This paper suggests that elderly trauma survivors are at elevated risk for re-traumatization in medical and long-term care settings. Findings from recent research in neuro-affective social cognitions are integrated with data about disparities in medical healthcare and with seminal insights from social psychology. The discussion of these various findings and their implications focuses on their relevance to clinical work. Evidence suggests that dehumanizing perceptions toward certain patients can emerge even in well-intentioned professionals who are invested in caring for others. The origins of such dehumanization are discussed from the perspective of the evolution of the human species and the human brain. Throughout evolution, there was a high survival value for rapid, automatic categorization that allowed humans to scan the physical and social environments, recognize potential danger, and differentiate between friend and foe. In the current multicultural environment of healthcare, these automatic categorization processes might create subtle, non-intentional emotional prejudices in healthcare providers toward certain patients, especially those who are perceived as different from the provider. Such non-intentional, automatic biases which are primarily non-conscious might negatively impact clinical decisions and quality of care. Studies also show that people who are perceived as not having a fully functioning human mind, or those who elicit the neurobiological response of disgust, are at elevated risk for dehumanized perceptions. These observations are of note since patients in hospitals or long-term care facilities, due to transient or chronic medical conditions, might manifest compromised mental functioning and might require care that can evokes responses of disgust in medical staff. Additionally, particular features of medical settings might inadvertently promote dehumanized perceptions of patients. Some of these features are necessary, functional and unavoidable in the practice of modern medicine, while others are not necessary or functional and might be modified. Finally, the paper highlights the need to educate healthcare professionals about specific and effective ways to counter unintentional dehumanization of elderly trauma survivors in order to avoid re-traumatization of such patients in their final years.
The last cohort of Holocaust survivors is aging and ailing as survivors are reaching the end of their lives. It is our moral responsibility to make sure that survivors’ treatment during their last days will be as humane as possible, as they have lived through inconceivable atrocities and have already suffered extreme cruelty and dehumanization. These traumatic experiences in earlier times render elderly trauma survivors particularly vulnerable to many of the processes and the losses that often accompany aging and illness (Cook, 2001a, 2002; Dasberg, 2003; Graziano, 2004; Lapp, Agbokou, & Ferreri, 2011; Martinez-Clavera, James, Bowditch, & Kuruvilla, 2017). In the last phases of life, many survivors require care in medical settings and long-term care facilities. Unfortunately, as Haque and Waytz state, “Dehumanization is endemic in medical care” (2012). This is a very grave statement, since dehumanization has been shown to allow people to experience fewer moral concerns regarding their actions toward dehumanized others, and to justify acts that otherwise would be considered harmful (Bandura, 2002). Causing harm to others, especially in medical care, can occur by omission, such as a lack of response or attention to a patient’s distress, or by commission, when the professional conducts him- or herself in ways that directly inflict pain or suffering upon the patient. Ignoring potentially knowable triggers for the patient’s distress constitutes a form of passive harm that falls somewhere between these two categories. However, knowledge about the traumatic history of elderly patients is not always available to their healthcare providers, and the connections between this traumatic past and current puzzling or even difficult behaviors are often not comprehended by nurses, physicians and paramedical staff. The diverse backgrounds from which healthcare professionals and patients come might mean that providers may have not been exposed to information about the Holocaust, or, sadly, about other cases of mass trauma, persecution and political violence across the globe to which elderly patients might have been exposed.
Consequently, and tragically, when elderly survivors are most frail and helpless, they might be re-traumatized by the treatment they receive from healthcare providers. As will be discussed, it is important to note that dehumanization in medicine is not necessarily the result of conscious, explicit attitudes. Rather, this paper reviews findings from several research perspectives that suggest that unintentional, implicit dehumanizing perceptions of others can emerge even in well-intentioned professionals who are invested in helping others. The potential sources of dehumanizing perceptions of patients by their healthcare providers are reviewed and it is proposed that these findings have particular relevance to the clinical care of elderly trauma survivors.
The definition of trauma in this paper follows those of the Substance Abuse and Mental Health Services Administration (SAMHSA) and the American Psychological Association. SAMSHA’s concept of trauma states: “Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being” (SAMSHA, 2014, p. 7). The definition of trauma in the Diagnostic and Statistical Manual of Mental Disorders (Diagnostic and Statistical Manual of Mental Disorders 5th edition DSM-5, 2013) requires that a person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. The exposure might be direct, which includes having witnessed the trauma or having learned that a relative or a close friend was exposed to a trauma, or can result from indirect exposure to aversive details of the trauma, usually in the course of professional duties. The traumatic event is persistently re-experienced by the victim/survivor through intrusive thoughts, nightmares, flashbacks, and emotional distress and physical reactivity following exposure to traumatic reminders. The person manifests avoidance of trauma-related stimuli after the trauma by suppressing thoughts or feelings about it and by trying to avoid trauma-related reminders. The person also demonstrates negative thoughts or feelings that either began or became more severe after the trauma, including an inability to recall key features of the trauma; overly negative thoughts and assumptions about oneself or the world; exaggerated blame of self or others for causing the trauma; negative affect; decreased interest in activities; feelings of isolation; or difficulty experiencing positive affect. Meanwhile, according to the definition, trauma-related arousal and reactivity must have also begun or become more severe after the trauma, and manifested in irritability or aggression; risky or destructive behavior; hypervigilance; heightened startle reaction; difficulty concentrating; or difficulty sleeping. Symptoms must have persisted for more than one month to fulfill the diagnosis, and must create distress or functional impairment (e.g., social, occupational). Symptoms cannot be due to any medication, substance use, or other illness. A meta-analysis of 71 studies of Holocaust survivors, comprising a total of 12,746 subjects, showed that symptoms of PTSD have persisted in many survivors even 60 years after the traumatic event, not only in clinical samples but also in community-dwelling samples of functional adults (Barel, Van IJzendoorn, Sagi-Schwartz, & Bakermans-Kranenburg, 2010).
Despite the torrent of research on many trauma-exposed populations that followed the introduction of the diagnosis of PTSD into the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1980), there is not much data available about PTSD in the older population (Böttche, Kuwert, & Knaevelsrud, 2011). In fact, the disorder remains largely unrecognized in the elderly (Martinez-Clavera et al., 2017). However, data from community studies indicate prevalence rates between 1.5% to 4% of current PTSD in adults over 60 ranges (Pless Kaiser, Schuster Wachen, Potter, Moye, & Davison, 2014).
Trauma exposure in the general population in the USA is not rare: 60%-90% of individuals will be exposed to at least one event that fulfills the criteria for trauma during their lifetime (Breslau, 2009; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Research evidence shows that experiencing shocking events causes serious damage to physical and mental health in a large minority of those exposed (F. H. Norris et al., 2002a; Norris , Tracy, & Galea, 2009; Norris, Tracy, Galea, Friedman, & Watson, 2002b). Lifetime prevalence of PTSD in the general population in the USA is 8% (Breslau, 2009), but much higher rates are observed in populations exposed to mass violence or living in conditions of continuous danger. An international study by the World Health Organization including samples from multiple countries across the glove showed that exposure to more than 4 traumatic events constitutes a higher risk for greater impairment and dysfunctionality (Karam, Friedman, Hill, & Kessler, 2014) and cumulative trauma exposure predicted higher severity of PTSD symptoms in a non-clinical sample of adults over 60 in the USA (Ogle, Rubin, & Siegler, 2014). In addition to PTSD, other symptoms and disorders, primarily depression and anxiety, but also medical issues and problems in living, might follow exposure to such trauma (F.H. Norris et al., 2002a; Norris et al., 2002b). PTSD is associated with an increased risk for multiple medical conditions (Sala, Cox, & Sareen, 2008) and in fact, it has been proposed (Lohr et al., 2014) that there may be a need to re-conceptualize PTSD beyond the boundaries of mental illness, and instead as a full systemic disorder.
