Acta Psychiatr &and 1999: 100: 35k358 Printed in UK All rights reserved

Copyright 0 Munksgaard 1999 ACTA PSYCHIATRICA

SCANDINA VICA ISSN 0902-4441

Fifty years later: the long-term psychological adjustment of ageing World War I1 survivors

Bramsen I, van der Ploeg HM. Fifty years later: the long-term psychological adjustment of ageing World War I1 survivors. Acta Psychiatr Scand 1999: 100: 350-358. 0 Munksgaard 1999.

Objective: Most studies of the long-term after-effects of war have focused on survivors seeking treatment or financial compensation. The present study examined the current psychological adjustment of a community sample of ageing World War I1 (WW 11) survivors, including survivors of bombardments, persecution, resistance, combat and other violence. Method: A community sample of 4057 Dutch WW I1 survivors answered a 4-page postal questionnaire. Of these, 1461 survivors answered a second follow-up questionnaire. Results: Even 50 years after World War 11, a statistically significant but modest relationship was found to exist between exposure to shocking war events and current psychological adjustment in terms of symptoms of post-traumatic stress disorder (PTSD), anxiety and anger. A total of 66 respondents (4.6%) met the criteria for PTSD. The highest level of current PTSD (1 3%) was found among survivors of persecution. The lowest level of PTSD (4%) was found among civilian war victims and resistance participants, while military veterans had an intermediate score (7%). With regard to absolute numbers, civilian war victims represented the largest proportion of PTSD sufferers. Conclusion: In a study of a community sample of WW I1 survivors, we found that most of these survivors had no severe symptoms of PTSD. Nevertheless, probably tens of thousands of Dutch individuals are still suffering from long-term after-effects from World War 11. For these vulnerable survivors, the ageing process will complicate the coping process.

Introduction

Immediately after World War I1 (WW 11) it was thought that individuals with shocking war experi- ences would recover within a foreseeable period of time. However, during the 1950s and 1960s it became clear that such experiences could have long- lasting consequences (1-3). Today we know that these after-effects may even extend to the families of survivors (4).

Many studies have demonstrated the negative after-effects of man-made violence on the lives of concentration-camp survivors, military veterans, prisoners of war and resistance fighters (5-9). In contrast, few studies have been conducted on the effect of acts of war on civilians, such as bombard-

1. Bramsen, H. M. van der Ploeg Department of Medical Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands

Key words: post-traumatic stress disorder; war. survivors; prevalence

lnge Eramsen. Vrije Universiteit Amsterdam, Department of Medical Psychology, Van der Boechorststraat 7, 1081 ET Amsterdam, The Netherlands

Accepted for publication March 3, 1999

ments or battle actions in populated areas. The prevalence of illness or psychological problems in adaptation is therefore not known for this group. Nor is there any information about the prevalence of medical and psychological after-effects among the Dutch survivors of the Japanese internment camps, who were also exposed to extreme violence during the Indonesian independence struggle imme- diately following WW 11.

Many studies on the after-effects of war have focused solely on those survivors who sought professional help or applied for financial com- pensation. The main focus of these studies was therefore on psychopathological consequences. Moreover, the findings of studies focusing on help-seeking populations cannot be generalized to

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people with similar experiences who did not seek help or financial compensation.

The first generation of WW I1 survivors is currently ageing. Due to demographic develop- ments, the number of survivors will decrease. However, the problems of the remaining survivors may increase. It is therefore important to follow the current psychological adjustment of these ageing survivors.

The objective of the present study was to examine the long-term after-effects of war in a community sample of ageing citizens who experienced and survived World War 11. Therefore, a large random community sample of Dutch people who were old enough to have experienced WW I1 was invited to participate in a survey. Such a sample would consist of help-seeking as well as non-help-seeking WW I1 survivors. Civilians as well as military veterans were included. The majority experienced the German occupation of The Netherlands (1940-1945). Others experienced the occupation of the Dutch East Indies by the Japanese (1942-1945) and the subsequent Indonesian independence struggle (1945-1950).

The following research questions were examined.

(i) Is there a relationship between reported war events and current psychological adjustment in terms of symptoms of PTSD, anxiety, depression, anger, somatic complaints and sleeping problems, 50 years after the end of ww II? Is there a relationship between the reported war events and a full or partial diagnosis of PTSD?

(iii) Which groups of survivors are particularly at risk for developing long-term after-effects?

