The psychopathological impact of the Holocaust, in which 5 820 960 Jews of all ages lost their lives, ^{Reference Bauer1} on survivors was compounded by events following the Second World War such as pogroms in Poland, residence in displaced refugee camps and illegal immigration to Israel. These adversities created emotional wounds that took years to heal, if at all. Psychiatrists treating those who survived upon liberation and during the early years after the war coined the term Konzentration Lager (German for ‘concentration camp’) syndrome, ^{Reference Eitinger2,Reference Eitinger3} since the modern term ‘post-traumatic stress disorder’ (PTSD) ⁴ was not then available to encompass the manifold psychopathological wounds and early scars they detected. ^{Reference Chodoff5} These were imputed to the multiple and repeated assaults on the person, family and community. ^{Reference Levav and Dohrenwend6}

Eitinger, in the early 1960s, searched for the presence of the Konzentration Lager syndrome in three paired samples of survivors in Israel and Norway. ^{Reference Eitinger3} Those in Israel were identified among in-patient psychiatric services (n = 396), psychiatric clinics (n = 92) and collective communities (kibbutzim) (n = 66). In Norway the samples included patients from psychiatric hospitals (n = 96), individuals referred for claim compensation (n = 152) and ex-prisoners of war (n = 50). Eitinger found different proportions of the syndrome by settings: in the three Israeli samples they were 27%, 55% and 35% respectively, whereas the respective findings in the three Norwegian groups were 36%, 81% and 6%. However, Eitinger's study, although showing the psychiatric impact of the war experiences, did not fit a true community-based design nor did it apply standardised methods to derive diagnoses.

Over the years, including long after the Second World War, ^{Reference Amir and Lev-Wisel7} several surveys on emotional distress have been conducted, for example in Canada and Israel. These community surveys relied on standardised instruments to measure emotional distress, such as the 12-item General Health Questionnaire. ^{Reference Goldberg, Gater, Sartorius, Ustun, Piccinelli and Gurejo8} Almost invariably respondents who had survived the Holocaust were found to have higher emotional distress scores than suitable comparison groups. ^{Reference Levav and Dohrenwend6} Importantly, all studies were conducted in contexts independent from secondary gains linked to compensation claims that could have compromised their reliability. The survivor groups often included people who were adults during the war, but rarely those who went through it as children or adolescents, as in our study.

Curiously, and in marked contrast to the rich clinical literature on the psychiatric disorders of Holocaust survivors, no epidemiological study on the true prevalence of those disorders ever followed Eitinger's inquiry. The Israel-based component of the World Mental Health Survey (Israel–WMHS) included both people who had survived the Holocaust and a suitable comparison group. ^{Reference Levinson, Lerner, Zilber and Levav9} This enabled reporting on the first community-based inquiry, and given the dwindling number of survivors through their advancing age, it may remain as the only study to examine relevant psychiatric diagnoses, e.g. depressive and anxiety disorders, including post-traumatic stress disorder (PTSD). In addition, we examined emotional distress, sleep disturbances, complaints of pain, body mass index (BMI), selected self-reported chronic medical conditions, smoking and mental health services utilisation.

Method

Results

Those who had survived the Holocaust were significantly older (mean age 74.6 years, s.d. = 6.9) than their counterparts (mean age 69.0 years, s.d. = 8.5; t = 6.31, d.f. = 282, P<0.001). There were significant age differences among the three Holocaust subgroups (P<0.01). People who had lived in ghettos or in hiding were younger than those in the other two subgroups (P<0.01) and closer in mean age to the people in the comparison group. The percentage of those with relatively higher education was lower than for the comparison group (23.2% and 47.2% respectively; χ² = 18.09, d.f. = 1, P<0.001).

Half of the survivor group defined themselves as secular, in contrast to 70% of the comparison group (χ² = 16.21, d.f. = 1, P<0.001). There was no statistically significant difference in gender or marital status between the two groups. On average, respondents in the survivor group were 15.6 years old (s.d. = 6.9) at the end of the war. Those who were in ghettos or in hiding (mean age 12.0 years, s.d. = 7.4) were significantly younger in 1945 than those in concentration camps (mean age 17.4 years, s.d. = 5.2; t = −3.92, d.f. = 139, P<0.001) and those who fled Nazi-controlled countries (mean age 16.5 years, s.d. = 7.2; t = −2.82, d.f. = 139, P<0.01).

