This document summarizes research on PTSD and grief among Holocaust survivors. It finds that PTSD persists in Holocaust survivors for several reasons, including their inability to mourn losses during the trauma, exposure at a young age without developed coping skills, and exacerbation of symptoms by later-life events like loss of a spouse. Studies show high rates of PTSD in survivors regardless of setting during the Holocaust. While concentration camp survivors exhibited more symptoms, all settings carried PTSD risk. Delayed grief and ambiguous loss may also contribute to PTSD in survivors decades later. Therapeutic interventions are needed to help survivors achieve healthy grieving processes for losses during and since the Holocaust.

1. PTSD and Grief 1
Running head: PTSD AND GRIEF AMONG HOLOCAUST SURVIVORS
Posttraumatic Stress Disorder and Grief among Adult and Child Holocaust Survivors
In Various Settings during Time of Trauma
Alana F. Knoppow
University of Michigan School of Social Work

2. PTSD and Grief 2
Although the Nazi Holocaust came to an end over 60 years ago, its consequences have
reverberated throughout history. For those who survived the Holocaust, its aftermath is
experienced firsthand, in what often manifests as posttraumatic stress disorder (PTSD). A
Holocaust survivor is cumulatively defined as an individual who has survived the Holocaust as
an adult or child, in one of several settings, such as in concentration camps, in hiding, as part of
the partisan resistance, or in foster homes. Additionally, a Holocaust survivor is defined in many
studies as any individual who views him or herself as such (Mtiller, & Barash-Kishon, 1998).
While the trauma of the Holocaust occurred among its survivors several decades ago,
PTSD can still be observed in this population for many reasons. The first reason is that
individuals who survived the Holocaust were unable to mourn the losses around them at the time
of trauma, due to their immersion in a constant struggle to survive from one day to the next. The
second reason is that many survivors ranged from ages of one year through adolescence at the
time of their trauma. These individuals did not have fully developed coping mechanisms, and
also experienced many broken attachments in being separated from their parents and other
family members. : ÿ,ÿ.
sÿ
A third reasoÿ that Holocaust survivors continue to experience PTSD is because their
symptoms are often exacerbated by life events that typically occur within aging populations,
such as the loss of a spouse or moving out of one's own home (Yehuda et al., 2009) and into an
assisted living facility. Events such as these may trigger episodic symptoms of PTSD, when the
individual feels that he or she is re-experiencing the initial losses that occurred several years ago.
A final reason for the continued presence of PTSD among Holocaust survivors is that
many did not consider themselves to be survivors until recently. Many individuals who survived
the Holocaust as young children or in settings outside of concentration camps tended not to view
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3. PTSD and Grief 3
themselves as survivors, or to view themselves as less of survivors than others. Because of this
tendency, this large number of individuals often did not seek treatment for their symptoms of
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PTSD, further allowing them to persist, f,...t.::/ÿ, < ,: " . ,
A rich body of literature exists in support of the aforementioned assertions regarding
PTSD among Holocaust survivors. In a study by Kuch and Cox (1992), 124 survivors of the
Holocaust were assessed for PTSD, whose ages ranged from 3-51. It was found thaÿt 46% of the
total sample met DSM-III-R criteria for PTSD, with the most common symptoms being sleep
disturbance, nightmares, and intense distress over reminders of their trauma (Kuch & Cox,
1992). It was found that survivors of the Auschwitz concentration camp had significantly more
symptoms and were three times more likely to meet the criteria for PTSD than the survivors who
were not in concentration camps. It was also found that most survivors in the sample had not
received adequate psychiatric care. The study also suggested that prolonged exposure to
atrocities produces irreversible effects (1992).
The authors of this study conclude that survivors who were detained in concentration
camps witnessed a greater degree of atrocities, which lead to a greater risk of developing PTSD.
However, many subsequent studies have found that survivors in various settings during the
Holocaust are equally likely to meet DSM-III-R and DSM-IV criteria for PTSD, though their
symptoms manifest in different ways depending on their setting at the time of trauma.
In a study by Lev-Wiesel and Amir (2000), a sample of 170 Holocaust survivors were
assessed for PTSD, as well as several other measures, such as quality of life, psychological
stress, self-identity, and potency. The survivors were divided into four groups, based on their
location during the Holocaust, which included hiding in Catholic institutions, Christian foster
families, in the woods and/or with Partisans, or as prisoners in concentration camps. The study