(ii)

Material and methods

Subjects

A 5% sample (n= 10 622) of individuals with dates of birth between 1920 and 1929 was randomly selected from the municipal population register of nine Dutch cities (with 85 000-700 000 inhabitants). The age range chosen included (i) people who experienced World War I1 (1940-1945) as ado- lescents or young adults and (ii) a large group of Dutch military veterans.

Procedures

The subject of World War I1 can be very emotive for the section of the population we wished to contact. Therefore, we designed a procedure that allowed for several ‘levels’ of participation. In the first phase, all

subjects received a short postal questionnaire (four pages long) with a covering letter and a stamped addressed envelope for return. Respondents who were willing to participate in the follow-up had to fill in their name and address. In the second phase, the subjects received an extensive questionnaire with a covering letter and a stamped addressed envelope for return. Respondents could apply for a report of the results and, to increase the response in the second phase, subjects were offered a gift voucher of 10 Dutch guilders (approximately 6 US $). Adequate arrangements were made to provide support and after care (10). This design, allowing for several ‘levels’ of participation, also enabled us to study possible selection of respon- dents into the second phase by means of several relevant first-phase variables concerning war expo- sure, general health, symptoms of PTSD, and health-care utilization.

Instruments

First-phase questionnaire. We asked whether subjects personally experienced any of 19 trau- matic war events. On the basis of these items, five categories were defined: (i) ‘civilians exposed’ (e.g. civilians who experienced bombardments); (ii) ‘persecuted in Europe’ (survivors of German concentration camps and Jewish people who survived the war in hiding); (iii) ‘persecuted in Asia’ (survivors of Japanese camps and perse- cution by Indonesian nationalists); (iv) ‘resistance participants’; and (v) ‘military veterans’.

‘No exposure’ and ‘multiple exposure’ groups were also differentiated.

With regard to stressor intensity, a list of nine additional events based on the A Criterion for PTSD according to the DSM-111-R (1 1) measured the degree of exposure to violence. The sum over the total number of 28 war events was used as an additional measure of stressor intensity.

With regard to perceived wartime stress, respon- dents were asked to choose which of the following statements was applicable to them. ‘What I experienced during or shortly after the Second World War ... (i) is the worst thing that ever happened to me, (ii) was bad, but not the worst, (iii) was fairly bad, or (iv) was not bad’.

With regard to physical and psychological well- being, a question taken from an annual large-scale health survey of the Dutch population (12) was included in order to obtain information about general health, namely ‘How is your health on the whole?, with five response categories ranging from ‘very good’ to ‘poor’. Two additional items asked respondents whether they had either physical or psychological complaints as a consequence of their

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war experiences. The response categories ranged from ‘not at all’ to ‘very much’.

With regard to anxiety, depression and PTSD symptoms, three high-loading items were selected from the Dutch validated adaptation of the State- Trait Anxiety Inventory (STAI) (13) and three high-loading items were selected from the Dutch validated adaptation of the Zung Self-Rating Depression Scale (SDS) (14). Significant correla- tions of 0.81 (anxiety) and 0.75 (depression) were found between the shortened scales and the full scales in the second phase. To measure symptoms of a Post-Traumatic Stress Disorder (DSM-111-R) (1 l), we included two items on re-experiencing the trauma (B), one item on avoidance (C) and two items on hyperarousal (D).

Second-phase questionnaire. Symptoms of PTSD (DSM-111-R) were measured by means of the Self- Rating Inventory for PTSD (SRIP) (15). Hovens et al. (15) found that the SRIP had a high test- retest reliability and validity scores and excellent sensitivity and specificity. The SRIP was designed to collect information on symptoms independent of the trauma. This approach has two important advantages since (i) it also enables the assessment of PTSD symptoms in survivors who do not attribute their symptoms to World War I1 and (ii) it allows comparison of the risk for PTSD among respondents who have been exposed to shocking war events and respondents who reported no exposure to such events, or who have been exposed to other events. Sum scores were derived for Intrusion (5 items), avoidance (9 items), hyper- arousal (8 items) and PTSD symptoms (SRIP- DSM). A full diagnosis of PTSD was determined by means of a cut-off score of 253 on the SRIP- DSM. Cronbach’s alpha values for this study sample for the scales of intrusion, avoidance, hyperarousal and the total scale were 0.80, 0.82, 0.90 and 0.9 1, respectively.

