PSYCHE, 1968, Jg. 22, Ausgabe 6

It has been said – even by psychoanalysts – that Freud's presentation of female psychological development is insatisfactory inasmuch as he dwells on the negative, non-masculine factors instead of stressing the positive, feminine aspects. His theoretical findings, however, provide safe guide-lines to the understanding of female sexuality and the development of the girl. These lines are the genetic approach with regard to libidinal development and object-relations; the relationship of narcissism to object-love; the dual libido-aggression; and the dynamics of the structures ego, id, and super-ego. In addition to a discussion of these basic positions, a summary is given of some of the elaborations and extensions made in the contributions of later psychoanalysts, such as H. Deutsch, A. Freud, Th. Benedek, J. Lampl-de Groot, Ph. Greenacre and others.

In the German extermination camps – such as Auschwitz – those who were not immediately sent into the gas-chamber were confronted with a series of traumatic experiences unknown in normal life, and undermining their sense of security. One of the most decisive factors was the daily confrontation with being without any future, as death was the only outcome one could count upon. Since the usual defence mechanisms were insufficient to cope with this reality, an ego-regression took place: In many of the victims this regression went so far that they lost all possibility of adaptation: they became so-called »Muselmans«, and soon succumbed. Others managed to establish a libidinal cathexis of a complex of archaic ego functions that made an adaptation in the »here and now« possible (provided they did not succumb to physical exhaustion or torture). After the liberation, these personality changes proved very difficult to reverse. The ex-prisoners were no Ionger able to engage in activities and social contacts directed towards the future. Since this is one of the decisive factors in the genesis of the so-called survivor syndrome, it is understandable that this syndrome constitutes a new and specific clinical entity. To confuse it with neurasthenic, paranoiac and depressive clinical pictures in the involutional period would mean to ignore the connection of the exprisoners' sufferings with the horrible experiences they had sustained.

Clinical experience over a number of years in the diagnosis and treatment of concentration camp survivors and victims of similar forms. of persecution indicates that we are dealing with a type of traumatization of such magnitude, severity and duration as to produce a recognizable clinical entity named by the author the »Survivor Syndrome«. This syndrome appears to be characterized by the persistence of multiple symptoms among which chronic depressive manifestations, anxiety reactions, insomnia, nightmares, personality changes, disturbances of memory and cognition (»lost and bewildered« states), impairment in the sense of identity, and far reaching somatization prevail. The incidence and severity of many of these persistent manifestations correlate closely with survivor guilt and certain specific traumata, such as: loss of children, parents, siblings, history of rape, total degradation, and other factors connected with the persecution. The clinical significance of the syndrome, its severity and relation to the massive traumata sustained during the persecution are discussed.

Dr. de Wind had the courage to overcome the usual resistance of concentration camp survivors to presenting themselves for analysis and to going through once more, in the course of treatment, what he had experienced in the years of his persecution. His analyst, too, had to overcome the usual resistance of analysts to undertaking such an objectivity-threatening analysis, because in the course of such treatment the reality experience may be revived in terms of, and with all the difficulties of a psychotic transference ( Nunberg, 1951). The utter submissive obedience of the concentration camp survivors has generally been seen as a manifestation of human masochism. However, one should consider whether this passivity may not also have been the result of a diminution of all vital functioning - instinctive, defensive and moral - caused by extreme biological starvation. The pattern of withdrawal to a simple »here and now« and »only myself counts« existence, with its »efficiency« of psycho-economic saving, which was laid down at the time of persecution, may cause considerable revival of guilt when it reappears in the survivor at times of conflict in relation to his present Iove objects. The guilt thus aroused may, in turn, stimulate a revival of persecution scenes as a self-punishment. The psychic sequelae which may affect the offspring of the survivor under these circumstances, must also draw our attention.

The author agrees with most of Dr. de Wind's paper, but thinks that Dr. Bettelheim's book demands a sharper criticism than that expressed by the speaker. A further point of disagreement on his part is with regard to Dr. de Wind's opinion on the psychological disturbances in those who have been traumatized by longlasting exposure to the concentration camp conditions. In his opinion, the former concentration camp inmates have suffered primary and Iasting injury to their narcissism and are incapable, therefore, of deriving pleasure frotn normal life processes. lt is possible that traumatization has also caused a permanent change in the attitude toward death.

After a brief survey of the pertinent literature, own experiences with evaluations and treatments of 148 survivors of severe persecution are reported. 147 of these patients suffered from psychosomatic reactions regardless of age, sex, socio-cultural background, type of persecution, and diagnostic classification. Psychosomatic disorders accompanied these conditions in 28 survivors. A thorough study of affects and an evaluation of their degree led to the working hypothesis: Moderate or strong anger, combined with regression and inability to sublimate, favors the occurrence of psychosomatic disorders. The two groups of psychosomatic reactions and psychosomatic disorders revealed no relevant difference regarding depression and withdrawal. Anxiety, however, of moderate to strong degree found its expression in psychosomatic reactions whereas it was predominantly bound in psychosomatic disorders. Two case histories serve as illustration for the close relationship between persecution and development of psychosomatic disorders. Apart from the constellation (Schur) the importance of affects for somatization and re-somatization is shown.