Respondents in the survivor group lived apart from one or both parents below the age of 16 years with greater frequency than their counterparts (25.5% and 16.1% respectively; χ² = 3.9, d.f. = 1, P = 0.06). Of the former group (n = 34), 22 individuals had lost a parent on account of death, in contrast to the comparison group (10 of 24 individuals).

Anxiety disorders

The combined lifetime rate of anxiety disorders among the survivor group (16.1%) was statistically significantly higher than among the comparison group (3.9%; OR = 4.8, 95% CI 1.8–12.4), and this was also the case for 12-month prevalence rates (6.9% and 0.6% respectively; OR = 12.1, 95% CI 1.5–99.3). The respective rate differences remained significant after controlling for age, religious observance and education (OR = 6.8, 95% CI 1.9–24.2 and OR = 22.5, 95% CI 2.5–204.8) (Table 1). When specific anxiety disorders were examined, we found that the lifetime rates of PTSD (3.8%), panic disorder (1.1%) and generalised anxiety disorder (2.9%) in the survivor group were not significantly different from the comparison group (0.0%, 0.0% and 2.6% respectively).

Table 1

Comparison of those exposed and not exposed to the Holocaust: anxiety and depressive disorders, emotional distress and other health dimensions

			Statistical significance
	Holocaust group (n=145)	Comparison group (n=143)	Uncontrolled OR (95% CI) a	Controlled OR (95% CI) a
All anxiety disorders, %
Lifetime rates	16.1	3.9	4.8 (1.8-12.4)	6.8 b (1.9-24.2)
12-month rates	6.9	0.6	12.1 (1.5-99.3)	22.5 b (2.5-204.8)
All depressive disorders, %
Lifetime rates	10.0	9.9	1.0 (0.5-2.7)	1.8 b (0.7-4.8)
12-month rates	5.6	4.7	1.2 (0.4-3.7)	1.9 b (0.5-7.6)
Sleep disturbances, past 12 months, %	62.4	33.0	3.4 (2.0-5.6)	2.5 c (1.4-4.4)
Mental health services utilisation, %
Ever	21.3	21.5	1.0 (0.6-1.8)	1.1 d (0.6-2.2)
Past 12 months e	18.1	11.0	1.8 (0.9-3.5)	1.0 c (0.5-2.0)
Smoking, %
Ever	48.4	44.0	1.2 (0.7-2.0)
Current	10.0	8.1	1.3 (0.5-3.0)
Pain (ever), %	48.5	35.9	1.7 (1.0-2.7)	1.7 f (1.0-2.9)
Cardiocerebrovascular (ever), %	64.0	48.0	1.9 (1.2-3.2)	1.5 b (0.8-2.5)
Overweight, measured by BMI, % h	60.3	58.2	1.1 (0.7-1.8)
Emotional distress score (past 30 days), mean (s.d.)	19.9 (6.1)	16.7 (4.8)	t = 4.8, d.f. = 282, P < 0.001	t = 3.6, d.f. = 279, P < 0.001 g

a. Comparison group as reference.

b. Controlling for age, religious observance and education.

c. Controlling for age, religious observance, education and past-year anxiety and mood disorders combined.

d. Controlling for age, religious observance, education and lifetime anxiety and mood disorders combined.

e. Utilisation of mental health professionals, doctors or other health professionals, psychotropic medications, religious counsellors or healers.

f. Controlling for age, religious observance, education and mood disorders during lifetime.

g. Product of linear regression controlling for age, religious observance and education.

h. Defined as a body mass index (BMI) ≥25 kg/m².

Discussion

The Second World War ended in 1945, yet for some – but not all – of those who survived the Holocaust the psychopathological impact seems to have been present over the years, and even six decades later. We found that anxiety disorders (combined), emotional distress and sleep disturbances were more frequent among Holocaust survivors living in the community than among their counterparts. All health dimensions analysed were controlled for possible confounders. Importantly, our findings of psychopathological problems did not seem to result from learning about symptoms in the clinical context, since those in the survivor group used mental health services no differently from the comparison group, and secondary gain was unlikely in the context of our survey. Other dimensions of morbidity investigated, such as depressive disorders (expected to be higher on account of the early losses sustained by those in the survivor group) and PTSD (following threats to their life and/or physical integrity), were not elevated. The latter two negative findings pose intriguing issues for further research in analogous populations. Also negative were the findings on pain, selected self-reported cardiovascular problems, obesity and smoking.

