Harold J. Bursztajn, MD

Mental health caregivers have all too often had to work in situations where patients’ needs far outstrip available resources. It is akin to the 

 experienced at times in emergency rooms, on the battlefield, or by clinicians dedicated to the care of underserved populations.

 The chaos and uncertainty generated by the COVID-19 pandemic mirrors historical reports of other global traumas, times when difficult decision making occurs amid great uncertainty, and tragic choices must be made.

 Making such choices can leave indelible effects on the human psyche.

The aftereffects of triage-like situations are often insidious and may remain hidden for years, sometimes expressing themselves somatically, psychologically, and behaviorally. Sadly, the COVID-19 pandemic has also challenged caregivers, as well as patients and their loved ones, forcing difficult triage choices. Experience reminds us that we need to be prepared for the aftermath of triage’s trauma.

Traumatic flashbacks, feelings of unconscious or dissociated survivor guilt or shame, and experiences of depression are common. Efforts to treat this posttraumatic spectrum of suffering, while often helpful if not curative, can also often fail, leaving clinicians concerned about what they have missed, how might they have been more helpful.

Much is written about the models and ethical issues raised by working with such individuals. How to help them remains a mystery. Clinicians are often left saying, “We’ve done the best we can, and it simply wasn’t good enough.”

Perhaps such self-flagellation and despair are the result of working from a limited perspective on the etiological components web of chance, causation, choice, and helplessness that entraps the individual in their suffering. Witnessing, experiencing, or perpetrating traumatic events does not only affect normative cognitive expectations; it also challenges an individual’s sense of self and fundamental expectations of their values. It can assault their 

: a sense of meaning and what is right and wrong, not simply as ethical choices, but as elements of their own inherent constitution and agency.

Moral integrity represents the depth of an individual’s inner core, not a simple dichotomy of right and wrong. As such, when a person’s moral integrity is jeopardized in some fashion, they lose touch with their inner identity. It may lead to overestimating or disowning personal agency as a protection against the aloneness and helplessness inherent in triage-limited decision-making. As a result, many of the components of posttraumatic suffering and chronic grief (such as guilt, remorse, shame, or considering oneself infallible) are experienced in a far deeper way, since the sense of meaning and existence are in jeopardy. Denial of uncertainty, compartmentalizing helplessness, and experiencing life-long anticipatory mourning are possible consequences. And when resilience is necessary, an inability to grieve helplessness and vulnerability can lead to culturally sanctioned, socially toxic prejudices.

Caregivers and patients suffering from moral injuries are different from those who are not. Moral injury means that an individual's self-definition is on the line. Efforts to mitigate their post-traumatic spectrum symptoms may only provide partial remedy for their problems. Individuals suffering greatly may become angry, blaming caregivers, in an effort to retain an illusion of control. They frequently experience feelings of doom greater than depression.

The aftermath of COVID-19 will likely leave many with posttraumatic spectrum and chronic grief. Many will also likely suffer from moral distress. “Did I do enough?” “I failed to take proper precautions.” “My god failed me.” Such cries of distress are likely to be misunderstood unless we recognize that they may well be expressions of existential moral suffering. Unaddressed, moral suffering may be a prelude to toxic resilience: dehumanization and destruction of members of a historically demonized and marginalized minority.

 Moral distress also may prompt self-destructive behavior, as in “

” from suicide, excessive risk taking, and looking for quick fixes or anesthesia via compulsive drug use.

Who can address such suffering? An initial step is to connect with those who have made triage decisions. Clinicians should make sure that they are not left with the choice of either feeling alone or being treated generically. Care providers must address a fundamental wish of perfectionism in themselves in order to be available to help those saddled with triage responsibility. While observing boundaries, at times self-disclosure of one’s own failures, fears and regrets in life can be helpful. As members of a supportive medical and mental health community, we need to be prepared to do no less during and after this pandemic.