4. PTSD and Grief 4
found that there were no significant differences among the four groups in presence of PTSD, or
in the particular symptoms of avoidance and arousal. However, it was found that survivors who
were in the woods and/or with Partisans had significantly lower instances of intrusive thoughts
than the other three groups (2000).
Patterns of varying PTSD symptomatology also emerged in studies which assessed
Holocaust survivors in regards to difference in age at the time of trauma. In a study by Yehuda et
al. (1997), a sample of 100 Holocaust survivors was assessed for varying symptoms of PTSD,
depending on their location during time of trauma. Of the total sample, 70 participants were in
concentration camps during the Holocaust, while 30 were in hiding. The study found that the
setting of being in concentration camps vs. in hiding were not associated with differences in
patterns of PTSD symptoms, however, age at the time of trauma was. Additionally, the
cumulative number of stressful events experienced was also associated with different patterns of
PTSD (1997).
Survivors who were in hiding were consistently younger than those in concentration
camps, with those in hiding having a mean age of 12.8 and those in concentration camps with a
mean age of 20.72 (Yehuda et al., 1997). Survivors who were younger at the time of trauma were
rh ÿ--ÿ riQenÿ.ÿ ÿenÿs 0ÿ omÿsoqÿf smÿch)eÿnicamnes,a emotaonaldetachment andmoe 'kelytoexpe' cecu t ympt py g ' " , '
hypervigilence, but less likely to report intrusive thoughts and nightmares. While the findings of
this study have proved impactful in expanding the definition of who constitutes as a survivor, the
authors acknowledge that a longitudinal study would be beneficial to supplement their findings
(1997).
In an additional study by Yehuda et al. (2009), a longitudinal assessment of Holocaust
survivors with and without PTSD was performed, evaluating symptoms at two intervals,

5. PTSD and Grief 5
approximately ten years apart. The original sample included 63 participants, with 40 who were
available for follow-up (2009). The authors found that although there was a general decrease in
PTSD symptom severity over time, 10% of the participants developed delayed onset of PTSD
symptoms between time one and time two of assessment. The study also demonstrated a
worsening of trauma-related symptoms over time for participants without PTSD at time one, but
an improvement for those with PTSD at time one (2009). For survivors who experienced a
delayed onset of PTSD symptoms, it was found that intrusive thoughts decreased between time
one and time two, while avoidance and hyperarousal increased. The authors note that "delayed"
PTSD in this group is reflective of a change in distribution of symptomatology, rather than the
introduction of previously absent symptomatology (2009).
The authors also assessed both groups for experience of additional traumatic events
between time one and time two. Such events included the death of a sibling, child, or premature
death of a spouse. It was found that a greater percentage of those with delayed onset of PTSD
experienced a traumatic loss between time one and time two (Yehuda et al., 2009). (' ,, i/<'
Several studies by other researchers support Yehuda et al. 's (2009) findings that PTSD in
Holocaust survivors may relate to the experience of new traumas commonly associated witk ÿ,
aging. A study by Trappler, Cohen, and Tulloo (2007) assessed a sample of 36 Holocaust (ÿ! iÿ tÿ
survivors for symptoms of PTSD and depression, in comparison of a group of older adults who
were not Holocaust survivors. The study found that both depression and PTSD were very high
among the sample of Holocaust survivors, and that depressed survivors had significantly worse
psychological and social functioning than depressed non-survivors. It was also found that
depressed survivors had more PTSD symptoms than non-depressed survivors (Trappler et al.,
2007).

