Background
There is evidence to suggest that children and persons of younger age are at greater risk of developing PTSD after exposure to war-related and other trauma [
1]. In particular, research has found long-lasting effects of childhood and early adult trauma during World War II (WWII) on the mental health of elderly survivors studied decades after exposure, e.g., [
2‐
8].
The emphasis of past research has been on adverse mental health outcomes following trauma but in recent years, there has been a shift towards a focus on resilience [
9], the notion that survivors can manifest positive adaptations after traumatic experiences [
10]. So far, resilience has been investigated in different contexts [
11‐
15], and also among elderly persons with traumatic experiences during WWII [
16‐
18].
Concepts of resilience
Although resilience has received considerable attention in recent years, no strict consensus exists on how to define and operationalize it. Some authors conceive resilience as the ability to recover from extreme experiences [
19], some as a reflection of general symptom improvement [
15], others as the capacity to preserve a stable personal equilibrium [
9]. Scholarly opinion even diverges on whether resilience may be considered as a—relatively—stable personality trait or not [
10,
19‐
21].
Resilience may incorporate different and also opposing dimensions and constructs on a trait level, like, e.g., hardiness, self-enhancement, repressive coping, or positive emotion [
9] (for a ‘multiple pathways’ view on resilience; see also [
22]). However, it may also depend largely on context [
21]. Furthermore, resilience may also require a life-span perspective on the processes involved, as these may vary across age groups [
13]. Aggravating this conceptual confusion is the sheer number of psychometric inventories of resilience currently available. Windle et al. [
23] identified 15 scales that may measure each as “an entirely different experience” (p. 1). Overall, the quality of most instruments was rated at best moderate. Alternative, outcome-oriented definitions to tackle this conceptual problem, like equating “resilience = absence of PTSD symptoms” [
24], may thus appear both simple and elegant. Currently, it is mostly unclear to which extent specific outcome-oriented and psychometric definitions and approaches agree and match with one another. Systematic investigation is needed to gain more insight into commonalities and differences.
Risk and protective factors: or just correlates, concomitants, and consequences of PTSD?
Some researchers [
9,
25] called for the investigation of factors promoting or vitiating resilience to examine the interaction of personal and situational characteristics [
22].
Research so far suffers from failing to delineate risk factors (also subsuming protective factors here) from correlates, concomitants and consequences [
26] strictly enough, and from failing to disentangle different outcomes (i.e., PTSD and non-PTSD) from the components of the psychometric construct of resilience that may promote a better outcome. Any factor that shows an association with an outcome is a correlate. Risk factors precede and alter the risk of an outcome, and may be fixed or variable. They are causal if their manipulation is shown to alter the risk. If a factor does not precede the outcome, it is a concomitant or consequence.
Across studies, some putative risk factors were not consistently found to alter the risk of the outcome. Effects of personal characteristics, like, for example, age (variable marker) or sex (fixed marker) on PTSD, non-PTSD, and psychometrically assessed resilience have been equivocal and inconsistent [
1,
27,
28]. Symptoms of depression were also reported to pose a risk for PTSD [
24], when equating “resilience = absence of PTSD symptoms”. However, in the cross-sectional study of Bonanno et al. [
24] precedence of depression among those who reported symptoms of PTSD was not ascertained empirically. Symptoms of depression are also characteristic of PTSD itself or may co-occur with PTSD. Hence, they may rather constitute a concomitant. This ambiguity highlights a possible drawback of the otherwise simple definition “resilience = absence of PTSD symptoms” and calls for adequate measures to guard against confounding in cross-sectional studies when using an outcome-oriented approach of research.
