Letters to the Editor
Absent Dose–Response in the Posttraumatic Stress Disorder Symptoms of 350 Holocaust Survivors
Dear Editor:
We examined the court files of 350 Holocaust survivors (193 women and 157 men) who had been examined by one psychiatrist using a semistructured psychiatric interview and the Hamilton Anxiety and Depression Scales. Clinical examinations took place between1995 and 2003. This sample was entirely separate from a similar sample reported previously (1).
The Hamilton results for 7 subjects were not scored because they had dementia symptoms. Overall mean scores suggested that depression (mean 21.53, SD 4.5) and anxiety (mean 19.17, SD 5.0) were in the severe range. Sleep disturbance (in 88.9%), recurrent dreams (in 81.1%), and diminished interest (in 53.7%) were most frequently reported.
Tattooed Auschwitz concentration camp survivors did not differ significantly from the survivors of ghettos in regard to their symptom scores. Therefore, this study failed to replicate our earlier findings that demonstrated the prevalence of severe posttraumatic stress disorder (PTSD) symptoms in tattooed Auschwitz survivors (1).
Negative findings are notoriously difficult to interpret. We favour 2 explanations for the difference between the first and the second study, although no statistical proof exists. First, all subjects in the second sample had applied for an increase in their compensation because their symptoms had worsened (for example, following the death of a spouse or related to emerging medical illness), whereas many subjects in the first study had applied for the first time. Thus the impact of more recent life events may have obliterated PTSD-related dose–response effects. Second, the assessments of this study relied heavily on Hamilton scales (to measure level of distress), whereas the first study used a detailed review of PTSD symptoms (to demonstrate causation).
In both Holocaust samples (combined n = 474), substance abuse was extremely rare, and social instability seemed almost completely absent. This is inconsistent with the hypothesis that PTSD may lead to substance use, violence, and social instability.
Only one case of full-fledged alcoholism was diagnosed in the part of our second sample with complete social histories (n = 332). Six women and 12 men admitted to modest but regular alcohol intake. Other substance abuse was entirely absent. Forty-eight of the women and 61 of the men used caffeine moderately. Nicotine use was admitted by 5 of the women and 5 of the men. Although irritability was widely prevalent, there were no known cases of violence or criminal charges. While we gained the impression that many survivors had unhappy marriages, no recent marital breakups were reported.
Our observations caution against the assumption that substance use, aggression, and social instability are common concomitants of trauma and PTSD. Instead, different populations may cope differently with the distress that results from traumatic life events.
This study was approved by the Ethics Committee of the University of Toronto, and the data have not been published elsewhere.
References
1. Kuch K, Cox BJ. Symptoms of PTSD in 124 Jewish survivors of the Holocaust. Am J Psychiatry 1992;149:337–40.
*Klaus Kuch, MD
Neil A Rector, PhD
Kate Szacun-Shimizu, BA
Toronto, Ontario
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