© Springer International Publishing Switzerland 2015Katie E. Cherry (ed.)Traumatic Stress and Long-Term Recovery10.1007/978-3-319-18866-9_16
16. Aging with Trauma Across the Lifetime and Experiencing Trauma in Old Age: Vulnerability and Resilience Intertwined
Department of Gerontology and the Center for Research and Study of Aging, University of Haifa, 199 Aba Khoushy Ave., Mount Carmel, 3498838 Haifa, Israel
Interdisciplinary Department of Social Sciences, Bar-Ilan University, 52900 Ramat Gan, Israel
School of Psychological Sciences and the Herczeg Institute on Aging, Tel Aviv University, 69978 Tel Aviv, Israel
KeywordsAging traumaTrauma in old ageHostile-world scenarioFavorable psychological environmentResilienceVulnerability
During their lifetime, most people are exposed to at least a few occurrences of traumatic, or potentially traumatic, events (Breslau et al., 1998; Norris, 1992; Shmotkin & Litwin, 2009) . According to criterion A of the Diagnostic and Statistical Manual (DSM, 5th edition; American Psychiatric Association, 2013), a traumatic event may occur when the individual is exposed to, witnesses, or learns about actual or threatened death, serious injury, or sexual violence. These events may occur directly to the person himself/herself or to others. Adverse conditions that do not ostensibly meet the DSM criterion A (e.g., experiencing severe economic deprivation, providing long-term care to a severely disabled family member) may be potentially traumatizing if they pervasively and chronically disrupt one’s ability to meet essential needs and goals (Bonanno, Westphal, & Mancini, 2011) . In most cases, these exposures do not lead to a justifiable diagnosis of posttraumatic stress disorder (PTSD; Breslau, Peterson, Poisson, Schultz, & Lucia, 2004; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995) . However, for many, such exposures bear long-lasting consequences on physical and mental health, as evident in later life (Keinan, Shrira, & Shmotkin, 2012; Krause, 2009) . Nevertheless, alongside its deleterious consequences, traumatic experiences may also be associated with resilience (Seery, Holman, & Silver, 2010; Shmotkin, 2003; Shrira, Palgi, Ben-Ezra, & Shmotkin, 2011b) . The body of literature on these topics often interchanges, or even confuses, related experiences or events such as trauma, traumatic stress, potential trauma, and adversity. Therefore, for the sake of clarity, we opted to use in this chapter the term “trauma” in its broad sense, denoting a presumably forceful experience or event that one perceives as an overwhelming threat to one’s life or to one’s physical and mental integrity.
For many years, the psychiatric literature paid little attention to the consequences of early-life, as well as late-life, traumatic experiences in older adults’ lives. Also, it was common to overlook real differences of manifest traumatic symptoms existing in younger versus older age (Thorp & Blazer, 2012) . For example, certain symptoms accounting for PTSD according to the DSM-5 (e.g., inability to remember an important aspect of a traumatic event, diminished interest in significant activities, sleep disturbance, and problems with concentration; American Psychiatric Association, 2013) may overlap in old age with aging-related symptoms. Possibly, this insufficient sensitivity to the impact of age indicated that developmental trajectories of traumatic reactions among adults were not taken into account (Scott, Poulin, & Silver, 2013) . It seems that the perception of trauma in old age is typically “age centric” because it is shaped from a young adult perspective.
Due to the demographically expanding segment of older individuals in the population, it becomes even more imperative to better understand what characterizes traumatic and posttraumatic reactions in old age (Shenk, Ramos, Kalaw, & Tufan, 2009) . Moreover, it is questioned whether the fusion of traumatic experiences and aging processes can be explained in terms of positive human adaptation. Presenting the pursuit of happiness in a hostile world model (Shmotkin, 2005, 2011) , we aim, in this chapter, to address the interrelated roles of vulnerability and resilience among individuals who age while still bearing past experiences of trauma, or otherwise facing trauma that typically occurs in old age.
How Is Trauma Across the Lifetime Manifested in Old Age?
The literature presents two differing perspectives concerning the manifestation of lifetime trauma in old age . The first is the psychiatric–epidemiological perspective, which seeks differences between younger and older adults mainly in the levels (i.e., severity) of PTSD symptoms. Following this perspective, it was suggested that older adults presented similar levels of symptoms as those reported among younger adults (Bleich, Gelkopf, Melamed, & Solomon, 2005) . However, in a longitudinal study, Yehuda (2009) found that posttraumatic symptoms decreased with age among older adults who endorsed PTSD, with the greatest decline revealed in intrusive thoughts and the survivor’s guilt (Averill & Back, 2000; Lapp, Agbokou, & Ferreri, 2011) .
