantly sitting postures compared to cases from occupations involving dynamic postures and frequent lifting and (b) if in the two occupational groups, different factors were associated with the presence of recurrent LBP. Hundred and eleven female subjects aged between 45 and 62 years with a long-standing occupation either in administrative or nursing professions, with and without recurrent LBP were examined. An extensive evaluation of six areas of interest (pain and disability, clinical examination, functional tests, MR examination, physical and psychosocial workplace factors) was performed. The variables from the six areas of interest were analyzed for their potential to discriminate between the four groups of subjects (administrative worker and nurses with and without recurrent LBP) by canonical discriminant analysis. As expected, the self-evaluation of physical and psychosocial workplace factors showed significant differences between the two occupational groups, which holds true for cases as well as for controls (P < 0.01). The functional tests revealed a tendency for rather good capacity in nurses with LBP and a decreased capacity in administrative personnel with LBP (P = 0.049). Neither self completed pain and disability questionnaires nor clinical examination or MR imaging revealed any significant difference between LBP cases from sedentary and non-sedentary occupations. When comparing LBP cases and controls within the two occupational groups, the functional tests revealed significant differences (P = 0.0001) yet only in administrative personnel. The clinical examination on the other hand only discriminated between LBP cases and controls in the nurses group (P < 0.0001). Neither MRI imaging nor self reported physical and psychosocial workplace factors discriminated between LBP cases and controls from both occupational groups. Although we used a battery of tests that have broad application in clinical and epidemiological studies of LBP, a clear difference in the pattern of symptoms between LBP cases from nursing and hospital administration personnel could not be ascertained. We conclude that there is no evidence for different mechanisms leading to non-specific, recurrent LBP in the two occupations, and thus no generalizable recommendations for the prevention and therapy of non-specific LBP in the two professions can be given.

To prevent, react, and rebuild: health research and the prevention of genocide

OBJECTIVE

To develop an approach to the primary prevention of genocide, based on established public health-based violence prevention methods derived from a variety of high-risk settings.

DATA SOURCES

(1) Peer-reviewed literature in the fields of public health, violence/injury prevention, medicine, economics, sociology, psychology, history, and genocide studies, (2) demographic and health data bases made available by governments and international organizations, (3) reports on recent episodes of genocide published by international and nongovernmental organizations, (4) newspaper and journalistic accounts of recent and past genocides, (5) archival testimonies of genocide victims and perpetrators, and (6) court transcripts of international genocide prosecutions.

STUDY DESIGN

The research was conducted as a medical-historical policy analysis synthesizing data within the following framework: (1) Assessment of current violence and injury prevention models for suitability in the prevention of extreme, population-wide violence, (2) analysis of morbidity and mortality data to quantify the impact of genocide on the health of populations, (3) making an inventory of the known societal risk factors for genocidal violence, (4) identification of the theorized, modifiable attitudinal risk factors for genocidal behavior within a population health model, and (5) assessment of existing projects targeting primary violence and injury prevention in high risk jurisdictions, for future adaptation within a structured, public health approach.

PRINCIPAL FINDINGS

Mortality rates due to genocidal violence are far in excess of other public health emergencies including malaria and HIV/AIDS. The immediate and long-range health consequences of genocide include the sequelae of infectious diseases, organ system failure, and psychiatric disorders, conferring an increased burden of disease on affected populations for multiple subsequent generations. The impact of genocide on local health economies is catastrophic, and the opportunity costs of diverting scarce global health dollars toward ameliorating genocide related outcomes are substantial. Structural risk factors for genocide within societies include: totalitarian government, exclusionary ideologies, armed conflict, economic hardship, and inaction of bystander nations. Proposed psychological risk factors for genocidal behavior include: moral exclusion, authority orientation, action in self-interest, desensitization, and compartmentalized thinking. Violence and injury prevention models, incorporating what is currently known about the societal and behavioral risk factors for genocide in high-risk populations, may be modified to address the primary prevention of catastrophic violence on a population-wide scale. A number of existent global peace building initiatives may serve as models for the design of future prevention initiatives in high-risk, pre-genocide jurisdictions.

CONCLUSIONS

Our analysis suggests that genocide is one of the most pressing threats to the health of populations in the twenty-first century. Recent advances in the public health discipline of violence prevention provide a blueprint for approaches to primary genocide prevention based on epidemiological methods.