Addressing moral distress is different. Post-triage trauma, confessions of regret are not enough. It is vital to recognize that there is a good deal of judgment inherent in decision making under conditions of uncertainty and limited resources. The key is to avoid both perfectionism and denial of responsibility, idle self-righteousness, and nihilism. Such insight can only be achieved in a safe space for conversation. As we recover and hope, it is vital to make time and resources available to treat not only checklist post-traumatic stress spectrum mental health symptoms, but also the larger, more persistent changes in personality and perception of self that constitute moral injury.

 is has been a faculty member of Harvard Medical School Department of Psychiatry Medical since 1976. He is co-founder, co-director and vice president of the American Bioethics Culture Institute, the American Unit of the International Network of the UNESCO Chair [Haifa] in Bioethics, Inc

 is co-founder of the Program in Psychiatry and the Law at Harvard Medical School and president of the American Unit of the UNESCO Bioethics Chair (Haifa). He is coauthor of 

Medical Choices, Medical Chances: How Patients, Families, and Physicians Can Cope with Uncertainty

 (1981/1990). He practices clinical and forensic psychiatry and risk management in Cambridge, MA.

1. Bursztajn HJ, Gutheil TG, Brodsky A. 

Ethics and the triage model in managed care hospital psychiatry

Other times, other realities: Toward a theory of psychoanalytic treatment.

4. Haque OS, De Freitas J, Viani, et al. 

Why did so many German doctors join the Nazi Party early?

5. Case A, Deaton A. Mortality and morbidity in the 21st century. 

6. Tanaka G, Tang H, Haque OS, Bursztajn HJ. 

Preserve Enduring Personality Change After Catastrophic Experience (EPCACE) as a diagnostic resource

Articles

Mental health providers who battle a pandemic may find that it unsettles their deepest sense of self.

Triage Trauma and Moral Distress 

Neither Deaths From Denial Nor Deaths From Despair

Weaving Beauty Into the Tapestry of the Pandemic

We want to be sure that just as when we treat psychiatric illness with medications or psychotherapy, there are no unintended consequences. The cure should not be worse than the disease; so must we be cautious about an exaggerated response to COVID-19.  To my mind, that is iatrogenesis.

More in this video with Harold J. Bursztajn, MD, Co-founder of the Program in Psychiatry and the Law at 

 and President of the American Unit of the 

 (1981/1990). He practices clinical and forensic psychiatry and risk management in Cambridge, MA.

The cure should not be worse than the disease; so must we be cautious about our response to COVID-19. More in this video with Harold J. Bursztajn, MD.

Slideshows

In a time of panic, despair, and demoralization, art continues to inspire the author's reflections as it has over the last 40 years. Here, he shares some images that he finds inspirational and helpful. Even in winter there is hope.

Prevention of Covert COVID Iatrogenesis

Local, state, and federal officials are rushing to implement massively life-altering measures in the current 

 even as we enter a situation that is still poorly understood. Given the initial level of denial, resulting in lack of preparedness and testing of inconsistent quality and quantity in different countries and regions, there will be deaths from denial that could have been prevented. We still lack valid data on the prevalence of the virus, fatality rates, or so-called “excess mortality” beyond what might be expected in the 2- to 18-month period that has been proposed as critical for this pandemic. There are, however, indications that, unlike during the influenza pandemic a century ago, fatalities from the coronavirus are occurring disproportionately among the fragile elderly and others with already reduced life expectancy because of underlying conditions that weaken their immune systems.

Our most vulnerable people deserve (as do we all) specific attention to prevention and special care-prevention and care that may be diminished by the drain on limited resources that a blind-panic community-wide quarantine approach, which diminishes the dignity of a community, makes inevitable. We have to be careful that in search for perfect COVID-19 community-wide contagion prevention perfection, we do not inadvertently enter into a malignant competition as to who can be more perfect at the art of prevention. Competition among individuals and communities striving for perfection in COVID contagion prevention can inadvertently dehumanize both individuals and entire communities. This is vividly illustrated by the post-Holocaust artwork of the Latvian born American painter Hyman Bloom, (1913-2009) 

. (Exhibited at the Boston Museum of Fine Arts 2019-2020). Marsayas, a musically gifted Satyr, aspired to outdo the artistic perfection embodied by the Greek god Apollo. Alas, such perfectionism ended as it inevitably does, in dehumanization of the self, of figuratively being flayed alive of one’s humanity.