Anxiety was measured with the trait-version of the Dutch validated adaptation of the State-Trait Anxiety Inventory (STAI) (1 3), which measures the tendency to react to situations that are experienced as threatening with an increase in anxiety, tension and heightened activity of the autonomous nervous system. Cronbach’s alpha for the study sample was 0.92.

For depression, the Dutch validated adaptation of the trait Zung Self-Rating Depression Scale (SDS) (14) was used, which measures the tendency to react to certain situations with feelings of depression and heightened activity of the autono- mous nervous system. Cronbach’s alpha was 0.83.

Anger was measured with the trait version of the Dutch validated adaptation of the Spielberger

352

State-Trait Anger Scale (STAS) (16), which mea- sures the tendency to react to situations with an increase in feelings of anger, tension and heightened activity of the autonomous nervous system. Cronbach’s alpha was 0.89.

Somatic complaints were measured with the somatic complaints scale of the Dutch validated adaptation of the SCL-90 (17). This scale measures complaints that are associated with a generalized feeling of physical malfunctioning. Cronbach‘s alpha was 0.88.

Participation

In the first phase, 4057 questionnaires were fully completed and could therefore be used for statistical analysis (38%). The age of responders was slightly older (mean=67.6 years; SD=8.1) than that of non- responders (mean=67.3 years; SD=8.3; P<0.05). Among responders, the proportion of males was 54%, while 44% of the non-responders were male (P<0.05). Of the 2189 subjects who were willing to participate in the second phase, 1461 individuals (67%) returned a fully completed second-phase questionnaire.

Logistic regression analysis of the first-phase variables showed that the respondents in the second phase reported a higher number of war events (partial correlation (PR)=O. 13 , had a higher level of education (PR=0.05) and were more often male than the non-respondents (PR=0.02). No signifi- cant differences were found in symptoms of PTSD and other psychological and somatic symptoms, or in the use of professional help.

Table 1 shows the classification of the respon- dents into seven war exposure groups. A large majority (86%) reported exposure to at least one war event. The largest group of surviving war victims consisted of civilians who had experienced a bombardment or other violence.

Data analysis

The research questions were studied using the standardized questionnaires of the second phase. The relationship between war stressors and the second-phase variables measuring current psycho- logical adjustment was studied by means of multi- variate analysis of variance (MANOVA). Since the sample sizes were unequal and Box’s M-test was significant (P<O.OOl), indicating that the assump- tion of multivariate homogeniety of variance was violated, Pillai’s criterion was used instead of Wilk’s lambda (18). The risk for PTSD in each war-exposure group compared to the non-exposed group was determined with common odds ratios and one-sided exact P-values testing that the odds

Psychological adjustment of ageing World War I1 survivors

Table 1. The seven war events categories according to the number of reported war events, and participation in the second phase of the study

n %

1. Non-exposed individuals 2. Exposed civilians 3. Persecuted individuals in Europe 4. Resistance participants 5. Military veterans 6. Persecuted individuals in Asia 7. Multiple exposed individuals

All respondents

561 2321

33 384 481 74

203

4057

14 57

1 10 12 2 5

1 DO

Number of reoorted war events Phase II

M SD >4

0.4 0.7 0% 4.2 2.6 41 % 6.0 3 1 61 % 6.3 2.9 67% 6.3 2.5 76% 7.2 3.2 78% 8.9 2.7 95%

4.6 3.4 45%

n %

135 9 800 55 21 1

169 12 209 14 34 2 93 6

1461 1 OD

ratio was unity. Most non-parametric techniques require that sample sizes are reasonably large and well balanced across the populations. Exact non- parametric procedures use permutational methods to compute exact P-values, and are consequently suitable for use in small and skewed samples such as that in the present study (19).

Results

PTSD symptoms, anxiety, depression, anger, sleeping problems and somatic complaints

First, we studied whether differences in current adjustment between the exposure groups can be fully described in terms of PTSD symptoms, or whether there are additional difficulties in adjust- ment that are reflected in the scales measuring anxiety, depression, anger, somatic complaints and sleeping problems.

A MANOVA showed that there were significant differences between the seven war exposure cate- gories on one or more of the dependent variables (Pillai’s criterion=0.07; P<O.OOl). A stepdown analysis with the dependent variables entered in the same sequence as mentioned above showed that the war exposure groups differed significantly in the level of PTSD symptoms (P<O.OOl), anger (P<O.Ol) and anxiety (P<O.OI). Univariate ana- lyses of the group differences showed that on all scales persecuted individuals in Europe had the highest mean scores, followed by persecuted individuals in Asia and multiple exposed individuals who belong to two or more war events categories. The mean scores are shown in Table 2.