Many trauma survivors continue to show trauma-related symptoms many years later. Rates of PTSD in elderly Veterans of WWII and survivors of the Dutch Resistance movement were observed to be 84% and 56%, respectively (Cook, 2001b; Op den Velde et al., 1993). Rates of diagnosis of PTSD in elderly Holocaust survivors have been measured as ranging between 24% and 90% (Barak et al., 2005). Elevated post-traumatic symptoms in Holocaust survivors have been observed in many studies even 40, 50, and 60 years after the end of WWII (Barel et al., 2010; Nadler & Ben-Shushan, 1989; Robinson, Rapaport-Bar-Sever, & Rapaport, 1994; Sharon, Levav, Brodsky, A., & Kohn, 2009; Shmotkin & Barilan, 2002; Shmotkin, Blumstein, & Modan, 2003; Stressman et al., 2008; Trappler, 2007).
The numbers of those who continue to suffer from the effects of trauma exposure are much larger when including those who experience partial symptoms of PTSD that do not fulfill the criteria for a formal diagnosis of the disorder. Studies show that the distress and the impairments associated with sub-clinical levels of PTSD are similar to those associated with the full disorder (Pietrzak, Goldstein, Southwick, & Grant, 2011a, 2011b). A large sample of community‐dwelling, older survivors of WWII – including survivors of bombardments, persecution, resistance, and combat – who did not meet full criteria for PTSD were still suffering long‐term negative effects (Aarts, 1996; Bramsen & Van Der Ploeg, 1999; Falk, Hersen, & Van Hasselt, 1994; Lapp et al., 2011; Trappler, 2007). Elevated symptoms of depression, anxiety and PTSD have been observed in community dwelling samples of elderly Finnish, English, German, Polish, and Danish survivors who were children during WWII (Berntsen & Rubin, 2006; Lis-Turlejska, Plichta, Luszczynska, & Benight, 2008; Pesonen et al., 2007; Waugh, Robbins, Davies, & Feigenbaum, 2007).
A series of studies on the effects of adverse childhood events (ACE) in the general population in the USA (Felitti et al., 1998) showed many health risks that are associated with each type of these events. A history of multiple adverse childhood events was associated with an even higher risk for a variety of health problems later in life. Individuals with early trauma histories in childhood are likely to be more vulnerable to stressful circumstances due to poorly regulated neurobiological stress- system changes, in particular the Hypothalamic-pituitary- adrenal system (HPA) regulating physiological stress. The ongoing need to be constantly alert to danger in childhood over-activates HPA axis and may exert detrimental effects on health in the long term. Child survivors of the Holocaust suffered countless and severe traumatic events and often lived for a long duration of time under stressful circumstances. Consequently, child survivors of the Holocaust display elevated levels of cortisol secretion indicative of increased alertness and anticipatory stress 60 years after the trauma (van der Hal-Van Raalte, Bakermans–Kranenburg, & van Ijzendoorn, 2008; Yehuda, Halligan, & Bierer, 2002). In comparison with peers of the same age who did not go through the Holocaust, child survivors were found to manifest more dissociative symptoms in everyday life, to express less satisfaction with their lives, despite achievements in relationships and career, and to have a bleaker general perspective on life to perceive current life events as more stressful in comparison to non-Holocaust related peers (Amir & Lev-Wiesel, 2003; Lev–Wiesel & Amir, 2000; Lis-Turlejska, Luszczynska, Plichta, & Benight, 2008) and to have more cognitive impairment than peers (Barak, 2013). All of these issues place individuals who were children or adolescents during the Holocaust at a higher risk than others for problems that will bring them into contact with healthcare providers. However, elderly child survivors may not establish the connections between their current problems and the traumatic events that they have endured as young children. The effects of exposure to extreme trauma during their early years are likely not only to increase the likelihood of health problems in this population and bring them into contact with healthcare providers, but it is also extremely relevant to the way these patient will experience their aging, their illness, and the relationships with professionals who care for them.
Most pertinent to the issues discussed in this paper is the association between late-onset PTSD and cognitive decline (Martinez-Clavera et al., 2017), which was observed in war veterans (Qureshi et al., 2010; Yaffe, 2010), as well as in Holocaust survivors (Grossman, Levin, Katzen, & Lechner, 2004; Yehuda et al., 2006). PTSD was demonstrated to be associated with impairments in memory, attention, and other executive functions (Moore, 2009), as well as with altered stress hormone levels and altered brain structure (Yehuda et al., 2009). It has been suggested (Ohry & Solomon, 1994; Yeager, Cutler, Swendsen, & Sills, 2013) that PTSD is associated with premature cognitive aging. Indeed, the odds for dementia diagnosis for elderly with PTSD are reported to be twice as high as for individuals without PTSD (Qureshi et al., 2010). Bidirectional pathways are hypothesized to be involved: PTSD might be associated with changes in the brain that lead to dementia, while neurodegenerative decline can disinhibit trauma memories that had been previously defended against more effectively. Trauma re-enactments are also frequently observed in cognitively impaired patients with previous diagnosis of PTSD. Episodes that appear dissociative can be dramatic, and a predominance of sleep-related enactments was reported in older war veterans with dementia (Dallam, Mellman, Bhatnagar, Nguyen, & Kurukumbi, 2011). Kuruvilla et al. (2017) posit that the incidence of delayed-onset PTSD in patients with dementia may be more widespread than previously recognized (p.5). They suggest that many of the symptoms, such as depression and anxiety, psychosis, and inappropriate behaviors such as wandering, shouting and agitation, often attributed to behavioral and psychological symptoms of dementia, are in fact related to PTSD. The authors emphasize the importance of recognizing the unique contribution of the patient’s trauma history in such co-occurring cases in order to choose the best pharmacological and psychotherapeutic interventions, and in order to increase the sensitivity among caretakers to potential environmental triggers associated with the individual’s particular trauma history.
Many professionals are not aware of the relationship between distal prior traumatic experiences and the distress experienced by elderly trauma survivors. During a visit to a facility that offers hospice care in Jerusalem only a few years ago, one that is known for the compassionate care it provides, I mentioned in discussion with staff the fact that Holocaust survivors who are cognitively impaired – whether temporarily, because of after-effects of anesthesia, transient delirium, or more permanently, due to dementia – often suffer from very frightening persecutory hallucinations and delusions related to the Holocaust. The medical director dismissed my statement summarily, stating that these symptoms “have nothing to do with the Holocaust” and are simply the manifestations of ‘sundowning’ in many elderly patients. Such a lack of understanding of the unique aspects of the experience of trauma survivors increases the risk of re-traumatizing these patients even during the administration of routine interventions by well-intentioned healthcare providers. A lack of attention to the individual patient’s trauma history makes it difficult to identify patterns of potential triggers and to make environmental modifications that may help to minimize misinterpretation of neutral cues (Martinez-Clavera et al., 2017, p. 5). Specific examples of the potential re-traumatizing impact of simple nursing care (such as being taken into the shower or being shaved) on elderly Holocaust survivors were described in Paula David’s excellent manual (David, 2008). A lack of understanding of the pervasive and lasting effects of massive trauma severely compromised the treatment that was available to Holocaust survivors, as well as to Vietnam veterans, in the early years after the end of their respective ordeals (Felsen, 2017a). It is critical that this tragic omission will not characterize the care they receive at the end of their lives.