Sweeping measures of debatable efficacy in saving lives strive for perfect prevention. We need to ask questions such as are we really closer to perfect prevention of death or are we further from the good life when a state’s police are ordered to stop motorists with out-of-state license plates. When  police are ordered to identify people as a threat to public health generically, as by their state license plate or whether they are wearing masks in even sparsely populated open air areas, there is the potential for abuse of power, and civil rights violations, humiliation, demoralization, and police and public health resource diversion. On the other hand, precise measures such as 

, recently initiated in Massachusetts, empower the identified individual with an understanding of the need to be quarantined.

Such measures respect dignity and agency and are not demoralizing for individuals-who can receive support while quarantined-or stigmatizing for entire communities. Avoidance of demoralization and stigma is essential in the current pandemic, which leaves those affected susceptible to the ongoing isolation and humiliation characteristic of 

Enduring Personality Change After Catastrophic Experience 

(EPCACE), a useful diagnosis unwisely eliminated from ICD-11. The catastrophic trauma for which many around the world are now at risk creates a timely 

, with its potential to support individual empowerment and the creation of healing communities.

In my psychiatric practice, I am now spending much of my time responding to panicked patients and advising colleagues who are faced with such patients. People who already experienced heightened anxiety, a sense of loss of control over their lives, concerns about mortality, or feelings of hopelessness, understandably find these difficulties exacerbated not only by the emergence of the virus but even more by an atmosphere of societal panic amid a sea of unknowns. Given my career-long interest in iatrogenesis (medically caused illness or injury), I need to ask whether draconian proposals with yet uncalculated consequences, such as indefinite, community-wide long-term quarantines, may prove to be a cure worse than the disease.

Surely, we must work to prevent deaths from denial due to the current lack of widespread testing accessibility. We must take appropriate precautions such as handwashing, staying home when ill, reasonable physical distancing, and reasonable restrictions on movement and large gatherings. But we must also consider at what point deaths from denial may yet be exceeded by deaths from disruption leading to despair. Bioethical analysis must consider that people also die of loneliness, of helplessness, of the feeling that their lives have gone out of control and likely will never return to normal. Then, too, there are the foreseeably devastating economic consequences of an ongoing breakdown of established networks of interaction and exchange. While we can all see ourselves as vulnerable due to the denial that preceded the emergence of the pandemic, not all of us can see ourselves as being vulnerable to deaths of despair. Yet unraveling the fabric of society will give many of the most vulnerable people ample reasons to despair and panic.

 by being condemned to work as sanitation workers fighting a typhoid epidemic in the Lodz ghetto in Poland, often spoke of the need to be realistic, yet not give in to panic and despair. The costs of panic and despair are many. Today, they include the racist scapegoating being directed at groups such as Asian-Americans and Hasidic Jews. There are also some who will exploit a chaotic situation for economic gain. Likewise, those who seek to concentrate political power can manufacture or inflame a crisis as a pretext for postponing elections, or pander to prejudices by proposing community-wide quarantine.

 is among the prudent alternatives to economically and socially devastating collective quarantines. In South Korea and Singapore, specific yet successful health measures have included reasonable precautions, targeted testing for those in massive public contact, identification of those infected and tracing their contacts, and contact-specific and infection-specific quarantine. Massachusetts has now become the first state in the nation to initiate contact tracing. This should be a nationwide policy. It is vital that we now ramp up testing, tracking, identifying, and quarantining those infected and their high-risk contacts and focus resources on those in need.

The pandemic need not leave in its wake community-wide, overwhelming despair and demoralization. Even as we implement effective and ethical public health measures, we can prevent the long-term 

 of panic-driven public health. Even under conditions of uncertainty, we can still treat communities and individuals with dignity, do the right thing, and be open to learn from those who in other times either suffered from EPCACE or were able to be effective during such catastrophes and resilient in the aftermath of those catastrophes.

, is Co-founder of the Program in Psychiatry and the Law at Harvard Medical School and President of the American Unit of the UNESCO Bioethics Chair (Haifa). He is coauthor of 

1. Tanaka G, Tang H, Haque OS, Bursztajn HJ. How catastrophe can change personality: why EPCACE is a clinically useful diagnosis. 