The second perspective is psychological–developmental, claiming that developmental processes along the life span shape the nature of the trauma in late life. According to this perspective, posttraumatic reactions join to aging processes in creating certain modes by which traumatized people survive to old age. In this vein, Shmotkin, Shrira, and Palgi (2011) delineated three cardinal modes: dementia-molded survival , embattled survival , and robust survival .
Dementia-molded survival refers to older adults with cognitive dysfunction due to dementia. For these persons, the dementia seems to reshape their traumatic memories while, in turn, the traumatic memories are presumably operative in the development and manifestations of dementia (Burnes & Burnette, 2013) . As traumatic remnants are mostly embodied in memory, two trajectories regarding this mode are available. In the first one, dementia-related deterioration of memory blurs, and consequently relieves, the long-lasting, agonizing experience of trauma (Kensinger, 2006) . In the second trajectory, the traumatic stress is intensified by dementia because common regulatory mechanisms are undermined, and formerly controlled traumatic memories are thus disinhibited (Butters & Delis, 1995; Cook, Ruzek, & Cassidy, 2003) .
The mode of embattled survival refers to cognitively intact older adults, for whom traumatic events that occurred during their lives have an accumulating detrimental effect on their late-life adaptation (Kraaij & De Wilde, 2001) . For these older adults, the lingering trauma may induce accelerating aging processes that intensify physical and mental frailty (Shrira, 2012, 2014; Shrira & Litwin, 2014) . Lingering trauma, in this mode, may appear as a chronic condition (Averill & Beck, 2000) , possibly in the form of PTSD.
Robust survival refers to older adults who exhibit good adaptation relative to their age, despite their past trauma. This mode is compatible with evidence that older persons do not differ from, or are even more resilient than, younger adults in their reactions to trauma (Bleich et al., 2005) , and show relatively low symptom levels even after high trauma exposure (Schnurr, Spiro, Vielhauer, Findler, & Hamblen, 2002) . This potential inoculation in old age can be explained by the maturity and experience that come with age (Hyer & Sacks, 2008) , as well as by the underestimated reserves of resilience that traumatized people can sustain in old age (Ryff, Friedman, Morozink, & Tsenkova, 2012) .
To sum, whereas the psychiatric–epidemiological perspective focuses mainly on age-related changes in levels of symptoms, the psychological–developmental perspective dwells on presumable processes operating behind the symptoms along the course of time. In fact, review studies on older adults found inconclusive results regarding the long-lasting effect of trauma (Böttche, Kuwert, & Knaevelsrud, 2012; Shenk et al., 2009). In the chapter, we further pursue the psychological–developmental perspective in order to examine the mechanisms that mingle issues of trauma and aging.
Aging Trauma Versus Trauma in Old Age
We define aging trauma as a distal traumatic experience or event that happened at an earlier point in the life span, but is still activated in one’s aging process. On the other hand, trauma in old age is a proximal traumatic experience or event that happened when one was already old and often in the context of aging-related contingencies (Martin, da Rosa, & Poon, 2011) . These two types of experiences present different, but not mutually exclusive, trajectories of trauma.
Aging trauma may exacerbate, or otherwise inoculate, one’s adaptation to aging. Often, it incorporates a number of events that involve life course chains of adversity (e.g., poverty, engaging in skirmishes, drug abuse, problems with the law, early marriage, occupational instability, divorce, social isolation), which placed a person at a greater risk to further deterioration in old age (Pearlin, Schieman, Fazio, & Meersman, 2005) . This cumulative effect may be exponential when a primary event leads to a secondary event. Moreover, the fact that the primary experience has been intensified challenges the individual’s ability to adjust to stress, especially in old age when adaptation mechanisms may be less flexible. The cumulative inequality theory (Ferraro & Shippee, 2009) takes a life-span perspective that might be relevant to understanding aging trauma . This theory proposes that social systems (class, race, income), as well as personal exposure to risk, generate inequality between individuals that accumulates across the life span. Hence, trauma occurring at young age, besides taxing one’s functioning at the time, may also create ruptures in abilities and resources that perpetuate inequality of functioning levels up to the particularly demanding period of old age. In contrast, other findings showed that aging trauma may enhance better preparedness for the challenges of aging. Thus, research showed that aging Holocaust survivors showed general resilience in their adaptation and only specific vulnerabilities in part of their functioning (Amir & Lev-Wiesel, 2003; Barel, Van IJzendoorn, Sagi-Schwartz, & Bakermans-Kranenburg, 2010; Shmotkin & Lomranz, 1998; Shmotkin, Blumstein, & Modan, 2003; Shrira, Palgi, Ben-Ezra, & Shmotkin, 2011a) .