PTSD diagnosis in relation to war exposure

Using the SRIP-DSM cut-off score, 66 respondents (4.6%; 95% confidence interval= 3.6%5.8%) met the criteria for a diagnosis of PTSD. Table 3 shows the percentage of PTSD in each war exposure group. Since some cell sizes were small, exact non- parametric procedures were used to test for

significance. The small numbers still need to be treated with caution, as is shown by the 95% confidence intervals in Table 3.

The risk for PTSD was highest among both groups of persecuted individuals. Of the persecuted individuals in Europe, 11.8% (n=4) currently had PTSD, while the corresponding figure was 13.2% (n=7) for persecuted individuals in Asia. They both had a significantly higher risk for PTSD than non- exposed individuals, with a prevalence of 1.5% (n=2).

The risk for PTSD among the military veterans (7.1%; n=21) was significantly higher than that among the non-exposed individuals. Of all the military veterans, 68 subjects fought against the Germans and 233 subjects took part in military actions in the Dutch East Indies in 1946-1949. In these two groups, the percentages with current PTSD were 8.8% (n=6) and 7.3% (n=17), respec- tively. Of the 37 military veterans who took part in more than one battle, 13.5% (n=5) had a current PTSD. All of these prevalence rates were signifi- cantly higher compared to those for the non- exposed individuals (P<0.05).

The percentages with current PTSD among the exposed civilians and among the resistance partici- pants were twice as high as those among the non- exposed individuals, but this difference did not reach the level of statistical significance.

The percentages of subjects with PTSD were also computed for four groups drawn on the basis of the number of reported war events. The proportion of respondents with PTSD increased from 2% (12=6) in the group reporting 0-2 events to 7% (n=28) among those reporting 8-18 events. The Spearman corre- lation showed that this increase in PTSD was statistically significant (P<O.OOl).

Table 1 shows that the exposed civilians had the lowest mean number of reported war events. The lower prevalence of symptoms of PTSD in this group may be due to the fact that this is a heterogeneous group with regard to level of exposure. Therefore, we also computed the pre-

353

Bramsen and van der Ploeg

Table 2. Mean scores on PTSD, anxiety. depression. anger, somatic complaints and sleeping problems in each war exposure group

Persecuted Persecuted Multiple individuals individuals exposed Resistance Militaiy Exposed Non-exposed in Europe in Asia individuals participants veterans civilians individuals

War exposure group (n=21) (n=34) (n=93) (n=169) (n=209) [ n= 800) (n= 135)

Scales Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

PTSD (SRIP) Intrusion"** 9.0 3.7 7.1 2.7 7.6 3.2 6.9 2.3 6.5 2.7 6.5 2.3 6.2 1.9 Avoidance*** 15.7 5.3 14.5 4.5 14.3 5.1 13.9 4.3 12.9 4.2 12.8 4.2 12.5 3.6 Arousal"" 15.6 5.1 13.6 5.2 13.6 5.0 12.9 4.0 12.0 4.2 12.1 3.8 11.9 3.6 SRIP-DSM""" 40.4 12.9 35.2 11.2 35.5 12.4 33.3 9.1 31.4 10.2 31.3 9.2 30.6 8.0 Anxiety (STAI)"'" 45.0 10.3 38.6 10.4 38.3 10.9 37.3 10.3 34.7 9.8 37.0 10.8 36.2 10.0 Depression (SDS)'" 42.1 8.8 37.0 9.0 37.7 8.9 36.2 7.4 34.6 7.6 36.2 8.4 35.7 8.0 Anger (STAS)"" 19.9 4.8 19.6 6.8 20.2 6.6 17.8 5.3 17.8 5.5 17.9 5.6 16.7 5.0

SCL-90 Sleep problems"" 8.5 4.0 6.5 3.9 6.2 3.7 6.4 3.4 5.3 3.0 5.8 3.2 6.1 3.5 Somatic complaints** 24.5 9.8 20.3 10.9 20.2 8.8 19.9 7.4 18.0 7.1 18.9 7.4 18.8 7.2

~ ~

SRIP. Self-Rating lnventoly for PTSD. STAI, State-Trait Anxiety Inventoiy, SDS. Zung Self-Rating Depression Scale, STAS, State-Trait Anger Scale, SCL-90. Symptom Check-List "P<O 05, " " K O 01, *"P<O 001

valence of PTSD for exposed civilians who reported 8-18 war events (n=309). Among them, 7% fulfilled the criteria for a diagnosis of PTSD.