Local, state, and federal officials are rushing to implement massively life-altering measures in the current pandemic even as we enter a situation that is still poorly understood.

We can reasonably quarantine infected individuals, but we should not squander our social and moral capital by quarantining whole communities.

As the pendulum has swung from denial to near-pandemonium about 

 in the US and worldwide, sensible public health strategies to contain the spread of the virus must compete for attention with panic reactions like calling for quarantining people of a particular nationality. Today it is the Chinese, tomorrow perhaps the Italians.

As a psychiatrist, clinical ethicist, and citizen, I struggle with the reality that panic and hysteria spread more easily and quickly, covering more space in less time, than does hope. When hope cannot be offered in the form of a quick fix, there is a natural tendency to plunge into despair, leading often to counterproductive measures. The Internet, through its instant, indiscriminate communication of simplistic, reductive messages, is much better at spreading fear, panic, and hopelessness than at raising hope, which is best fostered by people working together and learning to trust one another.

For an inspiring model of communal hope and 

under a dire threat to survival, I find myself turning to the Fekalists, the prisoners condemned to be sanitation workers in the Lodz ghetto in Nazi-occupied Poland, my parents among them. The Fekalists, who disposed of human waste and cleaned sewers, had an average life expectancy of six months. Yet, instead of succumbing to despair under the most horrific conditions, they worked with physicians and nurses-also ghetto residents-to prevent an epidemic of typhoid fever from getting out of control. Had they not succeeded, for example, in keeping sewage out of drinking water, the Germans would have liquidated the ghetto.

My father later recalled a Jewish physician who secretly ministered to him after he had been wounded in a resistance raid to obtain vital building materials from a German supply house. “I will die here,” my father said to the older man. “One of us will, but it will be me,” replied the physician. “I do not have any way to treat you, but you are young. If you don’t give up hope, you will survive.” Indeed, the Fekalists did not give up hope. Instead, through solidarity, humor, and song, they helped preserve community morale and became the heart of the Lodz ghetto resistance. Among those who were saved were 14 people who, using the materials obtained in the raid on the supply house, built an underground bunker cemented over a riverbed. My parents married in that bunker.

If the heroes of that imprisoned ghetto could maintain a resilient community without scapegoating, we can do likewise under much more benign conditions. We need not assume that a catastrophic 

is at hand, and we must not resort to racist measures like demonizing and shunning an ethnic community. Such panic can easily become a self-fulfilling prophecy, with demoralization and economic chaos cascading into a life-threatening catastrophe. Far better to understand that life goes on and that hope and resilience can be nurtured, even amid cases of illness and death.

Fortunately, the Internet can also serve to convey practical preventive measures for individuals, families, and communities, like those being developed by the 

Centers for Disease Control and Prevention

 (CDC). For example, a blogpost by Ian M. Mackay and Katherine E. Arden titled “

So you think you’re about to be in a pandemic?

” (on the Australian website Virology Down Under) lays out useful recommendations such as staying at least two meters away from visibly sick people, washing hands thoroughly, trying not to touch your face, and stocking up a two-week supply of food and other essential household items. We can reasonably quarantine infected individuals, but we should not squander our social and moral capital by quarantining whole communities.

This article was originally posted on March 3, 2020, and has since been updated. -Ed

 is Co-founder of the Program in Psychiatry and the Law at Harvard Medical School and President of the American Unit of the UNESCO Bioethics Chair (Haifa). He practices clinical and forensic psychiatry in Cambridge, MA.

For an inspiring model of communal hope and resilience under a dire threat to survival over COVID-19 fears, the author turns to the Fekalists, the prisoners condemned to be sanitation workers in the Lodz ghetto in Nazi-occupied Poland, his parents among them.