Environmental factors that possibly promote positive mental health despite traumatic experiences and protect against PTSD are social acknowledgement [
29,
30], social support [
31], relationships and relationship quality [
32], and stable living conditions during adolescence [
27]. Among the elderly, greater social engagement, defined as visiting with friends and family, was also reported to be associated with psychometrically assessed resilience [
13]. Yet, with regard to the sequence of events and the definition of a risk factor [
26], aspects of social support that did not clearly precede the outcome after adversity may not be considered true protective factors. Moreover, PTSD is also associated with relationship problems [
33]. As a consequence, this could effectuate lower social support in PTSD. Social support could thus constitute a concomitant of non-PTSD instead of representing a protective factor against PTSD. Research needs to guard against such artefacts.
Factors relevant for coping, like humour [
34] and spirituality [
12], are probably best interpreted as components of the psychometric construct of resilience [
9] that promote a better outcome. If individual cognitive-behavioural characteristics were present before the experience of a traumatic event and were shown to alter the risk of the outcome, they are protective factors. Otherwise, they have to be regarded as correlates (concomitant or consequence) of non-PTSD.
Mental health in WWII survivors
A number of studies so far have investigated factors promoting or vitiating resilience in WWII survivors. Displacement during WWII was found to contribute (causally) to psychopathology [
16], while for veterans and former child soldiers positive social recognition, social support and acknowledgement, as well as a positive personal evaluation of war efforts were repeatedly reported to exert beneficial effects on posttraumatic outcome [
18,
35,
36]. The impact of a lack of social support on posttraumatic symptoms was also documented in victims of WWII mass rapes [
37]. Again, these effects of social support on a better outcome may be a result of relationship problems in PTSD (see above) or are probably more indicative of posttraumatic growth than resilience [
38], when they did not clearly precede traumatic events.
A causal environmental risk factor, which has not been thoroughly investigated so far may lie in differences of traumatic load in different occupational zones post-WWII. Historical data suggest that people faced a higher risk of adversity in the Soviet occupied zones than in the Western allied (France, UK, and USA) zones in Germany and Austria [
39]. Austria was incorporated into the 3
rd Reich in 1938 and liberated in 1945. Occupation by Western Allied and Soviet troops lasted from 1945 to 1955. In a sample of civil survivors of WWII [
40], now 65+ years old, who experienced various kinds of trauma during their wartime-childhood and adolescence, over 92% reported experiences of war-related traumata or traumatic experiences with the occupational forces (termed generically WRTs in the following), and over 97% reported at least one lifetime-trauma. Prevalence of PTSD was 1.9% in this sample, but this rate increased to 14% taking into account sub-threshold PTSD. Specifically, even though not indicative of higher rates of PTSD, traumatic experiences with the occupational forces were reported more often by residents of the former Soviet occupied zone (56.5% vs. 16.7%).
This study
Resilience has been studied in samples of elderly persons with specific war-time histories such as veterans but to our knowledge, not in more general samples of WWII survivors who experienced various kinds of trauma during their wartime-childhood and adolescence. In this study, we asked for differences and correlates between PTSD and non-PTSD individuals in such a general sample of WWII survivors. Correlates might be specific personal and situational features and characteristics like, for example, active coping, humour or social support, that may enhance the individual cognitive and behavioural capacity to cope with adverse events and to adapt to a given environment [
34,
41].
We contrasted and combined outcome-oriented and psychometric approaches to disentangle symptoms of PTSD from personality characteristics and cognitive-behavioural components of the psychometric construct of resilience that may promote a better outcome. This strategy allowed us to arrive at a clearer picture of risk factors, correlates, and consequences of PTSD and non-PTSD. It also enabled the investigation of the impact of environmental variables and individual coping strategies on PTSD and non-PTSD to be examined in more detail. Data previously presented [
40] were used.
A 3-phased approach was used in analyzing the data. First, we examined correlates of PTSD and non-PTSD utilizing the outcome-oriented approach applied by Bonanno et al. [
24], allowing thereby direct comparisons with previous results. Specifically, we examined effects of social support and acknowledgment on coping with WRTs in this phase. Moreover, we assessed whether a short and reliable psychometric measure, the 10-item Connor-Davidson Resilience Scale (10-item CD-RISC; [
42]), also discriminated between the different levels of outcome according to the criteria of Bonanno et al. This allowed us to examine the extent to which the outcome-oriented and psychometric approaches overlapped.
