There has been considerable interest in the psychological and physical consequences of incarceration. When the repatriated prisoners of war (RPWs) from the Vietnam conflict returned home, there was speculation that many, particularly those held prisoner prior to 1 969 when physical brutalities were extreme, would return incapacitated. There was further concern that debilitation would increase with time. This article briefly delineates features of the Concentration Camp Syndrome as originally described by Leo Eitinger and compares those observations with findings thus far reported on Vietnam Prisoner of War studies.
Long-term psychological and physical effects of incarceration have been described by a number of investigators.1"4 The Concentration Camp Syndrome (KZ Syndrome), originally observed and reported by the Danish, compared signs and symptoms noted in former concentration camp survivors. Eitinger believed that long-term psychological symptoms were essentially related to physical trauma experienced during imprisonment.1 Chodoff, however, attributed chronic symptoms to psychological factors, although organic factors were recognized as quite important.5 While such distinctions are interesting, the practical aspects of an individual with impairment, and whether or not that impairment is a direct result of either physical or emotional insult, or a combination of both, is, in a sense, of academic importance. We cannot quantify torture or emotional insult. If a delayed result from imprisonment is to be expected, we work to prevent or, at the least, minimize the consequences. These are more readily measured.
The K-Z Syndrome, as defined by Eitinger, required at least five of a possible 1 1 symptoms. The 1 1 symptoms noted by Eitinger are: 1) increased fatigue; 2) impairment of memory; 3) dysphoria; 4) emotional instability; 5) impairment of sleep; 6) feelings of insufficiency; 7) loss of initiative; 8) nervousness, restlessness, irritability; 9) vertigo; 10) vegetative lability, and U) headache.1 Eitinger's original sample comprised 100 former concentration camp prisoners admitted to the Neurological Department of the Oslo University Hospital. These patients were part of a larger group examined at the request of the Norwegian Association of Disabled War Veterans who had observed that, despite the 12 years which had elapsed since the conclusion of World War II, a large number of former prisoner of war veterans were unable to adapt.
Three-fourths of Eitinger's sample had suffered edema secondary to chronic malnutrition, 65% had serious gastrointestinal disease, 58% had back injuries, and 50% had experienced head injuries with loss of consciousness. Subjective complaints by this group were related to profound psychiatric impairment and symptoms compatible with an organic brain syndrome. The percentage of prisoners reporting these symptoms were as follows: increased fatigue - 85%; nervousness, irritability, restlessness and memory impairment - 78%; dysphoric mood - 72%; emotional instability - 70%; sleep impairment - 61%; anxiety - 55%; feelings of insufficiency and loss of initiative - 54%; headache - 53%; vegetative instability - 48%; vertigo - 43%; nightmares and depression - 36%; tremor and other involuntary movements - 21%; alcohol abuse - 19%; reduced alcohol tolerance and diffused pains and paresthesias - 14%; and lastly, tinnitus - 11%. The strongest correlation, with the subsequent development of the Concentration Camp Syndrome, related to serious physical diseases during captivity, specifically encephalitis and typhus, head injuries, and weight loss greater than 30% (Table 1).
Altogether 65 cases had seven or more of Eitinger's 11 Concentration Camp Syndrome symptoms, 15 had six symptoms, five had five symptoms and in the remaining 15 cases, no evidence of the syndrome was found.1 Overall, 85% of Eitinger's group were found to have the K-Z Syndrome, which Eitinger related to organic changes secondary to head trauma, toxic disease and severe malnutrition.
Prisoner of war studies in the United States have consistently demonstrated disability of a greater severity for prisoners of war than that of veterans who served in the same Combat Theater and were not prisoners of war. Beebe has reported that repatriated prisoners from Japan and those of the Korean War suffered from the sequelae of tuberculosis infection and parasitic disease, while psychiatric impairment was high for all World War Il POWs and Korean War POWs. These problems correlated with higher hospital admission rates for these groups, more frequent VA disability awards and more frequent reporting of symptoms on medical questionnaires.6 Kuhn documented an increased mortality in former prisoners of World War II (Pacific Theater), and the Korean War resulting from trauma (both accidental and suicidal), while deaths due to cirrhosis were elevated for Korean and World War II European prisoners.7 Two significant differences in the experiences of the World War II European POWs related to a comparatively low mortality rate while being held prisoner and a shorter period of incarceration (Tables 2 and 3). All POWs, however, have a significantly higher incidence of serviceconnected disability and the most prevalent condition of those disabilities is anxiety neurosis."