As there are no similar studies in other countries where Holocaust survivors ultimately settled, such as Australia, Canada and the USA, it cannot be ascertained whether the higher rates of psychopathological morbidity elicited are confined to Israel, where survivors participated actively or passively in wars and were directly or indirectly exposed to terror throughout most of their lives. These events could have interacted with prior vulnerability resulting from Second World War adversities.

What was learned? Young survivors mostly lived in ghettos or in hiding (e.g. in forests, sheltered by non-Jewish families), whereas those in camps perished. ^{Reference Bauer1} Their personal narratives and psychopathology have been documented by Kielson in Europe, Kestenberg & Brener in the USA and Solomon & Chaitin in Israel. ^{Reference Kielson17–Reference Solomon and Chaitin19} What emerged from all these studies is that the young were vulnerable to adversity and stressful events, whether experienced directly, e.g. hunger and forcible separations, or indirectly, through victimisation of their parents and siblings. For some of the survivors who were young at the time, traumatic events continued after the war ended, such as upon leaving their places of hiding, with the resulting new separations from those who had protected them. ^{Reference Van del Hal, Brom, Solomon and Chaitin20} As for survivors who were born during the Second World War itself, stress may have affected them as early as during the intrauterine period of life. ^{Reference Glynn, Wadhwa, Dunkel-Schetter, Chicz-Demet and Sandman21} However, contrary to our expectations that the age at which the survivors faced adverse wartime experiences would affect them differently (age less than 10 years at the time of the Holocaust v. age 10 years or older), the interaction term between these relevant variables in the multivariate analysis yielded no significant effect.

To explain the psychological effects of Second World War adversities on young individuals and their lingering effects, theoreticians have suggested a number of different mechanisms that might act at different stages of life. Initially, these have been described for childhood. ^{Reference Van del Hal, Brom, Solomon and Chaitin20,Reference Garwood22} In later years, feelings attached to the encapsulated memories of the adverse past events might return, possibly reactivated by other events such as the national annual Remembrance Day, visits to the extermination camps in Europe, or war (e.g. the first Gulf War, when the threat of Iraqi missiles carrying lethal gas forced the Israeli population to wear masks and stay in sealed rooms). ^{Reference Solomon and Prager23} Lastly, in older individuals, who often engage in retrospection, past memories might vividly evoke those early years of deprivation, losses and persecution, and as a result repressed or suppressed feelings might emerge.

Noteworthy in the context of this trauma are the reported sleep disturbances, also found in a community-based study of elderly people who were Holocaust survivors. ^{Reference Shemesh, Levav, Radomislensky, Brodsky and Kohn24} The sleep disturbances could result from (or even be independent of) the lingering components of non-specific post-traumatic disorders, ^{Reference Rosen, Reynolds, Yeager, Houck and Hurwitz25} in which repeated and traumatic imagery or dreams regularly may appear during sleep. Rosen et al reported that the survivor group (n = 42) ‘had… more frequent awakenings due to bad dreams… than depressed (n = 37) and healthy subjects (n = 57)’. ^{Reference Rosen, Reynolds, Yeager, Houck and Hurwitz25} More recently, Bader et al attributed the primary insomnia found among adults with a history of childhood maltreatment to an ‘aftereffect of long-lasting stressful experiences in childhood’. ^{Reference Bader, Schaffer, Shenkel, Nissen, Kuhl and Schwander26}

Our results, late psychopathological effects of early severe adversity, agreed with those found by researchers studying abused and other persecuted children, ^{Reference Widom, DuMont and Czaja27,Reference Mollica, McInnes, Poole and Tor28} but differed from the findings of Sigal & Weinfeld in Canada. ^{Reference Sigal and Weinfeld29} Using proxy measures of psychiatric disorders, these authors obtained information from the offspring of parents who were children during the Second World War. They found no difference from a comparison group, a result attributed to the not-yet-developed cognitive capacity of young children to process and interpret traumatic information at the time the events occurred. Also, a study conducted on children who had survived the Holocaust interviewed in Israel during adulthood showed signs of adequate adjustment. ^{Reference Robinson, Rapaport Bar-Sever and Rapaport30} Our results differed from both studies, most probably because their authors did not use a structured psychiatric interview or interview unbiased samples of groups of survivors and comparisons, as done here.

Funding

The Israel National Health Survey (INHS) was funded by the Ministry of Health. The Israel National Institute for Health Policy and Health Services Research and the National Insurance Institute provided additional support.