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The Persistence of Traumatic Memories in World War II Prisoners of War

2009; Wiley; Volume: 57; Issue: 12 Linguagem: Inglês

10.1111/j.1532-5415.2009.02609.x

1532-5415

Jules Rosen,

Migration, Health and Trauma

And men will not understand us … we will grow older, a few will adapt themselves, some others will merely submit, and most will be bewildered;—the years will pass by and in the end we shall fall into ruin. All Quiet on the Western Front by E.M. Remarque (1928) The Persistence of Traumatic Memories in World War II Prisoners of War by Rintamaki et al.1 in the current issue of the Journal of the American Geriatrics Society reminds us as health professionals caring for elderly people of the importance of appreciating traumatic events throughout the life span. The authors identified a convenience sample of 157 prisoners of war (POWs) of the European and Pacific theaters from World War II (WWII). More than 60 years later, nightmares and flashbacks are common. For many, these symptoms have increased in frequency or intensity since retirement. Rintamaki and colleagues report that 30% to 40% of the POWs of the European theater, and 62% to 73% of POWs from the Japanese theater experience the key symptoms of intrusive recollections, dreams, and flashbacks, although only 12% and 34% of those POWs meet diagnostic criteria for posttraumatic stress disorder (PTSD). These data make the distinction that symptoms after trauma do NOT necessarily constitute a psychiatric disorder. Depending on the severity of the trauma, these experiences could be considered a normal human response, noting that more that half of the Pacific theater veterans report them. The presence of posttrauma symptoms in the absence of a psychiatric disorder is an important contribution of this article. Many of these veterans continue to live productive, wholesome, and fulfilled lives in spite of the presence of these distressing sequelae, yet the fact that these experiences continue puzzle and distress them. The effect of traumatic events on emotional and physiological functioning has been documented for centuries. Samuel Pepys chronicled the physical and emotional symptoms of what we now call PTSD in the aftermath of the Great Fire of London in the 17th century.2 Although the clinical experiences described remain consistent, the terminology changed with each major military campaign. Approximately 20 years after the end of the Civil War, the terms “irritable heart” or “soldier's heart” were used to describe physiological anxiety symptoms in the absence of overt heart disease in combat veterans.3,4 After World War I, veterans who were emotionally affected after their combat experiences were described as “shell shocked.” During WWII, Kardiner initially attempted to reconcile the psychiatric syndrome referred to as “combat fatigue” with traditional Freudian theory of repressed sexual drive in combat veterans,5 although he relinquished that position and proposed that these symptoms constitute a “physioneurosis,” in contrast to the classical Freudian “psychoneurosis.” Early in the Vietnam War, symptomatic veterans were described as having the “Vietnam Vets Syndrome.” Eventually, it was acknowledged that posttraumatic symptoms throughout history are similar, and the diagnosis of PTSD was added to the lexicon. Although much of the research on posttraumatic stress involves combat veterans or POWs, civilians exposed to traumatic events are similarly affected. Forty years after WWII, Holocaust survivors living in the United States6 and in Israel7 reported disrupted sleep patterns and frequent nightmares. Survivors of traffic accidents, fires, floods, rape, sexual abuse, and kidnapping report similar symptoms after these civilian traumas.8 What is the clinical importance of this study to healthcare professionals in their daily work? After all, there are few surviving WWII POWs, and their numbers are ever diminishing. All elderly patients have been through decades of challenges and stressors, both in war and in civilian life. For some, traumatic experiences have been integrated into their view of themselves and can serve as a sources of strength. Others immersed themselves in their work to avoid the intrusive memories and images. As retirees are faced with less structured time, loss of friends and family can result in the re-emergence of posttraumatic symptoms even decades later. More than half of the respondents in the current study report an increase in symptoms since retirement. The re-emergence of intrusive thoughts and nightmares can be extremely distressing and equally confusing. In clinical practice, patients are typically unwilling to spontaneously discuss these symptoms with their healthcare practitioners. Patients may feel shame that they are emotionally weak, and they assume that others with similar histories do not experience these symptoms after all these years. It is important to realize that avoidance is one of the core symptoms of PTSD. Initiating a discussion with a healthcare professional is likely to arouse more distress and increase symptoms and is thus avoided. Patients will feel comfortable asking for “sleeping pills” or “nerve pills” without providing any further details regarding the source of their anxiety. Substance abuse comorbidity with PTSD is common,9 and elderly people may seek alcohol or prescription medications for symptom reduction. Clinicians can sensitively evaluate the presence of posttraumatic symptoms and PTSD in the course of their clinical care. Traumatic stress should be considered in patients complaining of anxiety, social withdrawal, or sleep disturbance. Elderly patients commonly report sleep disturbance and inability to relax to their primary care physicians. A stepwise approach to gather information will permit exploration without unduly alarming the patient. All patients with these symptoms, men and women, should be asked whether they served in the military. Asking where and when they served initiates the discussion without broaching sensitive topics of actual traumatic exposure. If service was during a combat period and in a combat zone, inquiring about nightmares, sleep disturbance, or other posttraumatic symptoms after discharge will ascertain whether symptoms of PTSD were remotely present, still without soliciting details of the trauma. Finally, by observing with the patient that these symptoms can persist and continue to be problematic even 60 years later, inquire about current symptoms. The clinician should ask whether the patient feels comfortable discussing the specific trauma. For elderly people presenting with symptoms of anxiety or sleep disturbance who might be reacting to civilian trauma, inquiring about the presence of reoccurring troublesome memories or nightmares will safely initiate the discussion. Indicating to patients that these symptoms can be associated with remote emotional trauma will open the door further. Clinicians should not be surprised to learn that traumatic experiences have never been shared with anyone, including spouses. For many patients, simply learning from their healthcare professional that posttraumatic symptoms are common and are not signs of weakness or failure will be therapeutic. For others, especially those using alcohol or sedative–hypnotics to manage the symptoms, more specific treatment is indicated. Selective serotonin reuptake inhibitors are effective in reducing the effect of PTSD symptoms,10 and nonpharmacological interventions, including eye movement desensitization and reprocessing (EMDR), have also been reported to be effective. A recent study comparing a short-term course of fluoxetine, EMDR, and placebo supports the superior effectiveness of EMDR in reducing PTSD 6 months later.11 In summary, this study by Rintamaki et al. reminds us that traumatic life experiences can have an enduring effect on elderly patients. For some, simply knowing that residual symptoms of nightmares or flashbacks are normal and not a sign of weakness will reduce their anxiety. For those who are more symptomatic or have sought anxiety relief through alcohol or sedative–hypnotic abuse, more-specific treatments are indicated. Clinicians must approach the subject sensitively and reserve soliciting details for therapists who are skilled in this arena. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this editorial. Author Contributions: Sole author. Sponsor's Role: None.