Trauma-Informed Care (TIC)
Trauma-informed care (SAMSHA, 2014) is a much-needed effort to increase awareness of the persistent effects of trauma in patients and in healthcare providers. Trauma-informed care strives to address the relationships between environmental and subjective triggers, the perception of danger, and the neurophysiological activation that leads to distressed psychological states and their resulting problematic behavior (Yeager et al., 2013, p. 65).
Modern gerontological theories take a “lifespan perspective” on aging, which states that individual reactions to the many challenges of aging differ according to personal life histories: “The way in which we grow old and experience this process, our health and functional ability all depend not only on our genetic makeup but also on what we have done during our lives; what sort of thing we have encountered in the course of our lifetime, on how and where we have lived our lives” (Heikkinen, 1998).
Trauma-informed care with elderly patients takes into account the effects of the individual’s history on their aging processes, and on the way they experience themselves, their caretakers, and their treatment, with a strong focus on the impact of prior traumatic experiences. In order to be able to provide truly trauma-informed care to survivors of previous terrible life experiences, we must become aware of some fundamental processes that may render us susceptible to traumatize others, even if unintentionally. The next section addresses evidence suggesting that there are significant risks for traumatization of patients in medicine, due to processes that can lead to dehumanizing perceptions by their healthcare providers. In order to prevent or remedy a problem we must first take an honest and unprejudiced look at our own potential participation in it.
Dehumanization in medicine
“Dehumanization is endemic in medical practice,” state Haque and Waytz (p.75, 2012). The recognition that dehumanization might occur in the treatment of patients by their healthcare providers, and in the treatment of elderly trauma survivors in particular, is an egregious idea that we must make every effort to understand better in order to prevent it from happening.
The concept of dehumanization is complex, and a more detailed discussion of its various meanings goes beyond the scope of this paper (for an excellent review, see Haslam, 2006). Stated simply, dehumanization is the denial of full humanness to others. What defines the essence of the ‘humanness’ that is denied to others has been described from several somewhat different approaches. Infra-humanization theory (Demoulin, Leyens, Rodrı´guez-Torres, Rodrı´guez-Pe´rez, & Paladino, 2000; Leyens et al., 2000; Leyens et al., 2001) focuses on certain emotions and on traits which are “uniquely human,” in the sense that they differentiate between humans and other animals. Their evidence suggested language, higher order cognition, and refined emotion (“sentiments”). As these characteristics reflect socialization and culture, they might be expected to vary across cultures (and thus might lead to the perceptions of some people by others from another culture, as less human). The second approach emphasizes characteristics that are considered to be “human nature” —those traits which are typical, common, and universal in all cultures, but may not be unique to humans (for example, curiosity, warmth, and openness). Traits considered to be representative of human nature “should be seen as that which is essential to humanness, the core properties that people share “deep down” despite their superficial variations. In sum…fundamental, inherent and natural” (Haslam, 2006, p. 256).
Thus, two differing forms of dehumanization have been proposed, which involve the denial of two distinct meanings of what it is to be fully human. While denying uniquely human attributes to others represents them as animal-like, denying human nature to others represents them as objects or cold robots.
It is important to note that many of the characteristics included in either categorization of ‘humanness’ might place elderly trauma survivors at risk for dehumanizing perceptions. For example, uniquely human characteristics associated with cognition, sophistication, and refinement are often diminished in elderly trauma survivors due to impaired cognitive functioning or due to the dysregulated affect or dissociative effects of PTSD (Martinez-Clavera et al., 2017). Conversely, post-traumatic effects manifested in such traits as distancing and suspiciousness, mistrustfulness, or numbing and detachment might create perceptions of the survivor as ‘not quite human’ in terms of warmth and connection. Differences between survivors and their care providers in terms of ethnic and socio-cultural background can also create problematic perceptions and interpretations of each other’s humanness, which might be further exacerbated by the apprehensions of trauma-survivors about the humanity of strangers.
Dehumanization is not rare. Although it is mostly discussed in the context of extreme behavior, such as genocide or torture, it is in fact a common phenomenon that is often also part of much milder forms of discrimination. Haslam posits that “dehumanization is an everyday social phenomenon, rooted in ordinary social-cognitive processes” (Haslam, 2006, p. 252). It is important to understand the factors that allow dehumanization to occur in more mundane circumstances and in settings that are not extraordinary, such as war, captivity, and abuse. Rather, one must establish what are the determinants of dehumanization in settings that are a part of normal life and in the conduct of people within the institutions we all depend upon for medical care. Dehumanization of others poses serious danger in many settings as “it allows one to experience fewer moral concerns for their actions towards dehumanized others, and can justify acts that otherwise would be considered harmful” (Bandura, 2002). In the context of care of elderly patients, dehumanization, which compromises empathy, can cause tragic re-traumatization of trauma-survivors in the last stages of their life.
Haque and Waytz (2012) explain that dehumanization in medicine results from inherent features of modern medical settings, from the way medical care in such settings is delivered to how it impacts the doctor-patient relationship. Haque and Waytz identify routine clinical practices that contribute to dehumanization, some of which are non-functional and some which are functional and even necessary. Some of the functional features include, for example, the use of advanced technology and the mechanization of certain procedures, with an emphasis on precision and efficiency, which replaced the hands-on personal administration of such services by physicians.
Another necessary characteristic is a certain reduction in empathy that allows medical staff to tolerate both the frequent loss of patients and the need to inflict necessary pain, as well as to sustain the pressures of such a career in the long term, a phenomenon also described by as “medical doubling” (Lifton, 1986). Not surprisingly, a study in which fMRI’s examined brain activity in physicians who use acupuncture and in non-physicians as both groups watched needles being inserted into a person’s body showed that pain empathy was lower in physicians versus in non-physicians, while the reverse was true of executive control and self-regulation (Cheng et al., 2007 and Decety, Yang,Cheng, 2010 in Haque and Waytz, 2012)
Another inevitable but functional feature of modern medical care involves the de-individuation of care in large medical teams, which lessens the personal connection between the healthcare provider and patient, as well as the sense of responsibility the provider feels toward an individual patient. The increased specialization of medical professionals also contributes to a highly specific focus on the illness and the affected organ or system, or on a functional problem, rather than on the patient as a whole human being and on the patient’s whole subjective experience. Haque and Waytz state: “With all the measuring, palpating, listening for abnormal body sounds, percussing, injecting, and imaging of innards, doctors may treat patients like objects rather than a complete person with rich, subjective experiences.” (p. 178, 2012).
However, alongside the unavoidable features associated with some instrumental aspects of modern medicine, as well as those associated with the diminished agency inherent to the condition of the patients, there are some negative features of medical settings which are not necessarily unavoidable. Among these, Haque and Waytz enumerate de-individuating practices such as the use of uniform clothing and inattention to patients’ personal characteristics such as name, title, and occupation. The anonymity and lack of attention to such major personal characteristics in the interest of efficiency diminishes the personhood of the patient, thereby promoting dehumanizing perceptions in healthcare providers.
Insights from Research of Social Cognitions and Neuro-Social Cognitions
Studies from several empirical disciplines offer important insights into the sources and determinants of discriminatory behavior toward others. New neuro-imaging technology has led to the emergence of the burgeoning field of neuro-affective research. Imaging technologies allow for the non-intrusive study of neural networks in the brain while individuals are engaged in various tasks, which enables inquiry into the function of the brain with regard to emotions, cognitions, and social interactions. Social cognitions, or cognitions which are exclusively about other humans, are processed primarily in the medial prefrontal cortex (mPFC). Data from functional magnetic resonance imaging (fMRI) show that the mPRC is differentially activated in social cognitions (those about other people) as compared with nonsocial cognitions (L.T. Harris & Fiske, 2006, p. 848). Studies show that people who have been dehumanized elicit the negative basic emotion of disgust in the perceiver, which is correlated with reduced mPFC activation. In other words, others who are perceived as either disgusting or as not possessing a fully human mind can be treated as ‘not quite human’ (i.e., dehumanized) according to both the neural responses and the behavioral responses in the perceiver (L. T. Harris & Fiske, 2007).