Partial PTSD

Table 3 also shows the proportion of respondents who fulfilled one or two criteria for PTSD. For these variables the cell sizes are larger, leading to a higher level of precision, i.e. smaller confidence

intervals. Overall, the same pattern of group differences was observed. On all indicators of partial PTSD, the persecuted individuals in Europe had the highest scores, followed by the persecuted individuals in Asia and the multiple exposed subjects. The resistance veterans had significantly higher scores than the non-exposed subjects on two indicators of partial PTSD. Exposed civilians had the lowest scores.

Table 3. Proportions of full and partial PTSD in each war exposure group and in four groups based on the number of reported war events

Full PTSD

Group

Partial PTSD

c (96) SRIP-DSM cut-off score

D (%) 2 1 criterion 1%) n % 95% CI OR" 2 2 criteria (%) B (%)

Total War exposure groupsb

Persecuted individuals in Europe Persecuted individuals in Asia Military veterans Exposed civilians Resistance participants Non-exposed individuals

Multiple exposed individuals

Number of war events 0-2 3 4 5-7 8-1 8 Spearman correlation

1437

34 53 296 783 238 134

92

338 292 41 1 396

4.6 3.6-5.8 NA

11.8 3.3-27.4 8.6'" 13.2 5.5-25.3 9 9" 7.1 4.5-10.6 50" 4.0 2.7-5.6 2.7 3.8 1.7-7.1 2 6 1.5 0.2-5.3 1.0

8.7 3.8-16.4 6.2"

1.8 0.7-3.8 NA 4.1 2.1-7.1 NA 4.9 3.0-7.4 NA 7.1 4.8-10.1 NA 09"**

18 21 13 26 34

50"" 62"' 29" 53""" 71 *"* 36""" 36'" 25"" 42"" 47 20 21 16" 27 34 16 18 11 24 31 25"" 27 19"" 31 42 13 18 8 22 33

35""" 35"'" 26"" 38" 49'

12 15 7 21 28 18 20 10 26 32 16 18 12 23 31 26 29 21 32 44

12""" 0.12"" 0.15"" 0.08""' 0.1 1 *I*

SRIP, Self-Rating Inventory for PTSD; SRIP-DSM cut-off score, a score of 2 5 3 on the SRIP; 95% CI, 95% confidence interval; OR. odds ratio; NA. not applicable. 'Exact common odds ratios (OR) were computed with the 'non-exposed' subjects as the reference group. One-sided exact pvalues were computed for testing that the odds ratio is one. q h e war exposure groups are not mutually exclusive. Each group is compared with the non-exposed subjects. Those belonging to multiple war exposure groups are also shown separately in the 'multiple exposed individuals' group. *P<0.05. *"P<O.Ol, ""*P<O.OOl.

354

Psychological adjustment of ageing World War I1 survivors

Discussion

This study attempted to estimate the long-term after-effects of war on Dutch citizens who experi- enced and survived WW 11. The objective was to compare different groups of war victims, including civilians who had been exposed to high levels of wartime stress, and to find out which groups of surviving and now ageing war victims are at risk for long-term after-effects.

Of a community sample of 4057 Dutch nationals born between 1920 and 1929, 86% reported that they had experienced at least one WW I1 event from a list of 28 possible events. Bombardments were the most frequently experienced event. Victims of persecution had a small chance of surviving WW 11. Therefore, it is not surprising that they were only represented in very small numbers. The results show the long-term impact of such experiences on the average Dutch survivor. This impact had been considerable. One-third of the respondents report- ed, even 50 years afterwards, that the war was the worst thing they had ever experienced. Neverthe- less, the proportion of survivors with a full diag- nosis of PTSD was small.

On all measures of current psychological adjust- ment, including symptoms of PTSD, the highest scores were found among persecuted subjects in Europe and persecuted subjects in Asia. These groups included those who survived the war in hiding, as well as concentration-camp survivors and survivors of Japanese internment camps. This high prevalence is probably due to the fact that these people experienced several years of contin- uous and immense threat during which they lost many relatives and friends. Moreover, the per- secuted individuals in Europe had experienced the deliberate killing of their loved ones by a systematic and now virtually inconceivable strat- egy. Trying to attach some kind of meaning to such behaviour that inflicted so much suffering, while at the same time maintaining one’s belief in humankind, would seem to be an impossible task. In view of this, it is surprising that some survivors were able to manage their lives and that at the time of the study they had no major problems in psychological adjustment.