Resilience, Not Panic, in a Time of Pandemic

Any psychiatric diagnosis has the potential for empowering the clinician to treat the patient’s suffering as well as inspiring the patient to participate in an effective treatment. Alas, diagnosis also has the potential for stigmatization and dehumanization. Whereas diagnoses of personality disorder all too often have been used to stigmatize patients, the rush to eliminate Enduring Personality Change After Catastrophic Experience (EPCACE) from the International Statistical Classification of Diseases, Revision 11 (ICD-11) is foreseeably an instance in which patients vulnerable to aloneness will be less likely to receive effective treatment and thus will become even more voiceless, further disempowered, and more vulnerable to humiliation throughout the life cycle’s inevitable stressors and losses.

EPCACE was incorporated into ICD-11 as a form of Complex PTSD (cPTSD) as of June 2018. EPCACE is defined as an enduring personality change lasting for a minimum of 2 years that a patient experiences following a catastrophic stressor (ICD-10). The events of the stressor must also be so extreme that one should disregard any genetic vulnerabilities or predispositions that would further influence personality changes. These experiences can include imprisonment in concentration camps, disasters, and long-lasting capture with a persistent threat to life.

ICD-10 EPCACE represents the experiences of a particularly vulnerable population group, one marked by great loss, separation from a community, and aloneness. Such isolation from nourishing connections is a major dimension of deep and enduring personality change. Especially in cases of massive psychic trauma such as the Holocaust, involving the loss of an entire community and its way of life, fundamental bonds of social connection, trust, and support are broken, and the individual is left profoundly alone. Such affective changes point to the insufficiency of research on survivors left in such a devastated state.

We acknowledge that there is great variability in the experience and suffering of survivors of catastrophic events. As with any clinical diagnosis, a diagnosis of EPCACE is no substitute for a formulation tailored to the needs of the individual patient and that patient’s family. An EPCACE-based formulation can highlight such factors as extreme helplessness and aloneness, whether human agency was the cause of the catastrophic event, whether the event involved humiliation of the survivor, and whether the survivor remained in the zone of danger after the catastrophic event. These factors may be evident both individually and transgenerationally, as they are in the suffering of some of the survivors of the Holocaust who remained in areas where anti-Semitism and its dangers continued to be prevalent.

With careful attention to individualization of formulation, there is evidence for the benefits of EPCACE being included in the next revision of DSM as its own unique diagnosis. While care needs to be taken to avoid a reductionist and dehumanizing misuse of the diagnosis of EPCACE, the presence of this diagnosis in standard diagnostic taxonomies of psychiatric disorders can guide treatment formulations to good effect. Furthermore, EPCACE is an integrative diagnosis that offers clinicians the capacity to transcend diagnostic categorization by bridging personality disorder with trauma-related disorder, fulfilling an integrated biopsychosocial approach.

Our proposal has strong historical precedent. By 1992, the concept of trauma-inflicted personality changes had been well studied, as described by Herman and colleagues

 and later confirmed by many others, including Beltran and Silove,

 In an effort to distinguish personality changes as a result of catastrophic events from those with other causes, the ICD-10 task force decided on the inclusion of EPCACE. Personality traits such as hostile or distrustful attitude toward the world and social withdrawal, chronic feelings of emptiness or hopelessness, of being on edge as if constantly threatened, and estrangement distinguished EPCACE from related disorders.

With catastrophic genocidal trauma that includes extreme helplessness, humiliation, and the destruction of a validating community, resulting in aloneness, there is also a potentially lifelong vulnerability to shame.

 Such personality traits may emerge post-catastrophe and then become dormant. Nonetheless, they may reemerge with disruptive life-cycle events such as helplessness, humiliation, separation, loss, and grief or with news events, such as can occur for Holocaust survivors when anti-Semitism reemerges. Similar events may result in seemingly divergent personality traits emerging among survivors or even within a survivor, such as when there is an intensification of efforts to avoid massive grief concurrent with a counterphobic adaptation.

To test the validity of such an EPCACE diagnosis, Beltran and colleagues

 undertook a comprehensive survey of clinical psychologists and psychiatrists: 89% of respondents agreed that personality can be altered by trauma occurring in adulthood. Of those 89% of respondents, torture and concentration camp exposure were identified by 91% and 90% respectively as likely to produce changes to personality, followed by 72% for war exposure, 66% for sexual assault, 57% for hostage situations, 52% for domestic violence, 25% for natural disasters, and 24% for motor vehicle accidents.