Holocaust survivors coping with open heart surgery decades later: posttraumatic symptoms and quality of life

OBJECTIVE

History of prolonged traumatization has been associated with reduced quality of life (QoL) and difficulties in coping with major life-threatening conditions. We assessed the association between the impact of Holocaust experience (posttraumatic symptoms) and QoL of patients before and after an open heart surgery.

METHOD

Sixty-three Holocaust survivors were interviewed before open heart surgery (at admission), 52 at follow-up at 1 week, and 58 at follow-up at 6 months. The interview included background data, Impact of Event Scale (IES), Mastery scale, and QoL measured by the Nottingham Health Profile. Medical data were retrieved from the patients' charts.

RESULTS

The total IES score indicate a high level of posttraumatic symptoms at all the time points (close to a mean of 18), but there was a clear trend of changes in the avoidance subscale: At admission, the patients manifested lower avoidance compared with the levels after the surgery and at the follow-up. No significant differences in IES were found by Holocaust experiences. Significant improvements in most components of QoL were found at the follow-up. In multivariate analyses at each time point, the findings show that those with higher levels of posttraumatic symptoms are more at risk for problems in pain and mobility domains of QoL at admission, for emotional reaction after the surgery, and at the follow-up, these associations are only at trend level, while lower sense of mastery became significant.

CONCLUSIONS

The improvement in QoL despite persistence of the impact of the Holocaust may indicate that past severe prolonged traumatization does not necessarily reduce the survivors' ability to cope with and regain physical and psychosocial functioning after a severe life-threatening medical condition. This may be further generalized to other significant crisis situations in life, such as prolonged periods of stress, suffered by many populations throughout the world.

Tracing long-term effects of early trauma: a broad-scope view of Holocaust survivors in late life

This study addressed long-term effects of extreme trauma among Holocaust survivors (N = 126) in an older (75-94 years) sample of the Israeli Jewish population. Survivors were compared with European-descent groups that had immigrated either before World War II (n = 206) or after (n = 145). Participants in the latter group had had Holocaust-related life histories but did not consider themselves survivors. Controlling for sociodemographics, the results indicated that survivors fared worse than prewar immigrants in certain psychosocial domains, mainly cumulative distress and activity, rather than in health-related ones. Survivors and postwar immigrant comparisons had almost no differences. The study highlights the need for a wide view of functioning facets and comparison groups in delineating late posttraumatic effects.

Expressions of Holocaust experience and their relationship to mental symptoms and physical morbidity among Holocaust survivor patients

This study explores current expressions of past trauma among Holocaust survivors. Medical records and extensive interviews were analyzed for 38 Holocaust survivors who were hospitalized and/or under ambulatory care. The sample consisted of 55% women and 45% men whose mean age was 72 (SD = 9.2). Expressions of Holocaust experience yielded two factors: Holocaust-as-Present (e.g., feeling the Holocaust experience as continuing, Holocaust-related somatization) and Holocaust-as-Past (e.g., avoiding preoccupation with traumatic memories, feeling unduly stigmatized as a survivor). The results indicate that mental symptoms and the number of medical diagnoses are positively correlated with Holocaust-as-Present but negatively correlated with Holocaust-as-Past. However, scoring high on Holocaust-as-Past relates to a higher danger to life as a result of significant morbidity. The findings suggest two differential modes of either remaining enmeshed in the traumatic experience or attempting to contain the sequelae of the trauma. These modes differ in their implications for mental and physical health.

Does everyone have a name? Psychological distress and quality of life among child holocaust survivors with lost identity

Knowing one's identity, name, and biological parents is considered essential to personality development and psychological well-being. This study assessed post-traumatic stress disorder (PTSD) symptoms, subjective quality of life (QoL), psychological distress, and potency in a group of adults who were children during the Holocaust (child Holocaust survivors) and who did not know their true identity. Twenty-three such survivors were compared to 23 child Holocaust survivors who knew their identity. Results showed that survivors with lost identity had lower physical, psychological, and social QoL and higher somatization, depression, and anxiety scores than did survivors with known identity. The findings suggest that the psychological consequences of not knowing one's identity are long-lasting.