Despite some rather ominous predictions prior to their release, the Vietnam POWs have done amazingly well. This is not to say there have not been residual effects from their captivity. Some have endured, and continue to endure, the scars of their captivity, but the large majority appear to show no effects of their trauma. At repatriation, only 6% were given a psychiatric diagnosis, typically for a neurotic problem." Two years later, 71 repatriated Air Force POWs from Vietnam were given the Wechsler Adult Intelligence Scale with findings that "the RPW population, as measured at this time, demonstrates intact, integrated, and superior intellectual functioning."10 Wetzler, in studying 251 initial evaluations of Air Force RPWs and 229 re-evaluations done at the USAF School of Aerospace Medicine, noted that diagnoses of those RPWs with permanent disability at retirement were primarily orthopedic and neurologic. Further, it was his opinion that "combat egress, rather than captivity, was more detrimental for the RPW group."" Injuries sustained in ejection were usually treated at capture in a rudimentary manner, if at all. Despite stress, which was clearly extraordinary, a substantial number of the most harshly abused RPWs identified their captivity as having been beneficial psychologically in terms of how they subsequently viewed themselves and others.12
POW MORTALITY RATE DURING INCARCERATION11
ESTIMATED AVERAGE LENGTH OF INTERNMENT12,13
The strongest suggestion that Vietnam RPWs returned from prison brutalities with permanent psychological impairment comes from the work of Ursano, but even his findings stop well short of Eitinger's K-Z Syndrome. Ursano looked in depth at six Vietnam RPWs who had been evaluated both before and after captivity. He concluded: "These cases support the view that neurotic illness can develop under unusually stressful conditions in individuals with no predisposition to psychiatric illness. The perspective of personality change unrelated to the development of psychopathology is necessary to explain this data."" In parallel works, Ursano. Boydstun, and Wheatley found a significant degree of psychiatric readjustment problems among Air Force Vietnam RPWs, those problems being greatest among POWs captured before 1969. In that group, psychiatric diagnoses increased over a five-year period from 23.2Ci to 27. Kf, while diagnoses for the group captured after 1969 had decreased from 23.4% to 19.7%. u This suggested not only increased morbidity in the high stress pre-1969 group, but it also suggested a delayed effect similar to what Eitinger reported to be part of the K-Z Syndrome. What continues to be in marked contrast to Eitinger's study group are problems of lesser severity. The Air Force Vietnam RPW group problems have, for the most part, been adjustment reactions and marital/ occupational maladjustments.
Quantification of stress is, of course, difficult, particularly when two individuals exposed to the same conditions have strikingly different responses. The pathophysiology of starvation, the brutalities of torture and the profound deprivations of captivity often leave psychological theories wanting and superfluous. The Air Force Vietnam RPWs have differed from previous prisoner of war groups of all other wars not only by their small numbers, but most were older career officers rather than enlisted foot soldiers. Their formal education was higher than any previous group. These attributes were perhaps in some part protective.