Despite this substantial evidence, only 16% of clinicians had ever used EPCACE as a diagnosis for their patients, although it had been a valid ICD-10 diagnosis for 7 years before Beltran’s survey. Those who responded to the survey also cited issues of symptom overlap between EPCACE and more commonly used diagnoses, specifically depressive disorders and borderline personality disorder. However, EPCACE is marked by stable changes in personality, whereas borderline and depressive disorders are marked by instability in mood and affect.

It is foreseeable that post-traumatic avoidance of reminders by both patient and clinician is even more pronounced in catastrophic trauma. This may be another factor that contributed to the underutilization of EPCACE in its debut as a diagnosis. Alas, the underutilization of EPCACE is a loss for a significant proportion of patients who might otherwise have united as a treatment community. This loss is compounded by the fact that aloneness is often seen in the transgenerational transmission of EPCACE-related suffering. Group therapy is therefore a vital modality in EPCACE treatment across generations and in fostering the transgenerational transmission of resilience.

A follow-up study of the validity and utility of EPCACE in 2008 by Beltran attempted to redefine the broad aspects of the diagnosis and identify the key criteria that described a person with EPCACE. Twenty-four mental health clinicians who worked with patients who had experienced war and sexual assault as well as recently displaced refugees provided valuable feedback. Not only were the key attributes of “A hostile or mistrustful attitude toward the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of being ‘on edge,’ as if constantly threatened, and estrangement” identified, but mental health practitioners felt significant features were excluded from EPCACE’s operational definition. These include “somatization, self-injurious/self-damaging behaviors, sexual dysfunction, and enduring guilt,” which if included would differentiate EPCACE from complex PTSD and strengthen the operational validity of the diagnosis.

 Since then, no changes to criteria or follow-up studies have been conducted to improve the utility of EPCACE.

Research into EPCACE has been limited, as manifestations of the core symptoms can often differ depending on viewpoints and type of trauma. A core feature of EPCACE such as “a hostile or mistrustful attitude toward the world” can be operationally expressed by multiple symptoms such as anger, aggression, and other countless variations.

 Holocaust survivors who were identified as “feeling as if the Holocaust experience was continuing” were more likely to suffer symptoms of mental disorder, whereas those who avoided the traumatic memories altogether had a higher mortality rate due to illness.

 Patients with a diagnosis of EPCACE may isolate themselves not only from their communities, but also from proper mental health care.

Alternatives to inclusion of EPCACE as a distinct diagnosis

Critics of the inclusion of EPCACE in diagnostic taxonomy claim that it lacks specificity and is insufficiently utilized. To address these concerns, Maercker and colleagues

 proposed to reconceive EPCACE as part of cPTSD in ICD-11. Following this recommendation, the World Health Organization trauma team eliminated the diagnosis of EPCACE.

 cPTSD incorporates patients with personality changes as a result of exposure to single or multiple traumatic experiences, as long as the requirement of three core features of PTSD is met; these core features include changes in affect, self-concept, and relational function.

Alas, modifying the diagnostic criteria for cPTSD to consolidate EPCACE and other trauma-related disorders may also lead to mislabeling and downgrading the seriousness of personality changes, as well as overlooking potentially transgenerational personality changes. Because different experiences may produce different neurological and behavioral effects, it would be unwise to disregard the type of event and its impact on affect.

A later study noted a more specific set of criteria that must be met, as well as additional symptoms such as changes to somatization, self-injurious/self-damaging behaviors, and sexual dysfunction that would largely be left out of the criteria for cPTSD.

 The current criteria for cPTSD-which encompass the majority of EPCACE cases tested by Keeley and colleagues18-faced diagnostic issues when practitioners became aware of the origin of the trauma.

Another argument against the diagnostic inclusion of EPCACE is symptom overlap between EPCACE and cPTSD. While there is a spectrum of post-traumatic disorders, with overlap among diagnostic categories, the presence of such similarities does not invalidate the clinical usefulness of an EPCACE-inclusive categorical approach in the initial process of clinical reasoning, differential diagnosis, treatment planning, and prognosis. Therefore, future ICD workgroups should reconsider EPCACE’s inclusion into cPTSD, given the weight mental health professionals place on traumatic origin, and restore EPCACE as a distinct diagnosis.