These observations have tremendous implications for clinical work and for understanding critical aspects of the emotional responses of healthcare providers to some patients. As stated, hospitals and medical settings such as long-term care facilities often treat patients who are suffering from various degrees of cognitive impairment and dementia, or those who act in poor control of their dysregulated affects, who thus might be perceived as having less of a “working mind.” Patients with dementia manifesting cognitive deficits or behavioral dyscontrol may certainly appear as having less of those uniquely human characteristics, such as intelligence, agency, and the ability to communicate in language and to behave in a well-regulated and socially desirable manner. Additionally, Haque and Waytz (2012) point out that illness often alters appearance, behavior, and basic human functioning. Physical changes can go so far as to create a visible dissimilarity between the patient and the prototypical ‘human’. Due to such deficits, such patients might be perceived as not quite fully human by their healthcare providers.
The findings, which show the powerful impact of disgust on dehumanizing perceptions of others, have great relevance to clinical work with elderly patients, as part of the actual physical care of individuals incapacitated by illness inevitably confronts medical staff with aspects of the physicality of the patient which might trigger automatic neurobiological responses of disgust. Healthcare providers need to work closely with repugnant sights, smells, and various aspects associated with the physical changes caused by old age and disease. The need to handle excrement, other bodily fluids, and provide wound care in cases involving gangrene, infections, as well as other difficult aspects of care, may give rise to automatic responses of ‘neuro-disgust’ in the brain, even when the more conscious, intentional, and explicit attitudes of the care provider are well-intentioned. It is critically important to recognize the inevitability of such responses in order to help healthcare professionals develop a sensitivity to them, as being aware of these responses is the first step toward employing effective counter-measures.
In-Group and Out-Group Emotional Biases
Another crucial factor in dehumanization, as demonstrated by Leyens, Paladino, and their colleagues, is that people commonly attribute greater humanness to their in-group than to out-groups (Leyens et al., 2003; Leyens et al., 2000; Leyens et al., 2001). Once automatic categorization processes have identified the other as human and assume a working mind, people begin to differentiate among social categories. They interpret the behavior of others differently depending on their perceived affiliations, attributing more favorable characteristics to their own in-group members. Such implicit and explicit processes of social differentiation thus might be biased in favor of patients who belong to a social, ethnic, or other in-group to which the healthcare provider also belongs. In the diverse society in which we live, providers and patients come from many different groups, and the potential for in-group and out-group differentiation is great. This implies the possibility of serious bias in quality of clinical care.
Indeed, data shows startling evidence for discrepancies in healthcare quality among various ethnic and racial groups in the USA (Dovidio & Fiske, 2012). Such discrepancies are usually explained by differences in socio-economic status and access to healthcare. However, the authors suggest that another source for such healthcare discrepancies is bias among healthcare providers. Subtle bias is difficult to recognize in a specific instance (Crosby, Clayton, Alksnis, & Hemker, 1986); however, Dovidio and Fiske provide extensive evidence of bias in clinical decisions based on aggregate data about differences in the quality of healthcare received by different groups. Some of the more specific examples include the fact that physicians recommend more advanced and potentially more effective medical procedures (for example, coronary bypass surgery) for White patients than for Black patients. Racial and ethnic minority patients were also found more likely than White patients to be recommended for and to undergo unnecessary surgeries. Other indicators of prejudice could appear in inferior treatment and passive neglect (which, in the case of neglect of pain medication, can indicate passive harm). Dovidio and Fiske point out that these racial/ethnic disparities in medical treatment appear to be more pronounced when guidelines for treatment are not well defined (e.g., in treatment of pain). Clearly there are many professionals who would be very sensitive to the physical pain of their patients and to the ramifications of trauma in their current experiences. However, the goal of trauma-informed care is to create clear guidelines for assessment and treatment that will ensure more uniform attention and care in clinical decisions associated with an area of patient care that has been hitherto less highlighted in training of healthcare providers.
The Evolutionary Origins of Dehumanizing Perceptions of Others
Why is it that we, as humans, are so susceptible to dehumanizing perceptions of others? The origin of such neuro-affective responses is in the evolution of the human species and of the human brain, and in processes geared towards basic survival. As a species, humans are less strong, fast, and ferocious than other animals. Our species needed rapid abilities to scan for danger so as to avoid it. Meanwhile, in order to maximize their ability to survive in harsh environments, humans developed high levels of cooperation within small bands of tribesmen. Humans evolved as social creatures with interwoven brains, allowing them to communicate swiftly and respond rapidly (Cozolino, 2006). The human brain itself is a social organ that is built through experience and adaptation to the physical and interpersonal environments. In addition to rapid scanning for physical danger, our ancestors had to be able to immediately tell friend from foe, to separate those similar to them from strangers, potential enemies. All of these evolutionary embedded automatic categorization processes and cues for “social danger” (dissimilarity), though necessary at the time, are misleading in a modern, multi-cultural environment.
In addition, as in all social species, there are innate processes that make us susceptible to pressures from the other members of our in-group and to our place within the social order of the group. Findings from seminal experiments in social psychology have dramatically demonstrated the susceptibility of individuals to social pressures present within their social structures. These structures could quite easily be compared to the social organization of medical facilities, which rely on hierarchical order and on role-behavior norms in order to function. In one relevant study, Stanley Milgram (1963) demonstrated rather shockingly the willingness of university students to inflict what they believed would be painful and dangerous electrical shocks on other subjects, simply because the authority figure, the “researcher,” instructed them to do so. These findings showed both people’s inordinate willingness to comply with authority – which is, in fact, an institutionalized feature in medical settings – and the diffusion of moral responsibility that occurs when there is another who is in a higher power position relative to oneself giving the commands.
Additionally, the Zimbardo prison experiment (1971) demonstrated the rapid psychological adaptation of randomly assigned students to the roles of ‘guard’ and ‘prisoner,’ with concomitant and rapid emergence of sadistic and depressive behaviors. This experiment highlighted the dramatic consequences of power and control imbalances, which are also inherent features in the relationships between patients and healthcare providers in hospitals and long-term care settings. Finally, Asch (1956) demonstrated the powerful pressure to conform with the norms of the group when his experiment showed that, even with regards to a simple, unambiguous stimulus, people will change their response according to the social norms surrounding them. These findings suggest that individuals are likely to accept and even support behavior as long as it is condoned by the group, even if initially they might have perceived it as wrongful.
There are direct and relevant implications of the various types of evidence from social science to clinical care in medical settings. The medical model is one based on the authority of the care provider and on compliance with role norms defining a relationship between a superior and a subordinate. In such a structure, decisions being dictated by the professional, who is the authority figure; explicit and implicit pressures defining role-behavior norms; as well as the de-individuating treatment practices in large teams and the lack of personal responsibility of particular professionals to particular patients, can all lead to an overall diffusion of moral responsibility.