The persecuted individuals in Asia first experi- enced the occupation by the Japanese. Then, when the war was over, a new period of horror started when the Indonesian nationalists turned against Europeans and Indo-Europeans and many atrocities took place. Eventually, they were forced to leave the Dutch East Indies for The Netherlands. The prevalence of PTSD among the persecuted individuals in Asia (13% or 190/,) is very similar to that found in a recent study of

American survivors of Japanese internment camps, where 15% of subjects were estimated to have current PTSD (20).

We found the lowest prevalence of PTSD and other indicators of problems in psychological adjustment among the exposed civilians. This is probably due to the fact that this is a heterogeneous group which may contain individuals who did not meet the stressor criterion for PTSD. When we selected the highly exposed respondents who reported 8-18 war events, a current PTSD pre- valence of 7% was found, which is of the same order as the rates found among the multiple exposed and the military veterans. We have found no other studies of the prevalence of PTSD among civilians who have been exposed to wartime stress. This study is therefore the first to show the long-term impact of war on civilians. It is important to note that, in absolute numbers, they form the largest group of World War I1 survivors. It is also a group of survivors that, until now, have received little attention, not only in the research literature but also in Dutch society in general. This is illustrated by the fact that they had to wait until 1984 before a special law was established that rules the allowance of special government financed pensions. In contrast, for resistance veterans such a law was established immediately after WW 11, while victims of persecu- tion had to wait until 1973 before such a law was established for them.

The PTSD prevalence that we found among military veterans (7%) is higher than the 3% prevalence of current PTSD which Page reported among American veterans of World War I1 who had fought in the Pacific (9). However, it is lower than the percentages of PTSD found among American World War I1 combat veterans who had fought in Europe (9) or among Vietnam combat veterans (9, where prevalence rates of 13% and 15%, respectively, were reported. These discrepan- cies may be due to differences in war exposure and in the length of time that has elapsed since the war experiences, and also to differences in study methods.

The prevalence of PTSD among the resistance participants (4%) was much lower than the prevalence found in other studies of Dutch resistance veterans (6, 21, 22). These studies found prevalence rates of current PTSD ranging from 20% to 49%. However, the samples in these studies were not selected at random, but were based on those resistance veterans who received a special veterans’ disability pension or a special medal that had to be applied for personally or by a third party. It is therefore likely that in these studies resistance veterans with war-related disabilities (including PTSD) were over-represented, leading to a higher

355

Bramsen and van der Ploeg

number of veterans with PTSD. On the other hand, all of the resistance veterans who received a pension and/or a medal had to produce impartial evidence of resistance participation, making it likely that they all met the stressor criterion for PTSD. The resistance participants in our study may have included individuals who ran only small risks and did not meet the stressor criterion for PTSD. However, even if we selected individuals who reported a high number of war events (8-18 events), the prevalence of PTSD was not higher than 5%.

The more war events that were reported, the higher was the risk for PTSD. Such a dose-response relationship between stressor intensity and sympto- matology has frequently been observed (23, 24). This study showed that this dose-response relation- ship was present even 50 years later, and in a community sample, i.e. among survivors who did not necessarily label themselves as such. An important question is whether these findings may be generalized to survivors of other conflicts, or whether unique characteristics of this generation determined these results. Immediately following WW I1 there was very little knowledge about psychological adjustment following shocking war experiences. In addition, talking about personal difficulties was not generally regarded as acceptable behaviour. The prevailing attitude was to work hard and to forget the past. Even today, many Dutch war victims complain about the lack of understanding and recognition of their problems (25). It is possible that these special circumstances have aggravated the long-term after-effects. On the other hand, although methods for prevention and treatment have become available, the long-term effects of these interven- tions are still not known. Thus the important question remains of whether and how these long- term after-effects can be prevented, alleviated or reduced.