Most United States Air Force RPWs were generally aware of K-Z symptoms since they had been briefed to look for and expect these symptoms. Not surprisingly, a small number actually reported "K-Z Syndrome" as a chief complaint. The following composite case will illustrate, and generally represent, all four such evaluations: A was a 46-year-old Air Force Lieutenant Colonel (Lt. Col.), who came to the USAF School of Aerospace Medicine for a pre-retirement evaluation because he had observed "K-Z symptoms." During the preceding year, Lt. Col. A had noted five episodes of a strange sensation. "It was kind of like I was falling." He had not fallen, however, nor had he experienced dizziness, nausea, vomiting or any type of visual disturbance. He was understandably worried, however, that these sensations were an ominous harbinger of future debilitation. He described his current job as Director of Flight Operations to be quite satisfactory, although he did not have the same zest for his work since he had thought about and decided upon, retirement from active duty. He could not recall if his falling sensation antedated his decision to retire, but he was certain the two were unrelated. A's Vietnam captivity had been marked by deprivation, torture and malnutrition. By his estimation, he had, at one point, weighed 150 lbs., a 60 Ib. weight loss from his usual 210 lbs. A had been captured in early 1967. Overall, he had spent 19 months in solitary confinement. Eight of those months were continuous. His right shoulder had been separated at least twice in the course of having been tied with ropes used as a form of physical abuse. He had, on one occasion, been forced to sit on a stool for 29 consecutive days with his hands manacled behind his back, and his feet tightly bound. There were repeated beatings, repeated episodes when he lost consciousness after being struck in the head, sometimes with fists, sometimes with a rifle butt. He recalled as the greatest pain, however, edematous upper and lower extremities. There were also bouts of dysentery during his confinement. He summarized his first two years of confinement by saying, "The pain was out of this world." He recalled frequent dreams: "Usually I was winning the war, triumphing over all. Now I don't dream much at all. It's just like when I was a kid. I fall asleep and wake up." Lt. Col. A returned to an intact family, his wife and three children. All, according to A, were getting along well, except for his son, who was five years old when A was captured and 12 when A was released. This son, now 20, was a source of major concern to A. "He's a rebel without a cause. That's what he is. He's had five jobs since high school and now he's unemployed again." While A had accepted a desirable job offer, he reflected: "I'm going to miss flying. I've had a super job and I'll miss that too." Specialty examinations by Internal Medicine, Cardiology, Neurology, Ophthalmology, Otolaryngology, and extensive psychological testing turned up nothing remarkable. We hypothesized that his complaints of "falling" were associated with, and secondary to, the stress of separation from active duty, selection of a new career, and concern over his wayward son. The other three evaluations were similar.
In time, many of the RPWs will develop the usual maladies associated with aging. How to separate these "normal" afflictions from the sequelae of incarceration is not a simple task.
It is, however, an oversimplification to assume that, by virtue of being a prisoner of war, one will suffer delayed effects. Stress is so varied, both in presentation and individual experience, that any analysis or treatment must be patient specific. The delayed effects seen thus far in Vietnam RPWs cannot technically be called a K-Z Syndrome. In my eight years of experience with Air Force Vietnam RPWs, I did not see, nor was I aware of, any Air Force Vietnam RPW who met Eitinger's criteria. This is not to say there have not been or will not be problems directly attributable to their imprisonment, but, for now, their problems appear to be qualitatively and quantitatively different. What is abundantly clear is that, following extreme stress, there is no predictable response.
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2. Lonnum A: Delayed Disease and III· Health. Oslo. Norway. AS TeisenTrykk. 1969.
3. Thyyescn P. Hermann K. W iHanger R: Concentration camp survivors in Denmark: Persecution, disease, disability, compensation. Dan Med Bull 1970: 1 7; 6S- 1 OX.
4. Eitinger L, Strom A: Mortality and Morbidity After Excessive Stress. NewYork. Humanities Press Inc. 1973.
5. Chodofi' P: Psychiatric aspects of the Nazi persecution, in Arieti S (ed): American Handhook of Psychiatry, ed 2. New York. Basic Books Inc. 1975. vol 6. pp 932-946.
6. Becbe GW: Follow-up studies of World War Il und Korean War prisoners, Am J Epidemiol 1975: 101:400-422.
7. Keehn RJ: Follow-up studies of World War Il and Korean Conflict prisoners. Am J Epidemiol 1980: ?: 194-21 1.
8. Veterans Administration Studies and Analysis Service: Study of Former Prisoners of War. Government Printing Office. 1980.
9. United States Air Force. Office of the Surgeon General: Diagnosti! Conditions of Repatriated POWs. 1973; 24(11):46.
10. Green JL. Phillips JK III: Intelligence test performance of Vietnam prisoners of war two years post-return. Avita Space Environ Med 1976: 47:1210-1213.
11. Wetzlcr HP: Status of Air Force prisoners of war five years postrepatriation. VSA F Medical Service Digest November- December 1979. p 28.
12. Sledge WH. Boydstun .IA. Rahe AJ: Self-concept changes related to war captivity. Arch (ten Psychiatry 1980; 37:430-443.
13. Ursano RJ: The Vietnam era prisoners of war: Precapti ? it y personality and the development of psychiatric illness. Am J Psychiatry 1981: 138:315-318.
14. Ursann RJ. Boydstun JA. Whcatlcv RD: Psychiatric illness in l.S. Air Force Vietnam prisoners of war: A five-year follow-up. Am J Psychiatry 1981: 138:310-314.
POW MORTALITY RATE DURING INCARCERATION11
ESTIMATED AVERAGE LENGTH OF INTERNMENT12,13