As healthcare professionals, we would rather believe that dehumanization happens only elsewhere, in other places or in extreme situations. We would like to believe that those who are capable of dehumanizing others are inherently different from us. However, the Nazi doctors (Lifton, 1986) were highly educated professionals, not unlike ourselves, who committed atrocities during the Holocaust using concentration camp inmates as subjects in gruesome medical experiments. We would like to believe that we would never dehumanize others. However, there are examples, the most well-known of which is the infamous Tuskegee experiment, that serve to remind us that we are all susceptible to the processes that make such behavior possible.
The clinical study conducted between 1932 and 1972 in Tuskegee, Alabama, was a U.S. Public Health Service study of the natural progression of untreated syphilis in poor, rural Black men who thought they were receiving free healthcare from their government. 399 participants, all of whom had previously contracted syphilis, were recruited. The 40-year study remains infamous to this day because researchers failed to treat patients appropriately even after Penicillin was found to be an effective cure for the disease. A terrible example of diffusion of moral authority, compliance with role-norms and social conformity, and dehumanization in medicine, the Tuskegee study led to the establishment of the Office for Human Research Protections but did not stop four hundred men from suffering needlessly and horribly. This tragic case of dehumanized medicine occurred in the USA, by professionals not unlike ourselves, and should serve as a terrible reminder of the risk of dehumanization to which we are all potentially susceptible.
Summary and Conclusions
This paper points out several possible causes for elevated risk for dehumanization of elderly trauma survivors in medical settings and in long-term care facilities. Findings from research in social-cognitions and neuro-social cognition shed light on important facets in the relationships between patients and their healthcare providers. The studies identify particular non-conscious processes that constitute risk factors for dehumanization in the perceptions of certain others. Perceiving the other as not having a fully human mind, or as dissimilar from the prototypical “humanoid” figure, triggers neurobiological correlates of disgust in the perceiver. Additional risk factors include automatic in-group and out-group categorization due to perceived ethnic, racial, socio-cultural, or other emotionally relevant differences between the patient and the provider. Such dehumanizing perceptions might lead to the emergence of unintentional emotional biases and prejudices even in well-intentioned medical professionals who are invested in helping others. The dehumanizing perceptions of patients that this paper aims to address are implicit, non-conscious and unintentional biases that are evoked in professionals who are consciously genuinely committed to humanitarian, egalitarian views and to the provision of non-discriminating care to their patients.
The neurobiological substrates and the origins of dehumanizing perceptions are discussed as rooted in evolutionary processes of categorization of the physical and the social environment which required rapid, survival-enhancing strategies. The evolution of the human brain over the course of the evolution of the human species led to the emergence of automatic and implicit processes which were aimed, in addition to scanning for physical danger, also at providing quick responses to social danger. Historically, strangers represented potential enemies, and thus the human brain is exquisitely sensitive to perceived differences between oneself and those who look unlike one’s own kinship. These social categorization processes no longer function well in a multicultural, ethnically diverse environment such as modern medical settings and long-term facilities in the USA.
It is suggested that the risk for unintentional emotional reactions is particularly high with regards to elderly patients because of the very issues that bring them into medical settings and long-term facilities. Illness and old age deprive individuals of a fully working mind, render them less similar to the prototypical figure of a healthy human and less similar to their younger, healthier providers, and often require providers to encounter aspects of the patients’ physicality which might evoke automatic responses of “neuro-disgust.”
It is further argued that the risk for dehumanizing perceptions by healthcare providers might be even higher when the elderly patients are trauma survivors. Trauma survivors face greater risk of suffering from cognitive impairment and dementia due to the association between PTSD and dementia. Additionally, responses of distancing, disgust, and dehumanizing might be related to reactions of healthcare providers to disturbing details of the trauma that the patients experienced and now recount. Reactions of disgust that are evoked by images of sadism and cruelty related to the trauma itself might be unconsciously misplaced and associated, in terms of automatic neuro-social cognitions in the brain of the healthcare provider, with the person of the patient. Lastly, additional risk for trauma survivors to be perceived as “less human” is associated with difficult manifestations of problematic trauma-related symptoms and behaviors, which are often especially prevalent in elderly trauma survivor patients who suffer from concurrent cognitive impairment (Dallam et al., 2011; Martinez-Clavera et al., 2017).
The recent focus on trauma-informed care has providers recognize the importance of a patient’s trauma history and its potential impact on every aspect of their experiences, from reactions to treatment to their relationships with treatment providers. Holocaust survivors were victims of atrocities and extreme dehumanization. It would be tragic to think that they, as well as other elderly trauma survivors, would again be subjected to dehumanizing perceptions, and be at risk for less empathic treatment, by those who are supposed to provide them with compassionate care at the end of their lives. Yet many elements of the modern healthcare model, combine with the evolutionary adaptations and neuro-social cognitions formerly discussed, to create a situation ripe for unintentional dehumanization. The role of technology and the mechanization of treatment, which reduces patient-provider contact; the large treatment teams that don’t allow much of a personal connection between individual healthcare providers and patients; the customary de-individuating practices of healthcare settings, such as uniform clothing and focus on the illness rather than on the person, are all some of the features in modern medical practice that create conditions that diminish the awareness of healthcare providers to the individuality of the patient. However, recognizing the potential risk for implicit bias in medical practice and the potential influence of implicit responses towards specific groups or towards particular patients can help form interventions to reduce emotional bias and the subsequent negative consequences it has on patients.
Unfortunately, awareness of the risk for dehumanization is not sufficient to avoid it. The type of implicit emotional prejudice and biases that emerge from the risk factors delineated in this paper cannot be entirely countered with explicit, educational, and intellectual training of staff. Information and training about trauma and about the specific traumatic experiences and potential triggers of particular patients have been shown to be effective in improving staff attitudes towards trauma survivors (Bachar, Dasberg, and Shakhar, 1995; Rosenfield, 2001; Eisinger and Bedney, Kavod, this issue). However, staff members need additional self-regulations skills that will allow them to recognize and acknowledge the signs of dehumanizing attitudes in themselves, in order to counter them. Research offers some surprising and easy practical strategies to counter the automatic tendency to dehumanize others under certain conditions. The solution of any problem requires first recognizing its existence in order to take responsibility for its resolution. After learning to recognize internal states that indicate distancing, disgust, and other dehumanizing responses, professionals can be coached to develop self-regulation strategies that counter them. Studies show that merely thinking about the other person’s mind, regardless of their mental status, shifts the processing of that person back into the exclusively-social area in the mPFC of the perceiver (Fiske, 2009). Simple questions about the persons’ preferences, such as, “Did he or she like broccoli?” remind one of the individuality of the other person by thinking about their potential agency, preferences, choices, and emotions. Focusing on the other’s mind, even if the patient is no longer capable of thinking or communicating, activates our own mPFC and reminds us of their humanity. Meanwhile, in-group and out-group differentiations and biases can be countered by focusing intentionally on common group membership — for example, belonging together to the group of ‘Mothers,’ regardless of socio-economic or ethnic differences, or ‘Veterans’ as opposed to perceived racial differences.
Additional interventions that can meaningfully change the perceptions by healthcare providers of cognitively or physically compromised elderly patients who are at risk for dehumanization include attention to evidence of who they were, where and how they have lived their lives, what they achieved, whom they loved, and who loved them.
Displaying and sharing some meaningful personal information and concrete evidence about past achievements, significant relationships and important aspects of the life of the patient can be very powerful reminders of the personhood of the patient. For example, the knowledge that someone was a dancer, or a teacher, that they attended Woodstock, that they went to a particular college one has heard of, provide a social context, encouraging social cognitions. Displaying visual or concrete evidence of something the patients had created in their previous professional or social roles, or what they liked doing, can be very impactful. Display of photograph(s) is very important, in particular enlarged ones which bring the images into near-life size. Photographs that are particularly evocative are those of the patient in their younger years (looking more ‘like us’) with their loved ones. Most impactful are photographs that capture emotional interactions or moments of closeness when the patient was caught mid-action, as opposed to static, posed pictures. Images of the patient engaged in loving relational animation remind our brains of the fact that they loved people and were loved, and that they had warm and meaningful relationships, which are characteristics universally observed to be the most typical human traits (Haslam, 2005).