PTSD frequently coexists with one or more additional diagnoses, such as anxiety disorder and major depression, or even somatic complaints (26). Since the co-existence of diagnoses may be a function of an overlap in definition (27), we determined whether the above symptoms indicated additional differences in psychological adaptation between the war exposure groups, or whether the differences between the groups were fully described in terms of PTSD symptoms. PTSD symptoms appeared to show the strongest relationship with war exposure, but anger and anxiety were also important for discriminating between the war exposure groups. Somatic complaints appeared to be secondary to PTSD and the other symptoms.

The finding that anger was an important symptom is consistent with the results of a study

of Dutch resistance veterans. Those veterans had higher anger scores than a control group (21). Feelings of anger may be regarded as a response to the powerlessness experienced during the event (28). A sense of anger may also be prevalent because the assumption that the world is benevolent, safe and meaningful (29) has been undermined, making it more difficult for the individual to trust other people and authorities. Unresolved feelings of hatred and rage may lead to problems in inter- personal relationships (30), and it has even been found that victims may themselves become perpe- trators (31). Better insight into the role of anger in response to traumatic events is certainly needed in order to be able to prevent such negative con- sequences.

The results reported here must be viewed in the context of several limitations inherent to survey research with a cross-sectional retrospective design and a self-report format. First, the subjects of the present study not only survived WW 11, but they were still alive 50 years later. We have to acknowledge that they form a selected group of all those who had been exposed. Healthy individuals with relatively few problems in adaptation may therefore have been over-represented in this study. Secondly, less than 50% of the population approached actually participated in the study. Therefore there may have been a substantial response bias. On the basis of the reasons people gave for non-participation, we learned that many non-respondents had experienced no shocking war events or after-effects, and consequently consid- ered that they had no important information to provide. On the other hand, there were also individuals who did not want to revive old emotions and who wanted to let the past rest. Thirdly, we had to rely on retrospective self- reports of war experiences which may have resulted in some recall failure. In designing the questionnaire, we reasoned that exposure to shocking war events would be a salient event in the memory of the survivor, but that the exact details of the event might be subject to distortion, Therefore, we did not ask for exact dates or frequencies of war events, but only whether or not the subjects had personally experienced those events. This approach was supported by two recent studies (32, 33) . Fourthly, since a small proportion of the participants had a full diagnosis of PTSD, and some war exposure groups were small, the analysis of the relationship between PTSD and the reported war events included some small cell sizes. Therefore, we also compared the war exposure groups on indicators of partial PTSD and found the same pattern of differences. The issue of small cell sizes is inherent to the

356

Psychological adjustment of ageing World War I1 survivors

problem under study. Before the start of the study it was not known exactly how many survivors of shocking war events we would ‘find’, and how many of them would have a full diagnosis of PTSD. The available estimates of the number of surviving war victims were based on populations seeking treatment or financial compensation (34). Therefore we started out with a very high number of subjects (n=lO622). From this point of view, the small cell sizes may be viewed as an interest- ing finding. Apparently, studying the relationship between WW I1 and PTSD in a community sample that was exposed to war, instead of in help-seeking or compensation-seeking samples, leads to the finding of a relatively small proportion of partici- pants with severe symptoms.

Nevertheless, it must be realized that such ‘low’ prevalence estimates do refer to tens of thousands of individuals. To give a rough indication, if (i) we take the difference in current PTSD between the non- exposed individuals and the total sample as an estimate of the prevalence of war-related current PTSD (4.6% minus 1.5%=3.1%) and (ii) we generalize this figure to all Dutch individuals who are now over 50 years of age (n=4 182 573) and who therefore experienced World War 11, approximately 130 000 individuals would have war-related current PTSD (the 95% confidence interval ranges from 92 000 to 167 000). These figures relate only to The Netherlands. There can be no doubt that in Europe and South-East Asia as a whole, a very large number of people are still suffering from the long- term after-effects of World War 11.

These survivors are now ageing. As a result, their symptoms may be exacerbated, or existing symp- toms may become more difficult to manage. In addition, their social network will become smaller, resulting in a decreasing level of social resources and perhaps an increasing burden of care for those remaining in the social network. Further research into the interaction between the ageing process and the long-term after-effects of trauma earlier in life is certainly needed (35).

Among these ageing survivors are many civilians who have experienced bombardment or other battle actions. Until now, these civilians have received little attention not only in the literature but also from society at large. It is important that health- care professionals are aware of the existence of this group of elderly survivors and have knowledge of their experiences so that, if they present with these problems, they will receive adequate care or treatment.

Further research is needed to determine to what extent these findings on long-term after-effects can be generalized to other groups of survivors.

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