The American Psychiatric Association has opted for a more conservative route in DSM-5 by incorporating elements of cPTSD and EPCACE into the diagnosis of PTSD. DSM-IV had largely suffered from “poor interrater reliability of personality disorder diagnoses, poor stability over time, poor discriminant validity, and poor general coverage of personality disorder as well as poor clinical utility.”

 DSM-5 requires that adult patients being evaluated for stress disorders meet eight symptomatic criteria following exposure to trauma. Galatzer-Levy and Bryant

 found that the current diagnosis for PTSD could arise from 636,120 unique combinations of the eight criteria listed in the newly formulated definition. With so many combinations, PTSD has been utilized as an all-encompassing definition that lacks the specificity needed to adequately diagnose trauma. The diagnosis of trauma-related disorder should not be done on a one-size-fits-all basis, but rather should consider the elements of trauma and its disparate effects on individuals.

Why EPCACE should be reborn as a distinct diagnosis

As it currently stands, EPCACE has lost its core values in the newly revised ICD-11 and the previously published DSM-5. Given that EPCACE is marked by hostile attitudes toward society, withdrawal, emptiness, and hopelessness as well as constant vigilance and estrangement, the salient characteristic of the disorder is the sense of aloneness that leads to massive social disconnection. EPCACE has significant features in common with the kinds of compounding trauma seen in autism spectrum disorder or adolescent-onset psychosis as a person becomes isolated and marginalized. With EPCACE, patients suffer a loss of community and trust with the outside world. With the loss of community, as in the Holocaust, there is an ever-greater risk of the transgenerational transmission of trauma and far fewer transgenerational resources for resilience such as loving grandparents or an extended healthy family.

EPCACE should be a stand-alone diagnosis rather than a formulation because diagnoses are heuristics for formulations, which guide prognosis and treatment planning. Also, if diagnoses are missing key ideas, those will also be missing in formulations. Aloneness and vulnerability are distinct factors characteristic of EPCACE that are coherent only at the diagnostic level. Moreover, with catastrophic experiences the life cycle and transgenerational dimensions of trauma and resilience are more likely to be central.

The majority of mental health clinicians in active practice or completing graduate education will utilize either DSM-5 or ICD-11. When Evans and colleagues

 surveyed a global sample of psychologists, they noted that 78% of respondents opted for a diagnosis that is flexible enough to account for cultural differences. Severity of a diagnosis was highly rated as a goal of clinical care, as 88% of the respondents believed that it should take the form either of a subtype based on severity or degree of functional impairment or of a separate diagnosis.

Further research has linked trauma to quantifiable changes in personality. In a comparison of late-onset personality pathology due to wartime trauma with prior personality disorders, 24.3% of patients had a personality disorder develop only after exposure to catastrophic events. When compared with those who had preexisting personality disorders, those with late-onset personality pathology had a three-fold higher rate of PTSD symptoms. Moreover, there were higher rates of suicidal ideation and self-reported emotional distress compared with persons with pre-trauma pathology.

Additional research has shown not only physical changes to the brain but also transgenerational effects that pass from parent to offspring.

 Such a link between catastrophic experiences and personality necessitates the use of integrative criteria such as EPCACE, which will serve the interests of patients and empower clinicians in making treatment decisions.

Self-help networks for EPCACE patients not only ease personal growth but also offer a safe communal space for patient empowerment. For example, since the aftermath of World War II, displaced and persecuted populations have found themselves unified and united by their shared experiences. Illustrative are reports of suffering experienced throughout Europe by survivors of massive psychic trauma with loss of their nurturing emotional milieu. Having the capacity to identify such traumatized populations from various countries and backgrounds and to unite them under a self-help support network enables survivors to create community for one another and foster therapeutic approaches which, via an empowering community, seek transgenerationally to treat the transmission of trauma and encourage the transmission of resilience.