Trauma-informed care perspective includes also an awareness to the role of trauma in the lives of the providers. We must become aware of our own histories, traumatic experiences, and the ways we have dealt with them, so that these will not drive our clinical decisions or the quality of care we are able to offer. A personal history of trauma in the healthcare provider might make them more compassionate, or instead they might be hardened by their own experiences and less understanding and tolerant toward those who did not go through such hardships or did not cope as stoically as they have. Some providers with a trauma history might be struggling internally, using distancing, avoidance, and numbing to deal with their own pain as well as with others’ pain. Some ‘wounded healers’ might be over-involved and have difficulties distinguishing between their own pain and that of the patient, thus imposing their personal attitudes and judgments on the patient or on the patient’s family. Trauma-informed care requires awareness and ability to reflect upon one’s own trauma history, as well as the patient’s.
Trauma-informed care also requires that specific questions about the possibility of traumatic experiences in the life of the patient be included in every assessment. These questions must be very direct, especially with elderly patients, who might not otherwise mention events that occurred decades earlier. Neither the patient nor their relatives might establish a connection between current symptoms of late-onset depression, anxiety, or PTSD and a distant index trauma that occurred very far in the past. There are brief assessment instruments for depression, anxiety, and PTSD which can be used with elderly patients, and are accessible online (For example, the PCL-5, at https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp). However, it is important when assessing for various mental health disorders in the elderly that lower cutoff scores must be used to diagnose older adults on the various screening measures (Cook, 2001b)
Finally, I would like to include briefly some lessons from a study that was conducted by Dori Laub and myself in Israel with chronically hospitalized Holocaust survivors (Strous et al., 2005). Most of the survivors spent several decades in psychiatric institutions and most carried the diagnoses of chronic schizophrenia or schizoaffective disorders. Many of the patients had gone through extensive treatments with old-fashioned antipsychotic medications, which were accompanied by many side effects. Despite the skeptical initial attitudes of the treatment team at the hostels where the survivors lived, the study collected the patients’ testimonies about their experiences before, during, and after the Holocaust. More about the study and its outcomes can be found in a series of articles and a book that describe it in detail (Felsen, 2016, 2017b, 2017c; Greenwald, Ben-Ari, Strous, & Laub, 2006; Strous et al., 2005). Some important lessons can be drawn from this study for the purpose of this paper and for emphasizing the importance of paying attention to the patients’ trauma history. The most important lessons include not only the surprising reduction in avoidance symptoms observed in these chronic patients more than 50 years after the end of the Holocaust, but the impact of the testimonies on the staff and on the entire atmosphere in the units that the project took place in. As stated by Greenwald in his paper about the effects of the testimonies: “We may be dealing with a long-term PTSD with psychotic features, in some cases. We are well aware of the fact that survivors previously unable to discuss their traumatic past are now forming new bonds with staff members, who, as a result of the survivors’ testimonies, are much more aware of the patients’ history. A therapeutic group, using both the contents of the testimonies and other reminiscing techniques, has provided new venues for self-expression, and even the social outings of the patients have now taken on a new significance, since staff members have been able to convince some of the previously immobile residents to participate. Knowing and understanding their past has made its impact. Realizing that as a result of the Holocaust trauma, the individual’s very sense of self was very often erased, we are attempting to take steps to restore that self, by enabling more self-expression and encouraging empowerment.” (p. 214).
Many of us, as scientists, healthcare providers, maybe even as sons and daughters of aging Holocaust survivors who have become aging patients, are recognizing the need for a heightened sensitivity to the meaning of their past traumatic experiences in their current care, as well as for a wider change in the culture of healthcare and in the treatment of the elderly in general. This change will not usher itself in. We must usher it, through small but impactful changes to the way things are done in our healthcare facilities. As the great American writer William Faulker stated aptly: “The past is not dead. In fact, it is not even past.” The past is certainly not past for aging survivors of trauma, especially those who survived man-inflicted trauma and were subjected to cruel and inhumane treatment. Healthcare providers must be informed of the risk of unintentional dehumanization and taught how to process and work with the effects of trauma in their own lives as well as in the lives of trauma-survivor patients. We must strive to make our patients’ last moments as compassionate as we can, in order to honor both their humanity and our own.
Aarts, P. G., Op den Velde, W. (1996). Prior Traumatization and the Process of Aging: Theory and Clinical Implications. In B. A. Van der Kolk, McFarlane, A. C. (Ed.), Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York: Guilford Press.
Amir, M., & Lev-Wiesel, R. (2003). Time Does Not Heal All Wounds: Quality of Life and Psychological Distress of People Who Survived the Holocaust as Children 55 Years Later. J Trauma Stress, 16(3), 295-299.
Asch, S. E. (1956). Studies of independence and conformity. A minority of one against a unanimous majority. Psychological Monographs, 70(9), 1-70. doi:10.1037/h0093718
Bandura, A. (2002). Selective moral disengagement in the exercise of moral agency. Journal of Moral Education, 31, 101–119.
Barak, Y. (2013). Aging of Child Holocaust Survivors. Kavod(3).
Barak, Y., Aizenberg, D., Szor, H., Swartz, M., Maor, R., & Knobler, H. Y. (2005). Increased Risk of Attempted Suicide Among Aging Holocaust Survivors. The American Journal of Geriatric Psychiatry, 13(8), 701-704. doi:http://dx.doi.org/10.1097/00019442-200508000-00009
Barel, E., Van IJzendoorn, M. H., Sagi-Schwartz, A., & Bakermans-Kranenburg, M. J. (2010). Surviving the Holocaust: A Meta-Analysis of the Long-Term Sequelae of a Genocide. Psychological Bulletin, 136(5), 677-698.
Berntsen, D., & Rubin, D. C. (2006). Flashbulb Memories and Posttraumatic Stress Reactions Across the Life-Span: Age-related effects of the German Occupation of Denmark during WWII. Psychology of Aging., 21(1), 127–139. doi:10.1037/0882-79184.108.40.206.
Böttche, M., Kuwert, P., & Knaevelsrud, C. (2011). Posttraumatic stress disorder in older adults: an overview of characteristics and treatment approaches. International Journal of Geriatric Psychiatry.
Bramsen, I., & Van Der Ploeg, H. M. (1999). Fifty years later: The long-term psychological adjustment of ageing World War II survivors. Acta psychiatrica Scandinavica, 100, 350-358.
Breslau, N. (2009). The epidemiology of trauma, PTSD, and other posttrauma disorders. Trauma Violence Abuse, 10(3), 198-210. doi:10.1177/1524838009334448
Cook, J. M. (2001a). POST-TRAUMATIC STRESS DISORDER IN OLDER ADULTS. The National Center for Post-Traumatic Stress Disorder PTSD RESEARCH QUARTERLY, 12(3).
Cook, J. M. (2001b). Post Traumatic Stress Disorder In Older Adults. PTSD Research Quarterly, 12(3).
Cook, J. M. (2002). Traumatic Exposure and PTSD in Older Adults: Introduction to the Special Issue. Journal of Clinical Geropsychology,, 8(3), 149-152.
Cozolino, L. (2006). The Neuroscience of Human Relationships Attachment and the Developing Social Brain. New York: Norton.