6. PTSD and Grief 6
The authors speculate that trauma victims who have experienced significant loss are more
vulnerable to the effects of a spousal loss, which compounds the effect of frailty on the ability of
the survivors to mobilize their social support systems (Trappler et al., 2007). They further
suggest that because Holocaust survivors are often reluctant to discuss their traumatic symptoms,
their depression goes unnoticed. This is supported by the finding that most of the participants in
this study were non-treatment-seeking (2007).
In addition to the experience of new trauma following the Holocaust, findings from other
studies suggest alternative explanations for the salience of PTSD among survivors. In a separate
study by Yehuda et al. (1997) than that mentioned previously, a sample of 56 non-treatment-
seeking Holocaust survivors was assessed for alexithymia, using the Toronto Alexithymia Scale-
Twenty Item Version. The authors also compared associations among alexithymia, severity of
trauma, and severity of PTSD symptoms. The symptoms that were measured were intrusive
thoughts, avoidance, and hyperarousal. It was found that survivors with PTSD had significantly
higher scores for alexithymia than survivors without PTSD. The authors noted a strong
association particularly between alexithymia and symptoms of avoidance and hyperarousal
(Yehuda et al., 1997).
The study also found that alexithymia scores were significantly associated with severity
of PTSD symptoms, but not with severity of initial trauma experienced (Yehuda et al., 1997).
The authors hypothesize that the characteristic of alexithymia is a component of PTSD, rather
than an effect of trauma. Alternatively, they hypothesize that alexithymia may be an adaptation
to having PTSD. Lastly, the authors suggest that alexithymia in Holocaust survivors with PTSD
is a preexisting trait that facilitates the expression of PTSD in response to trauma (1997).

7. PTSD and Grief 7
The presence of PTSD among Holocaust survivors can be explained by many theories
pertaining to grief and loss, presented by Worden (2009) and Doka (1989, 2002). The first of
these is the concept of disenfranchised grief. In disenfranchised grief, the mourner experiences
losses that are not socially sanctioned (Doka, 1989, 2002; Worden, 2009). As a result, the gravity
of the loss is minimized to the mourner by those around him or her. This can in turn result in the
mourner minimizing the loss to her or himself. This then results in the failure of the individual to
seek treatment, as is the case for many Holocaust survivors with PTSD (Yehuda et al., 1997;
Yehuda et al., 2009).
Disenfranchised grief can be observed in multiple populations of Holocaust survivors.
This is true both for child survivors, and for survivors who were not in concentration camps
during the Holocaust. Most studies of PTSD in Holocaust survivors pertained to adult survivors
who were in concentration and labor camps (Lev-Wiesel and Amir, 2000). In the case of child
survivors, they were often viewed as not being "full" survivors, and that they were not old
enough to understand the atrocities around them. This is also true of survivors who were not in
concentration or labor camps, who are not always viewed as "full" survivors. As an 87-year-old
woman who escaped from Germany and lived with a Christian foster family in England stated, "I
was surprised to learn that I was considered a Holocaust survivor," (Anon., personal
communication, November 21, 2010).
For this large number of individuals who had for many years been viewed as less than
complete survivors, their losses were minimized by those around them, and by themselves.
However, several studies (Lev-Wiesel & Amir, 2000; Trappler, Cohen, & Tulloo, 2007; Yehuda
et al., 1997), have found that child survivors in various settings outside of concentration camps
experience the same degree of PTSD as adult survivors who were in concentration camps. With

8. PTSD and Grief 8
the support of these studies, and others (Dasberg, Bartura, & Amit, 2001; Fogelman, 1988;
Clements-Cortds, 2008), these survivors can begin to recognize their losses, and seek treatment
towards healthy grieving. For Holocaust survivors with PTSD, healthy grieving can only be
achieved as the result of a therapeutic intervention, which will be discussed in the final section of
this paper.
An additional theory brought forth by Worden (2009) is that of delayed grief, as well as
the related experiences of multiple losses, bereavement overload, and ambiguous loss. Delayed
grief occurs when the mourner did not have a reaction that was sufficient to the scale of the loss,
at the time of the loss. The mourner then experiences the symptoms of grief at a later time in
response to a subsequent loss, where the grieving will seem excessive (Worden, 2009). Worden
also points out that one mediator that is frequently associated with delayed grief is the lack of
social support at the time of loss (2009). Multiple losses occurring at once can also cause
grieving to be postponed, as the scope of the combined losses may lead to grief overload (2009).
Delayed grief can be observed in the cases of many Holocaust survivors. In the
longitudinal study by Yehuda et al. (2009), it was found that Holocaust survivors who were not
previously diagnosed with PTSD did ultimately meet the criteria for the disorder, following the
death of a sibling, child, or premature death of a spouse. For these individuals, the onset of
particular symptoms associated with PTSD occurred several decades after the trauma of the
Holocaust was experienced, as was triggered by the event of a new loss.
Multiple losses and grief overload can also be observed in many Holocaust survivors,
where losses refer not only to witnessing deaths, but also to the loss of normal daily life and self-
identity. Such cases are discussed in the study by Lev-Wiesel and Amir (2000), in reference to
survivors who were in different settings during the Holocaust.