Aging trauma is often reprocessed through the task of life review whereby older adults integrate their past experiences in a coherent way (Butler, 1963; Erikson, 1998) . This task provides another opportunity to narrate, and thus transform and integrate, the past trauma into one’s identity-defined life story (Maercker, 2002; Pals & McAdams, 2004) . The idea of treating present traumatic symptoms by retelling and reconstructing past events is well documented in the trauma literature (see, e.g., Palgi & Ben-Ezra, 2010; Palgi, Palgi, Ben-Ezra, & Shrira, 2014) . Indeed, older individuals are better off if they are able to contrast their past suffering with their present well-being and formulate a life story where the trauma is demarcated and controlled (see Chap. 23, this volume). These mechanisms appear empirically intricate. Thus, while Holocaust survivors were found to be less able than controls to separate between their most miserable period in the past and their present life satisfaction, there were still survivors who were able to better separate between suffering in other periods and their present life satisfaction (Shrira & Shmotkin, 2008) . Also, Holocaust survivors were found to maintain a higher subjective well-being (SWB) if they could deflate their emotional investment in the Holocaust period of their life while strengthening their emotional investment in non-Holocaust periods (Cohen & Shmotkin, 2007) .
Furthermore, one’s time perspective can either help or hinder coping with the challenges of aging. For example, it was found that the best-functioning participants in very advanced age were those whose time trajectory appeared stable, meaning that they could make their past experiences and future expectations correspond with their present experience (Palgi & Shmotkin, 2010) . Traumatized older adults, however, may find it hard to do this integration. Separating the survivors into those who conceived the Holocaust as past and those who conceived the Holocaust as present, showed that those in the former category were able to draw an effective line between the traumatic past and their present, thus allowing themselves to move forward (Shmotkin & Barilan, 2002) .
Summing together the previously mentioned studies suggests that aging trauma , by its nature, keeps the traumatic remnants of the past active through interaction with one’s aging processes in ways that either ameliorate or aggravate the lingering endurance of the trauma during late life.
Unlike aging trauma, trauma in old age represents a usually proximal traumatic experience or event that occurs after one’s aging processes have evolved. Naturally, the typical declines of old age may restrict the vigor and scope with which older adults encounter newly experienced traumas (Bei et al., 2013) ,. In this case, aging-related phenomena may serve as moderators of the occurrence. For example, it was found that among American older adults, exposure to Hurricane Sandy (which hit the US East Coast in 2012) was associated with PTSD symptoms to a higher degree for those who reported stronger fear of aging (Palgi, Shrira, Goodwin, Hamama-Raz, & Ben-Ezra, 2014) .
Yet, not in line with lay notions, older adults largely exhibit a better emotional regulation and a stronger bias for positivity (Mather & Carstensen, 2005) . This old-age resilience is further supported by the tendency of older adults to retain positive, meaningful social interactions (Carstensen, Isaacowitz, & Charles, 1999) . Hence, despite the expectation to see much frailty in old age, older adults may appear surprisingly potent in front of exposure to current traumas (Böttche et al., 2012). In this vein, post-disaster psychopathology is generally lower among older adults (Norris, Kaniasty, Conrad, Inman, & Murphy, 2002; Shrira, Palgi, Hamama-Raz, Goodwin & Ben-Ezra, 2014) .
Studies that examined the effect of age at the time of the exposure to trauma found that older adults who experienced their most distressing traumatic event during childhood exhibited higher symptoms of PTSD and lower subjective happiness compared with those who experienced their most distressing event after the transition to adulthood (Ogle, Rubin, Berntsen, & Siegler, 2013; Ogle, Rubin, & Siegler, 2014) . However, some studies indicated that traumatic events that occurred at young adulthood and midlife, compared to other life periods, were stronger predictors of negative posttraumatic outcomes in old age (Dulin & Passmore, 2010; Krause, 2005) . Another study showed that events experienced after 50 years of age are most detrimental for late-life mental health (Shrira, Shmotkin, & Litwin, 2012). The aforementioned findings, which present examples of aging trauma in our current term, point to the importance of timing in traumatization, and yet they are not conclusive. Even less is known about the timing effect of trauma during old age (Palgi, Gelkopf, & Berger, 2015) , as the temporal boundary between aging trauma and trauma in old age may in some cases be blurred because aging itself is socially constructed, with no clear start point that is immanently felt by individuals.