In a second phase, correlates of PTSD and non-PTSD were re-investigated in a matched sample of PTSD cases and non-PTSD controls, matched with regard to sociodemographic characteristics and known risk factors of PTSD (e.g. number of life-time traumata). An examination of CD-RISC total and item scores in this matched sample was also undertaken to delineate more clearly positive components of resilience from negative outcomes in this psychometric instrument implied by the presence of PTSD symptoms.
In the third phase, we investigated which cognitive-behavioural characteristics were indicative of having successfully coped with an environmental risk factor in the past among those who were overall ‘resilient’ in a positive outcome-oriented sense [
9]; i.e., able to preserve a stable personal equilibrium. Residents of the Soviet occupation zone post-WWII had a higher risk of adversity than residents of the Western zones [
39]. Thus we compared ;CD-RISC scores of persons whose psychological health was above average at the time of the assessment (whose self-reported overall symptom severity did not exceed the 50th percentile of the population norm) from the two occupational zones (i.e., the West and Soviet zones).
Results
Correlates of resilience in the total sample
The multinomial regression model had a significant fit on the data (
χ
2(24) = 53.22,
p < .001;
N = 277 because of partially missing data). A medium level of education, a lower number of lifetime traumata, the absence of symptoms of depression, and involvement in voluntary work were associated with non-PTSD (‘resilient’) compared to PTSD (see Table
2). In contrast, mild-to-moderate trauma was associated with a lower probability of being married and a higher probability of being involved in voluntary work compared to PTSD. We also checked on differences between the ‘resilient’ and ‘mild-to-moderate trauma’ groups by setting the latter as reference category in the regression model (reporting only significant results here,
p < .05): non-PTSD (‘resilient’) was specifically associated with a smaller number of life-time traumata (OR = 0.81, 95% CI = [0.68, 0.98]) compared to mild-to-moderate trauma. Age, sex, residing in a nursing home, social support and acknowledgement on WRTs, and positive contributions of the occupational forces on the coping with WRTs showed no significant association with any status group.
Table 2
Multinomial logistic regression predicting outcome (reference category = PTSD)
Age | | 0.95 [0.94, 1.07] | 1.03 [0.96, 1.10] |
Female Sex | | 0.58 [0.23, 1.46] | 0.72 [0.26, 1.99] |
Education (compared to < 10 years) | 10–12 years |
2.46 [1.01, 6.05]
| 2.59 [0.98, 6.82] |
| > 12 years | 1.57 [0.43, 5.72] | 0.93 [0.20, 4.25] |
Marital status (compared to | Married | 0.59 [0.22, 1.59] |
0.26 [0.87, 0.80]
|
widowed or divorced) | Single | 0.84 [0.14, 5.09] | 1.74 [0.30, 10.24] |
Living at own home (compared to nursing home) | 1.02 [0.41, 2.49] | 0.91 [0.35, 2.37] |
Number of lifetime traumata | |
0.73 [0.59, 0.91]
| 0.90 [0.71, 1.14] |
Symptoms of depression | |
0.21 [0.06, 0.71]
| 0.29 [0.08, 1.04] |
Engaged in voluntary work | |
4.86 [1.42, 16.70]
|
4.34 [1.12, 16.79]
|
Social support on WRTs | | 0.91 [0.64, 1.29] | 1.00 [0.68, 1.47] |
Positive contribution of occupational forces | 0.82 [0.37, 1.80] | 0.49 [0.21, 1.19] |
Current status had a significant impact on CD-RISC total scores (see Table
2) with a medium effect size,
F (2, 283) = 12.04,
p < .001, η
2 = .078. Bonferroni-corrected, non-PTSD (‘resilient’) participants differed significantly from mild-to-moderate traumatized participants (
p = .011) and from participants with probable PTSD (
p < .001). Mild-to-moderate traumatized participants and participants with probable PTSD did not differ (
p = .105). The covariates had no significant impact (age:
F (1, 283) = 0.03,
p = .874; number of life-time traumata:
F (1, 283) = 1.20,
p = .274).