9. PTSD and Grief 'ÿi
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For children who hid in Catholic institutions, they were forced to give up their religion,
which was a significant part of their identity (Lev-Wiesel & Amir, 2000). Hiding in foster care
with Christian families often meant the same degree of loss of one's religious identity. Survivors
in both settings often faced the loss of their family or neighbors, who were not necessarily
rescued with them. This is particularly the case for children who were hidden, who faced the loss
of their parents, uncertain of whether they survived or were murdered in any number of ways.
This experience can result in multiple losses, compounded by the additional experience of
ambiguous loss.
For survivors who were in concentration camps, these individuals often witnessed the
death of their entire families, as well as numerous others, simultaneously. This meant that they
were not able to grieve for each family member individually, and that they did not have the
mediating social support mentioned by Worden (2009), as their social supports were often those
who were annihilated. Survivors in this setting also faced the challenge of day-to-day survival, as
they constantly suffered from cold, thirst, and hunger. This also prohibited them from adequately ÿ) ÿ"
grieving their many losses. -.{ . ÿ ,
For survivors who hid in the woods and/or with Partisans, this meant that they were 'ÿ.:' !ÿ ÿ /
constantly running from place to place, and also suffered from constant cold, thirst, and hunger, ÿ"ÿ'ÿ:ÿ"
j
(Lev-Wiesel & Amir, 2000). Although they were in a different setting than those in
concentration camps, they faced many analogous struggles of daily survival, prohibitive of
grieving. They also suffered from multiple losses, of their families, villages, and normal daily
living. For survivors who hid with or who became Partisans, their families did not always come
with them. In some instances they had watched their families perish, while in others, the fate of
their families were unknown, which also resulted in multiple and ambiguous losses.