Overall, our proposed distinction between aging trauma and trauma in old age may facilitate a closer inspection of the dynamics underlying each kind of experience. In the case of aging trauma, the various aging processes have to accommodate one’s handling of the lingering traumatic narrative, whereas in the case of trauma in old age, the relatively recent traumatic narrative often appears assimilated within one’s aging processes. While overlaps of the two kinds of trauma are evident, the suggested difference between the two becomes clearer in view of the typical themes associated with each. Aging trauma often relates to events such as childhood deprivations, sexual abuse, wars and violent conflicts, car and occupational accidents, or breakup of marriage and close relationships (see Chap. 9, this volume for discussion of early childhood adversity). In comparison, trauma in old age typically relates to late-life events such as bereavement and widowhood, major debilitating and life-threatening diseases, caregiving, and dependency due to loss of vital functions.
Resilience Versus Vulnerability: Which One Prevails?
As implied in the previous discussion, the gerontological literature dealing with the contradiction of vulnerability versus resilience in coping with trauma suggests two competing hypotheses. The vulnerability hypothesis (Shrira et al., 2014; Solomon & Ginzburg, 1998) argues that older adults constitute an at-risk group with regard to the impact of trauma due to the age-related decline in functioning and the depletion of physical, social, and financial resources. In contrast, the inoculation hypothesis (Eysenck, 1983; Lapp et al., 2011) argues that older adults are less vulnerable to trauma than younger counterparts due to a better emotional regulation, higher maturity, and longer life experience (Hyer & Sacks, 2008; Urry & Gross, 2010) .
Nevertheless, these two hypotheses are not mutually exclusive and sometimes complement each other. One kind of resilience is posttraumatic growth, referring to a positive psychological change that occurs as a result of a struggle with the consequences of a traumatic exposure. Such change is manifested by a new meaning in one’s perspective on life, enhanced personal strength, and better relations to others (Tedeschi & Calhoun, 2004; see Chap. 17, this volume, for a related discussion) . However, studies have suggested a paradoxical “double-edge sword” association between higher posttraumatic stress and higher posttraumatic growth (Boals & Schuettler, 2011) . The intricate links between vulnerability and resilience were also exposed in studies of massive trauma such as the Holocaust, showing that it is nearly impossible to disentangle resilience and vulnerability within the individual survivors (Shmotkin, 2003; Shmotkin, Shrira, Goldberg, & Palgi, 2011). However, research sheds light on specific moderating variables that may determine whether resilience or vulnerability prevails. Certain variables of this kind are mentioned next.
In line with the aforementioned inoculation hypothesis , prior exposure strengthens resilience in face of current trauma. For example, a recent study showed that older adults, who reported to have experienced lower levels of traumatic events, found it harder to cope with first-time exposure to rocket attacks at the south of Israel, compared to those who had previously experienced higher levels of traumatic events (Palgi et al., 2015). Similarly, American older adults who had had a low level of exposure to the World Trade Center terrorist attacks on September 11, 2001, reported higher PTSD symptoms following Hurricane Sandy that occurred 11 years later (Shrira et al., 2014). While these studies suggest that older adults tend to rely on successful coping with previous traumatic experiences when confronting a new potential trauma, younger adults, on the other hand, may use other resources that are more easily available to them, such as broader social support and greater flexibility in response to stressors.
Another moderating variable that may explain the relative prevalence of resilience versus vulnerability is the quantitative aspect of the trauma. Thus, findings showed that the accumulation (i.e., the number) of lifetime adversities is associated with decline, as well as with continuous impairment, in major markers of physical, cognitive, and psychological health at the second half of life (Shrira, 2012, 2014; Shrira & Litwin, 2014) . On the other hand, the mere exposure to a single traumatic event, even if extreme in its nature, may still leave easier ways to mobilize coping mechanisms and focus them on the particular experience (Averill & Beck, 2000; Böttche et al., 2012; Lapp et al., 2011). These findings are in line with the dose–response model, which posits that the extent of repeated exposures to a traumatic event has a specific impact on the trauma’s sequelae (March, 1993) . Notably, this experiential dose of cumulative life adversity is not necessarily linear in its effect on functioning outcomes (i.e., the highest dose of exposure may not generate the strongest impact), and it may be associated not only with a stronger distress (as usually expected) but also with eventually enhanced well-being (Keinan et al., 2012) .