Crosby, F., Clayton, S., Alksnis, O., & Hemker, K. (1986). Cognitive biases in the perception of discrimination: the importance of format. Sex Roles, 14(11/12), 637-644.
Dallam, D. L., Mellman, T. A., Bhatnagar, A., Nguyen, S., & Kurukumbi, M. (2011). Trauma reenactments in aging Veterans with dementia. Journal Of The American Geriatrics Society, 59(4), 766-768. doi:10.1111/j.1532-5415.2011.03344.x
Dasberg, H. (2003). Late-onset of post- traumatic reactions in Holocaust survivors at advanced age: Peter Lang, Berlin- New York.
David, P. (2008). Caring for Holocaust Survivors. Retrieved from http://www.baycrest.org/HolocaustSurvivors/
Demoulin, S., Leyens, J. P., Rodrı´guez-Torres, R., ,, Rodrı´guez-Pe´rez, A., & Paladino, P. M., Fiske, S.T. (2000). Motivation to support a desired conclusion versus motivation to avoid an undesirable conclusion: The case of infra-humanization. International Journal of Psychology, 40(6), 416-428.
Diagnostic and Statistical Manual of Mental Disorders 5th edition DSM-5. (2013). American Psychiatric Association.
Dovidio, J. F., & Fiske, S. T. (2012). Under the Radar: How Unexamined Biases in Decision-Making Processes in Clinical Interactions Can Contribute to Health Care Disparities. American Journal of Public Health, 102(5), 945-102.
Falk, B., Hersen, M., & Van Hasselt, V. B. (1994). Assessment of post-traumatic stress disorder in older adults: A critical review. . Clinical Psychology Review, 14, 383-415.
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . al., e. (1998). The relationship of adult health status to childhood abuse and household dysfunction. American. American Journal of Preventive Medicine, 14, 245-258.
Felsen, I. (2016). Encounters with Chronic Psychiatric Holocaust Survivors: Trauma, Psychosis and Functionality. Kavod(6).
Felsen, I. (2017a). Adult-Onset Trauma and Intergenerational Transmission: Integrating Empirical Data and Psychoanalytic Theory. Psychoanalysis, Self and Context, 17(1), 60-77.
Felsen, I. (2017b). The Israel Story: My Story.
Felsen, I. (2017c). Traumatic psychosis: narrative forms of the muted witness. In Psychoanalysis and Holocaust Testimony: Routeledge.
Fiske, S. T. (2009). From Dehumanization and Objectification to Rehumanization Neuroimaging Studies on the Building Blocks of Empathy. Annals of the New York Academy of Sciences, 1167(1), 31-33.
Graziano, R. (2004). Trauma and Aging. Journal of Gerontological Social Work, 40(4), 3-21.
Greenwald, B., Ben-Ari, O., Strous, R. D., & Laub, D. (2006). Psychiatry, Testimony, and Shoah. Social Work in Health Care, 43(2-3), 199-214. doi:10.1300/J010v43n02_14
Grossman, A. B., Levin, B. E., Katzen, H. L., & Lechner, S. (2004). PTSD symptoms and onset of neurologic disease in elderly trauma survivors. . Journal of Clinical and Experimental Neuropsychology,, 26, 698-705.
Harris, L. T., & Fiske, S. T. (2006). Dehumanizing the lowest of the low: neuroimaging responses to extreme outgroups. Psychological Science, 17, 847-853.
Harris, L. T., & Fiske, S. T. (2007). Social groups that elicit disgust are differentially processed in mPFC. Soc Cogn Affect Neurosciv, 2(1), 45-51. doi:10.1093/scan/nsl037
Haslam, N. (2006). Dehumanization: An Integrative Review. Personality and Social Psychology Review, 10(3), 252–264.
Heikkinen, R. L. (1998). The Role of Physical Activity In Healthy Aging. Retrieved from Geneva: www.who.int/iris/handle/10665/65231
Karam, E. G., Friedman, M. J., Hill, E. D., & Kessler, R. C. (2014). Cumulative traumas and risk thresholds: 12-month PTSD in the World Mental Health surverys. Depression and anxiety, 31(2), 130.
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry, 52(12), 1048-1060.
Lapp, L. K., Agbokou, C., & Ferreri, F. (2011). PTSD in the elderly: the interaction between trauma and aging. International Psychogeriatrics, 23(6), 858–868.
Lev–Wiesel, R., & Amir, M. (2000). Post–traumatic Stress Disorder Symptoms, Psychological Distress, Personal Resources and Quality of Life in Four Groups of Holocaust Child Survivors. Fam Process, 39(4), 445-460.
Leyens, J. P., Cortes, B. P., Demoulin, S., Dovidio, J., Fiske, S. T., Gaunt, R., . . . Vaes, J. (2003). Emotional prejudice, essentialism, and nationalism. . European Journal of Social Psychology,, 33, 703-717.
Leyens, J. P., Paladino, M. P., Rodriguez, R. T., Vaes, J., Demoulin, S., Rodriguez, A. P., & Gaunt, R. (2000). The emotional side of prejudice: The attribution of secondary emotions to ingroups and outgroups. . Personality and Social Psychology Review, 4(186-197).
Leyens, J. P., Rodriguez, A. P., Rodriguez, R. T., Gaunt, R., Paladino, M. P., Vaes, J., & Demoulin, S. (2001). Psychological essentialism and the differential attribution of uniquely human emotions to ingroups and outgroups. . European Journal of Social Psychology, 31, 395-411.
Lifton, R. J. (1986). The Nazi Doctors: Medical Killing and the Psychology of Genocide USA: Basic Books.
Lis-Turlejska, M., Luszczynska, A., Plichta, A., & Benight, C. C. (2008). Jewish and non-Jewish World War II child and adolescent survivors 60 years after war: Effects of parental loss and age at exposure on well-being. . Journal of Orthopsychiatry,, 78, 369–377.
Lis-Turlejska, M., Plichta, A., Luszczynska, A., & Benight, C. C. (2008). Jewish and non-Jewish World War II child and adolescent survivors 60 years after war: Effects of parental loss and age at exposure on well-being. . Amercian Journal of Orthopsychiatry, 78(3), 369–377.
Lohr, J. B., Palmer, B. W., Eidt, C. A., Aailaboyina, S., Mausbach, B. T., Wolkowitz, O. M., . . . Jeste, D. V. (2014). Is Post-Traumatic Stress Disorder Associated with Premature Senescence? A Review of the Literature. Am.Journal of Geriatric Psychiatry.
Martinez-Clavera, C., James, S., Bowditch, E., & Kuruvilla, T. (2017). Delayed-onset post-traumatic stress disorder symptoms in dementia. Progress in Neurology and Psychiatry, 21(3).
Milgram, S. (1963). Behavioral study of obedience. Journal of Abnormal and Social Psychology, 67, 371-378.
Moore, S. A. (2009). Cognitive abnormalities in posttraumatic stress disorder. Current Opinion in Psychiatry, 22(1), 19-24. doi:10.1097/YCO.0b013e328314e3bb
Nadler, A., & Ben-Shushan, D. (1989). Forty Years Later: Long Term Consequences of Massive Traumatiazation. Journal of consult clin Psychol, 57, 287-293.
Norris, F. H., Friedman, M. J., Watson, P. J., Byrne, C. M., Diaz, E., & Kaniasty, K. (2002a). 60,000 disaster victims speak: Part I. An empirical review of the empirical literature, 1981-2001. Psychiatry, 65(3), 207-239.