Comparison of PTSD cases with matched controls
Cases and controls matched perfectly with regard to sex, educational level, and residence during WWII. They were comparable regarding all other matching criteria (age: M = 82.05 vs. 81.98, t(82) = 0.06, p = .952; total number of life-time traumata: M = 4.24 vs. 4.07, t(82) = 0.43, p = .668; MMSE score: M = 26.64 vs. 27.21, t(82) = −1.28, p = .205). 13 of the controls were classified as mild-to-moderate trauma. This was inevitable, as a larger number of traumata (which served as a matching criterion) raised the probability of showing symptoms of PTSD (see above).
Cases and controls differed in none of the examined variables that were no matching criteria (marital status: likelihood ratio = 3.27, df = 2, exact p = .157; symptoms of depression: OR = 3.06, 95% CI = [0.75, 12.46], p = .194; current residence in nursing home: OR = 1.22, 95% CI = [0.51, 2.96], p = .822; voluntary work: OR = 0.39, 95% CI = [0.11, 1.37], p = .227). They also did not differ with regard to zone of occupation (Soviet zone: OR = 0.74, 95% CI = [0.31, 1.78], p = .658). However, cases more often had children (n = 38 vs. 29, OR = 4.26, 95% CI = [1.26, 14.43], p = .028). The mean number of children among those with children did not differ between cases and controls (M = 2.11 vs. 1.90; t(65) = 0.70, p = .489). All cases and 26 of the controls reported that they also had regular contact with their children.
Total CD-RISC scores differed between cases and controls by a large amount (see Table
3). With regard to items, differences were significant in Items 6, 10, 7, 8, 2 and 5 (in descending order with regard to effect size) and there at least of medium size. No significant differences were found for Items 1, 3, 4, and 9.
Table 3
Differences in CD-RISC item and total scores in the matched case–control sample
1. Able to adapt to change | 3.23 (1.10) | 3.36 (1.14) | −0.53a
| .595 | −0.12 |
2. Can deal with whatever comes | 2.66 (1.10) | 3.21 (0.93) | −2.48b
| .015 | −0.54 |
3. Tries to see humorous side of problems | 2.05 (1.30) | 2.45 (1.44) | −1.34b
| .184 | −0.29 |
4. Coping with stress can strengthen me | 1.27 (1.38) | 1.81 (1.57) | −1.67b
| .099 | −0.37 |
5. Tend to bounce back after illness or hardship | 3.15 (0.91) | 3.60 (0.73) | −2.43a
| .018 | −0.54 |
6. Can achieve goals despite obstacles | 2.56 (1.42) | 3.40 (0.91) | −3.24b
| .002 | −0.71 |
7. Can stay focused under pressure | 2.58 (1.28) | 3.24 (1.06) | −2.57a
| .012 | −0.57 |
8. Not easily discouraged by failure | 2.68 (1.25) | 3.31 (1.05) | −2.50a
| .015 | −0.55 |
9. Thinks of self as strong person | 2.95 (1.32) | 3.33 (0.85) | −1.57b
| .120 | −0.35 |
10. Can handle unpleasant feelings | 2.63 (1.22) | 3.38 (1.06) | −2.98b
| .004 | −0.65 |
Total score | 25.93 (6.65) | 31.10 (6.12) | −3.65a
| < .001 | −0.81 |
Successful coping with an environmental risk factor in the past
In our sample we identified 173 participants whose psychological health was above average (GSI T score < 51) at the time of the assessment, 94 (54.3%) of whom had resided in the Soviet zone (cases) and 79 (45.7%) in the Western Allied zone (controls). Cases differed from the controls in CD-RISC total scores by d = 0.39 (M = 32.86 vs. 30.49, t(170) = −2.57, p = .011); i.e., the cases had higher scores. In single item analyses, this difference could be traced to Items 3 (‘humour’; M = 2.98 vs. 2.29, t(171) = 3.51, p < .001, d = 0.54) and 4 (‘stress strengthens’; M = 2.23 vs. 1.54, t(171) = 3.03, p = .003, d = 0.46). The cases and controls did not differ in any of the other items (ps ≥ .088). Ratings in Items 3 and 4 were in both the cases and controls slightly positively correlated, but this was significant only with regard to the cases (Spearman rho = .21 and .18, ps = .040 and .120). Dichotomizing items at a rating of 2 (sometimes true), the cases had a more than eightfold chance to rate one item at least sometimes true, provided they had also rated the other item at least sometimes true (OR = 8.07, 95% CI = [2.07, 31.47], p = .002). No such association was observable among controls (OR = 1.98, 95% CI = [0.77, 5.14], p = .235).