10. PTSD and Grief 10
In the instances of multiple losses, grief overload, and ambiguous loss in Holocaust
survivors, the path to healthy grieving could not be initiated immediately following the time of
the loss, often resulting in delayed grief. It follows that because grieving was not achieved at the
time of the losses and trauma during the Holocaust, PTSD developed for many of these
survivors. In order to guide Holocaust survivors with PTSD toward healthy grieving, outside
interventions and social support (Worden, 2009) are again necessary.
There are many interventions discussed in the literature pertaining to Holocaust survivors
who suffer from PTSD. While individual psychotherapy for Holocaust survivors has largely been
ineffective (Somer, 1994; Miller & Barash-Kishon, 1998), many treatment modalities have
emerged employing group, family, and couples therapy.
Researchers Miller and Barash-Kishon (1998) developed group therapy programs for
Holocaust survivors. In this model, a group of 14 Holocaust survivors who had been diagnosed
with PTSD met once monthly. The survivors were in various settings during the Holocaust, and
were different ages. None had previously participated in group therapy (Miller & Barash-
Kishon, 1998). The main goals of the model were to improve group members' adaptation to their
inner and outer worlds, and to help them reach the "working-through" phase of mourning and
coping with stress. These goals were worked towards through the technique of allowing the ,,
group members to talk about their experiences openly, while the two group leaders occasionally
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interceded to help bring clarity and understanding of difficult or contradictory thinking expressed "i::' ?,.
by group members. The leaders also intervened to resolve issues resulting from various defense
mechanisms expressed by group members. The leaders further intervened to mediate heated
arguments among group members, while maintaining neutrality (1998).
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11. PTSD and Grief 11
The researchers found that the supportive atmosphere of the psychodynamic therapy
group allowed its members to share their past traumas and present life events, as well as positive
• To determine if the participants ÿ. ÿj '('ÿevents occurring in their lives (Mtfller & Barash-Kishon, 1998) ÿ.:-,
were on the path ..........towards healthy grieving, they were observed for whether or not they had : 'J
reached the "working-through" phase of grieving. This was determined by the presence of
minimized intrusive thoughts. The other major determinant was whether they began to reach
self-acceptance, thus no longer minimizing or denying their own losses (1998).
In this model, the researchers exhibit several techniques that can be used as best practices
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among other practitioners. One technique is to allow input and guidance from the participants.
This is particularly important with respect to achieving the appropriate balance between
exploring past events and being overcome by emotions from painful memories. For instance, the
group leaders asked the group members if they would like to increase their meeting times, and all
group members responded emphatically that they would prefer not to (Miiller & Barash-Kishon,
1998). Another standard of practice employed by the researchers was to allow room for
dissention within the discussion, while mediating with a sense of neutrality (1998). This was of
particular importance, as one of the main tenets of the group was to give its members an outlet
for their feelings, which will inevitably collide with those of others, in some instances. By
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remaining neutral, the group leaders were able to maintain the trust from all group members that
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was vital to the success of the group.
However, in some instances, individual therapy has been effective when using techniques
outside of traditional psychotherapy. One technique that has been beneficial is music therapy, as
presented in a study by Clements-Cortds (1998). The researcher focused her intervention on
"Yetta," a child survivor nearing the end of her life. The goals of this therapeutic technique were

12. PTSD and Grief 12
for Yetta to increase her social interaction through music making and discussion, to engage in
play through the use of percussion instruments, to reflect, reminisce, and carry out a life review,
to use music to enhance and facilitate emotional expression, and to increase current quality of
life (Clements-Cort6s, 1998).
Through sharing her life history in conjunction with music making, Yetta was able to
express feelings and emotions about her life in hiding during the Holocaust. She felt that she was
able to release feelings of anger, and reengage with her true identity, which were feelings that
had been stifled since the Holocaust ended. Through these means, Yetta was able to achieve her
therapeutic goals (1998). ÿ,ÿ':v-; )ÿ ÿ ÿ<ÿ,,ÿ, .ÿ ....
}
In this study, Clements-Cortds ÿexhibited many of the same standards of best practices
employed by the previously mentioned researchers. The researcher also used the technique of
allowing the participant to guide the content of dialogue, while practicing sensitivity in response
to painful topics. In addition to allowing the participant to maintain autonomy during therapy,
Clements-Cortds worked collaboratively with her, helping her to write songs. These songs served
as a means for Yetta to express her memories about her time in hiding, and to honor the people
who perished during the war (1998). ÿ ÿ: jr v" ÿ;7 ,< ....
In addition to the predetermined goals outlined by the researcher, this helped Yetta to
bring meaning and closure to the losses she experienced. Through this experience, she was also
able to integrate her early life experiences to see how they impacted her choices later in life,
which reduced much of her unresolved anxiety (Clements-Cortds, 1998). By experiencing
reduced anxiety, a sense of closure, and a regained sense of identity, Yetta was able to achieve
healthy grieving in her final years in life. " : L¢ÿ';:?