Still another moderating variable relating to the prevalence of resilience versus vulnerability is the durational aspect of the trauma. Whereas individuals can recover from prolonged exposure to trauma occurring in young age (Brom, Durst, & Aghassy, 2002; Shrira et al., 2011a) , prolonged exposure to trauma occurring in old age tends to prove more deleterious due to lower flexibility and plasticity of the nervous system and the behavioral repertoire in late life (Charles, 2010; Charles & Piazza, 2009) . Research has shown that prolonged chronic stressors are associated with increased morbidity and mortality (Troxel, Matthews, Bromberger, & Sutton-Tyrrell, 2003) . These findings are in line with the allostatic load theory, which postulates that frequent activation of the body’s stress response, while essential for managing acute threats, can damage the body in the long run (McEwen, 1998; see Chap. 9, this volume, for related discussion) . Furthermore, several studies conducted among Israelis exposed to prolonged missile attacks for years found age to be positively associated with PTSD symptoms (Dekel & Nuttman-Shwartz, 2009; Gelkopf, Berger, Bleich, & Silver, 2012) .
Mechanisms That Help Older Adults Deal with Trauma
It is curious to identify the coping mechanisms that older adults use in order to adjust to aging trauma , or trauma in old age, while handling the common burdens of aging. In fact, we have presented here certain mechanisms stemming from larger adaptational strategies that become particularly vital for sustaining the mental health of older people. The aforementioned strategies include the formulation of one’s life story, the adoption of a time perspective on one’s life course, and the emotional regulation that improves with age. Next, we address several more mechanisms of particular relevance.
Selection, Optimization, and Compensation
Baltes (1997) maintained that in old age, the incomplete segment in the architecture of human development is getting larger, as optimal functioning is doomed to disruption by irreparable biological dysfunctions. Nevertheless, psychological mechanisms such as selection, optimization, and compensation may attenuate this process. Moreover, these mechanisms are not overwhelmed by physical deterioration and may even gain power among older adults who were exposed to traumatic events. In a later conceptual development, the socioemotional selectivity theory (Carstensen et al., 1999) claims that, in the face of shorter time horizons, people optimize their priorities regarding their emotional goals. While young adults invest their efforts in knowledge-related goals, older adults adopt goals related to emotional regulation (Carstensen et al., 1999). Thus, older adults focus more on positive emotional experiences and less on negative ones (Charles, Mather, & Carstensen, 2003) , and select particularly positive and meaningful social interactions (Carstensen, 1995; Carstensen et al., 1999) . This positivity bias of older adults (Mather & Carstensen, 2005) can attenuate, to some degree, the negative consequences of trauma, provided that the trauma does not disrupt irrevocably one’s primary adaptational resources, notably the supportive social networks (Isaacowitz, Smith, & Carstensen, 2003) .
According to Baltes and Staudinger (2000) , wisdom is defined as a person’s expertise in the fundamental pragmatics of life. That is, wisdom entails abilities of retaining knowledge and exercising judgment about the essence of the human condition, as well as conceived ways as to how people might best plan, manage, and understand the lives they lead within the context of whatever values they hold important. Wisdom does not refer to intellectual or acquired academic knowledge, but rather to insight into human nature and the ability to resolve life complexities through practical experiences and personal reflections. Unlike cognitive functioning that decreases with age, wisdom is appropriate for aging-related developmental tasks as it frequently remains intact in old age.
Wisdom has been shown to be related to stress and posttraumatic growth (Webster & Deng, in press) . Similarly, Linley (2003) has suggested that adaptation to traumatic exposure requires recognition and management of uncertainty, integration of affect and cognition, and the awareness and acceptance of human limitations. Arguably, adaptation to traumatic exposure also requires an effortful reconstruction of world assumptions, such as living in a benevolent and predictable world, which are often utterly shattered by trauma (Janoff-Bulman, 1992; Webster & Deng, in press) . Older adults may be particularly in need of integrating and stitching together non-cohesive parts of their perceptions regarding human nature and themselves. One manifestation of wisdom in old age is understanding the dialectical nature of the world after experiencing trauma. This ability to withstand contradictions and paradoxes in life is explicated in the aintegration theory (Lomranz, 2005) . Following this conception, wisdom among older adults facilitates adjustment to trauma by the ability to reconcile with unbridgeable parts of the self, such as a devastating trauma and everyday life.