Discussion
Our study shows that outcome oriented and psychometric research approaches on resilience converged to some extent. Yet, each was deficient in its own way. By using different research vistas and diligent control for confounding, we were able to avoid bias and to identify more clearly predictors and correlates of positive mental health despite trauma. Our findings corroborate some previous results but also expand these findings with regard to the elderly who had traumatic experiences during their childhood and adolescence.
With regard to the outcome oriented approach, comparing persons with mild-to-moderate trauma or PTSD with non-PTSD (‘resilient’) persons, a higher number of life-time traumata and current depressive symptoms were found to be associated with current symptoms of posttraumatic stress, corroborating previous results [
24,
54]. While the number of previous traumata may be reliably regarded as a variable risk factor, analyses with our matched case–control sample suggest that depression is most likely no true risk factor but rather a concomitant of PTSD and its symptoms. Evidence substantiating this conclusion in the elderly was recently reported by Chaudieu et al. [
55]. Symptoms of depression may thus indicate current posttraumatic stress rather than pose a risk factor of PTSD in the elderly. This needs consideration in clinical treatment.
A medium level of education, compared to a low level, also appeared beneficiary for non-PTSD in our study. Previous studies reported conflicting evidence on this issue [
11,
24]. Judging from our data, a high level of education does not impede adaptation to trauma [
24]. It rather seemed to have no specific beneficial effect compared to a lower level of education. The effects of education need to be investigated more specifically in future research.
Sex did not emerge as a risk factor in our study, corroborating findings by Spitzer et al. [
7] in a community sample of elderly Germans. However, full and sub-threshold PTSD was more frequent among married persons in our study, compared to persons with some symptoms of PTSD but no probable diagnosis. Matching with regard to marital status and a number of other sociodemographic characteristics, persons with full or sub-threshold PTSD were also more likely to have children. These findings are somewhat at odds with previous results on higher levels of perceived social support [
18,
24,
27] and greater social engagement [
13] in resilient persons. Yet, our findings may reflect an aspect of help-seeking behaviour in persons with PTSD. Recent research suggests that spouses’ emotion-focused coping strategies may have a beneficial impact on victims’ PTSD symptoms [
56]. Stronger familial ties and an increased likelihood to rear children may be a consequence of this kind of help-seeking behaviour. Marital status and a higher likelihood to rear children may in this respect be regarded as consequences of PTSD in the elderly. More research is, however, needed on this topic.
Voluntary work in old age was also associated with a lower probability of full or sub-threshold PTSD. In absence of longitudinal data, we suggest that this may be inversely interpreted as a consequence of the debilitating symptoms of PTSD: persons with PTSD may be less able — because of their symptomatology — to involve themselves in such activities [
57]. Volunteerism may thus be understood as an indicator (i.e., a concomitant or consequence) of non-PTSD but not as a protective factor against PTSD.