13. / ÿ;!:; ' "/ÿ PTSD and Gfieÿ
/.: . i;ÿ ÿ . /w .
In other instances, pharmacological interventions have also proved beneficial for
13
Holocaust survivors who have PTSD. In a study by Peskinjÿ et al. (2003), a sample of nine older
adult males with PTSD in response to military or Holocaust trauma were prescribed the drug;/. ......,
Prazosin for treatment-resistant trauma-related nightmares. The goal of this intervention was to ,:j 5 " ;/ÿ
*,/J !('./
treat the specific symptom of trauma-related nightmares. It was found that the drug substantially " ,;;ÿ-' "' ' ,, ;
,,f
reduced nightmares and moderately or significantly reduced overall PTSD severity in eight of
the nine participants (Peskind et al., 2003), thus accomplishing the goal of the study.
By eliminating one profound symptom of PTSD, nightmares, the patients in this study
were able to begin moving towards healthy grieving. Because it is not always possible to treat
certain symptoms of PTSD in other therapy settings, using pharmacological means when
available is an important aid to those suffering from PTSD. Treating and eliminating the
symptoms of PTSD one at a time will allow the individual to begin to grieve in a healthy
manner. Best practices in this study included evaluating each patient's medical history, to
confirm that the drug intervention would not have adverse effects. As a result, the drug was well-
tolerated among all patients.
While many Holocaust survivors continue to experience PTSD so many decades after
they experienced trauma, it is possible for practitioners to initiate interventions to alleviate their
suffering. The experience of PTSD as unhealthy grief among Holocaust survivors does not have
to persist. By recognizing the losses of various populations of survivors, and by employing the
standards of best practices outlined in the literature, it is possible to help Holocaust survivors
experiencing PTSD, even in their final years of life.

14. PTSD and Grief 14
References
Clements-Cortds, A. (2008). Music to shatter the silence: A case study on music therapy, trauma,
and the Holocaust. Canadian Journal of Music Therapy, 14(1), 9-21.
Dasberg, H., Bartura, J., & Amit, Y. (2001). Narrative group therapy with aging child survivors
of the Holocaust. Israel Journal of Psychiatry and Related Sciences, 38(1), 27-35.
De Graaf, T.K. (1998). A family therapeutic approach to transgenerational traumatization.
Family Process, 37(2), 233-243.
Fogelman, Eva. (1988). Intergenerational group therapy: Child survivors of the Holocaust and
offspring of survivors. Psychoanalytic Review, 75(4), 619-640.
Klaus, K., & Cox, B. (1992). Symptoms of PTSD in 124 survivors of the Holocaust. The
American Journal of Psychiatry, 149(3), 337-340.
Lev-Wiesel, R., & Amir, M. (2000). Posttraumatic stress disorder symptoms, psychological
distress, personal resources, and quality of life in four groups of Holocaust child survivors.
Family Process, 39(4), 445-459.
Mazor, A. (2004). Relational couple therapy with post-traumatic survivors: links between post-
traumatic self and contemporary intimate relationships. Contemporary Family Therapy,
26(1),3-21.
Mtiller, U., & Barash-Kishon, R. (1998). Psychodynamic-supportive group therapy model for
elderly Holocaust survivors. International Journal of Group Psychotherapy, 48(4), 461-
475.
Peskin, E.R., Bonner, L.T., Hoff, D.J., & Raskind, M.A. (2003). Prazosin reduces trauma-related
nightmares in older men with chronic posttraumatic stress disorder. Journal of Geriatric
Psychiatry and Neurology, 16(3), 165-171.
Somer, E. (1994). Hypnotherapy and regulated uncovering in the treatment of older survivors of
Nazi persecution. Journal of Aging and Mental Health, 14(3), 47-65.
Trappler, B., Cohen, C., & Tulloo, R. (2007). Impact of early lifetime trauma in later life:
Depression among Holocaust survivors 60 years after the liberation of Auschwitz. American
Journal of Geriatric Psychiatry, 15(1), 79-83.
Worden, W. J. (2009). Grief counseling and grief therapy." A handbook for the mental health
practitioner (4th ed.). New York: Springer Publishing Company.
Yehuda, R., et al. (1997). Alexithymia in Holocaust survivors with and without PTSD. Journal
of Traumatic Stress, 10(1), 93-100.
Yehuda, R. et al. (1997). Individual differences in posttraumatic stress disorder symptom profiles

15. PTSD and Grief 15
in Holocaust survivors in concentration camps or in hiding. Journal of Traumatic Stress,
10(3), 453-463.
Yehuda, R. et al. (2009). Ten-year follow-up study of PTSD diagnosis, symptom severity and
psychosocial indices in aging holocaust survivors. Acta Psychiatrica Scandinavica, 119(1),
25-34.