Norris, F. H., Friedman, M. J., Watson, P. J., Byrne, C. M., Diaz, E., & Kaniasty, K. (2002a). 60,000 Disaster Victims Speak: Part I. An Empirical Review of the Empirical Literature, 1981–2001. Psychiatry, 65(3), 207-239.
Norris , F. H., Tracy, M., & Galea, S. (2009). Looking for resilience: Understanding the longitudinal trajectoriesof responses to stress. Social Science & Medicine, 68, 2190–2198.
Norris, F. H., Tracy, M., Galea, S., Friedman, M. J., & Watson, P. J. (2002b). 60,000 disaster victims speak: Part II. summary and implications of the disaster mental health Psyhchiatry, 65(3), 240-258.
Ogle, C. M., Rubin, D. C., & Siegler, I. C. (2014). Cumulative exposure to traumatic events in older adults. Aging Ment Health, 18(3), 316–325. doi:doi: 10.1080/13607863.2013.832730
Ohry, A., & Solomon, Z. (1994). The aftermath of captivity: An 18-year follow-up of Israeli ex-POWs. Behavioral Medicine, 20(1), 27.
Op den Velde, W., FalgerJohan, P. R. J., HovensJan, J. E., de GroenLouise J. H. M., Lasschuit, L. J., Van Duijn, H., & Schouten, E. G. W. (1993). Posttraumatic Stress Disorder in Dutch Resistance Veterans from World War II. In J. P. Wilson & B. Raphael (Eds.), International Handbook of Traumatic Stress Syndromes Plenum.
Pesonen, A., Ra¨ikko¨nen, K., Heinonen, K., Kajantie, E., Forse´n, T., & Eriksson, J. G. (2007). Depressive symptoms in adults separated from their parents as children: a natural experiment during World War II. American Journal of Epidemiology., 66(10), 1126–1133. doi:10.1093/aje/kwm254
Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2011a). Medical comorbidity of full and partial posttraumatic stress disorder in U.S. adults: Results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Psychosomatic Medicine, 73, 697-707.
Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2011b). Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Anxiety Disorders, 25, 456-465.
Pless Kaiser, A., Schuster Wachen, J., Potter, C., Moye, J., & Davison, E. (Producer). (2014). Posttraumatic Stress Symptoms among Older Adults: A Review. PTSD : National Center for PTSD, The Stress, Health, and Aging Research Program (SHARP). Retrieved from http://www.ptsd.va.gov/professional/treatment/older/ptsd_symptoms_older_adults.asp).).
Qureshi, S. U., Kimbrell, T., Pyne, J. M., Magruder, K. M., Hudson, T. J., Petersen, N. J., . . . Kunik, M. E. (2010). Greater prevalence and incidence of dementia in older veterans with posttraumatic stress disorder. Journal Of The American Geriatrics Society, 58(9), 1627-1633.
Robinson, S., Rapaport-Bar-Sever, M., & Rapaport, J. (1994). The present state of people who survived the holocaust as children. Acta psychiatrica Scandinavica, 89(4), 242-245.
Sala, T., Cox, B. J., & Sareen, J. (2008). Anxiety disorders and physical illness comorbidity: An overview.
. In M. J. Zvolensky & J. A. J. Smits (Eds.), Series in anxiety and related disorders. Anxiety in health behaviors and physical illness (pp. 131-154). New York: Springer.
SAMSHA. (2014). SAMSHA’S Concept of Trauma and Guidance for A Trauma Informed Approach.
Sharon, A., Levav, I., Brodsky, J., A., S. A., & Kohn, R. (2009). Psychiatric disorders and other health dimensions among Holocaust survivors 6 decades later. The British Journal Of Psychiatry: The Journal Of Mental Science, 195(4), 331-335. doi:10.1192/bjp.bp.108.058784
Shmotkin, D., & Barilan, M. Y. (2002). Expressions of Holocaust Experience and Their Relationship to Mental Symptoms and Physical Morbidity Among Holocaust Survivor Patients. Journal of Behavioral Medicine, 25(2), 115-134.
Shmotkin, D., Blumstein, T., & Modan, B. (2003). Tracing Long-Term Effects of Early Trauma: A Broad-Scope View of Holocaust Survivors in Late Life. Journal of Consulting and Clinical Psychology, 7(2), 223-234.
Stressman, J., Cohen, A., Hammerman-Rozenberg, R., Bursztyn, M., Azoulay, D., Maaravi, Y., & Jacobs, J. M. (2008). Holocaust Survivors in Old Age: The Jerusalem Longitudinal Study. Journal Of The American Geriatrics Society, 56, 470–477. doi:DOI: 10.1111/j.1532-5415.2007.01575
Strous, R. D., Weiss, M., Felsen, I., Finkel, B., Melamed, Y., Bleich, A., . . . Laub, D. (2005). Video testimony of long-term hospitalized psychiatrically ill Holocaust survivors. Am J Psychiatry, 162(12), 2287-2294. doi:10.1176/appi.ajp.162.12.2287
Trappler, B., Cohen, C. I., Tulloo, R. (2007). Impact of Early Lifetime Trauma in Later Life: Depression Among Holocaust Survivors 60 Years After the Liberation of Auschwitz. The American Journal of Geriatric Psychiatry, 15(1), 79-83.
van der Hal-Van Raalte, E. A. M., Bakermans–Kranenburg, M. J., & van Ijzendoorn, M. H. (2008). Diurnal cortisol patterns and stress reactivity in child Holocaust survivors reaching old age. Aging & Mental Health, 12(5), 630-638. doi:10.1080/13607860802343134
Waugh, M. J., Robbins, I., Davies, S., & Feigenbaum, J. (2007). The long-term impact of war experiences and evacuation on people who were children during World War Two. Aging & Mental Health, 11(2), 168-174.
Yaffe, K., Vittinghoff, E., Lindquist, K., Barnes, D., Covinsky, K., Neylan, T. et al. . (2010). Post traumatic stress disorder and risk of dementia among US Veterans. . Arch Gen Psychiatry, 67, 608-613.
Yeager, K. R., Cutler, D. L., Swendsen, D., & Sills, G. M. (2013). Modern Community Mental Health: An Interdisciplinary Approach.
Yehuda, R., Halligan, S. L., & Bierer, L. M. (2002). Cortisol levels in adult offspring of Holocaust survivors: relation to PTSD symptom severity in the parent and child.
. Psychoneuroendocrinology, 27(1-2), 171-180. Yehuda, R., Schmeidler, J., Labinsky, E., Bell, A., Morris, A., Zemelman, S., & Grossman, R. A. (2009). Ten-Year Follow-Up Study of PTSD Diagnosis, Symptom Severity, and Psychosocial Indices in Aging Holocaust Survivors. Acta Psychiatr Scand. 2009, 119(1), 25-34. doi:10.1111/j.1600-0447.2008.01248.x
Yehuda, R., Schmeidler, J., Labinsky, E., Bell, A., Morris, A., Zemelman, S., & Grossman, R. A. (2009). Ten-Year Follow-Up Study of PTSD Diagnosis, Symptom Severity, and Psychosocial Indices in Aging Holocaust Survivors. Acta Psychiatr Scand. 2009, 119(1), 25-34. doi:10.1111/j.1600-0447.2008.01248.x
Yehuda, R., Tischler, L., Golier, J. A., Grossman, R., Brand, S. R., Kaufman, S., & Harvey, P. D. (2006). Longitudinal Assessment of Cognitive Performance in Holocaust Survivors with and without PTSD. Biological Psychiatry, 60(7), 714-721. doi:10.1016/j.biopsych.2006.03.069
Zimbardo, P. G. (1971). The power and pathology of imprisonment. California. Washington, DC: U.S. : Government Printing Office.