In contrast to other reports on positive posttraumatic outcome [
30,
35], PTSD and non-PTSD were not characterized by differences in social acknowledgement or of having had the opportunity to talk openly about war-time experiences with someone. These conflicting results may be due to sampling differences: Forstmeier et al. [
35] investigated former WWII child soldiers, whereas Maercker and Müller [
30] studied survivors of political imprisonment in former Eastern Germany and recently traumatized crime victims. These samples may have been representative of persons who had some ‘special’ or uncommon traumatic experience. Most civilian WWII child-survivors are not recognized as having a special or in some way outstanding history to tell. Consequently, social acknowledgement and the seeking of such may be generally lower in the cohorts of civilian WWII child-survivors. While social acknowledgement could have been beneficial to them, they might not have had the chance to acquire it.
With regard to the psychometric approach, the 10-item CD-RISC was found to discriminate reliably between PTSD and non-PTSD persons in our study. In the matched case–control sample, differences were accordingly also greatest in items that were related to PTSD symptoms of clusters B and D (Items 6, 7, and 10). Thus, resilience as measured with the CD-RISC evidently mirrored to a large extent only PTSD symptom severity, calling the utility of the CD-RISC somewhat into question [
54]. Moreover, being able to adapt to changes (Item 1), considered an essential indicator of psychometrically defined resilience [
15], did not discriminate between matched PTSD and non-PTSD persons. Yet, among those whose psychological health was above average, seeing the humorous side of problems (Item 3) and maintaining the impression that coping with stress can be strengthening (Item 4) were found to be indicative of having dealt successfully with an environmental risk factor in the past. This study thus corroborated that humour is an important component of resilience and coping [
34,
58]. Yet, our study also shows that it is complemented by a challenge-oriented attitude towards life. We suggest that these two inter-related cognitive-behavioural characteristics should be regarded as protective factors. Fostering these two factors could thus be important for prevention programmes that seek to boost resistance against posttraumatic stress and PTSD. Experimental and longitudinal research is needed here.
With regard to the initially posed question (‘Is it resilience?’), our study provides no definite answer. We obtained evidence of a risk and a protective factor (number of life-time traumata, medium education), and of a number of likely correlates and consequences of PTSD and non-PTSD in the elderly (symptoms of depression, voluntary work, marital status, likelihood to rear children). From this perspective, only fewer traumata and a medium level of education appeared to promote better mental health and resilience (i.e., showing less likely symptoms of PTSD), replicating previous results [
24]. Humour and a challenge-oriented attitude towards life were found to be important aspects in coping successfully with an environmental risk factor in the past. However, these characteristics did not discriminate PTSD from non-PTSD. Thus, our study’s main contribution may lie in pointing out that the question ‘
What is resilience?’ needs reformulation. Studies need to examine in more detail which specific factors contribute to good mental health in which specific way. Likewise, studies need to differentiate more systematically between different levels of outcome (e.g., PTSD and non-PTSD), types of correlates (i.e., risk factors, concomitants and consequences), and cognitive-behavioural characteristics of psychometric definitions and operationalizations of resilience that may promote a better outcome. In conclusion, our results underline that the psychometric assessment of resilience needs improvement and should be based on a stringent definition of resilience that avoids too large an overlap with the symptomatology of PTSD. Such an instrument should incorporate — in a ‘multiple pathways’ approach — different and various components that are thought to bring resilience about or for which ample evidence already exists (i.e., humour).
Limitations of our study pertain to its cross-sectional character, which precludes direct inference on causality, problems of reporting bias given the old age of the participants and the large time spans covered, and only limited control over confounding variables that may have introduced further bias, like sampling. In the absence of normative data with regard to the base population of war-exposed Austrians, it is unclear whether our sample was truly representative. The use of ad-hoc scales and single items with regard to social support and acknowledgement on WRTs may have biased results. Associations with the Big Five personality traits and specific coping styles [
32,
59], which may help in mapping out the terrain of resilience as a personality trait [
22], were also not considered in this study.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
UST and TMG contributed equally to this manuscript. UST and TMG wrote the paper, planned and conducted the statistical analysis, BLS designed and supervised the project and contributed to writing and revising the paper. All authors read and approved the final manuscript.