Aloneness, along with helplessness about being alone and feeling humiliated, has increasingly been found to be a major risk factor across the illness spectrum. Aloneness post-trauma and in the midst of grief, to which persons who suffer from EPCACE are highly vulnerable, can reasonably be expected to compound this risk factor. Therefore, the diagnosis of EPCACE can be an important step toward remediation rather than exacerbation of the aloneness, helplessness, and humiliation that, in a vicious cycle, can lead to further isolation.

To avoid the misuse of EPCACE, it is vital to be aware that some survivors of catastrophic experiences in which terror involves dehumanization, degradation, and humiliation may therefore experience a heightened sensitivity to helplessness and humiliation. Receiving any psychiatric diagnosis is humiliating; therefore, patients frequently avoid seeking clinically based help. However, a newly empowered population brought together by that very catastrophic experience can provide solace, rebuild self-esteem, and relieve ongoing collective suffering.

All too often, both the fragility of aging and disturbing news events bring home to EPCACE sufferers disturbing reminders of catastrophic trauma. When applied with care, EPCACE as a diagnosis is not only helpful in clinical formulation and treatment planning but also has the potential to support the creation of healing communities for life-cycle stressors and losses. EPCACE-informed development of additional treatment modalities, such as group bereavement therapy and support groups outside of the clinical context that are focused on supporting survivors’ agency, empowerment, self-respect, connectedness, and creativity, has the potential to reduce post-catastrophic isolation, demoralization, and suffering.

Dr Bursztajn is corresponding author and can be reached at 

Dr Bursztajn wishes to dedicate his contribution to this work to his family, friends, and patients, Shoah (Holocaust) survivors and resisters.

Dr Tanaka is Assistant Professor of Psychiatry, Oregon Health & Science University (OHSU) School of Medicine, Portland, OR; Mr Tang is MS-1, Pacific Northwest Health Sciences, Yakima, WA; Dr Haque is Lecturer on Global Health and Social Medicine, Harvard Medical School, Boston, MA; and Dr Bursztajn is Associate Professor of Psychiatry, Part-Time, Harvard Medical School, Boston, MA. The authors report no conflicts of interest concerning the subject matter of this article.

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 Palic S, Zerach G, Shevlin M, et al. Evidence of complex posttraumatic stress disorder (CPTSD) across populations with prolonged trauma of varying interpersonal intensity and ages of exposure. 

 Keeley JW, Reed GM, Roberts MC, et al. Disorders specifically associated with stress: A case-controlled field study for ICD-11 mental and behavioural disorders. 

 Galatzer-Levy IR, Bryant RA. 636,120 ways to have posttraumatic stress disorder. 

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 Briere JN, Elliott DM. Prevalence, characteristics, and long-term sequelae of natural disaster exposure in the general population. 

This article explores why Enduring Personality Change After Catastrophic Experience (EPCACE) is a clinically useful diagnosis.

How Catastrophe Can Change Personality

It is easy to deride “selfies” and the scads of photos that people today often compulsively take and share via their cellphones. But let’s not write them all off as meaningless. 

As I’ve seen in my parents’ remarkable journey from the doomed Jewish ghetto in Lodz, Poland, and in my psychiatry practice, photographs have immense power to heal.

My parents grew up in Lodz, which then was home to one of the largest Jewish communities in Europe. On February 8, 1940, the Nazis established the Lodz ghetto. My father, Abraham Bursztajn, was condemned to be part of a sanitation crew called the Fekalists, literally the feces carriers. It was responsible for removing sewage from the ghetto and preventing the spread of infectious disease. The task, which meant near-certain death, was his punishment for refusing to join the ghetto’s Jewish police force, which answered to and worked for the Nazis.

One day Abraham saw Miriam Bryks, a girl he had met before the war, preparing to board a train bound for Auschwitz. In an act of bravado, he told a German soldier guarding the train that Miriam was an essential member of the sanitation crew, and brought her back with him to the ghetto. They married in secret, worked together as Fekalists throughout the war, engaged in nonviolent resistance, and were among the handful of survivors of the 200,000 Jews who had been imprisoned in the ghetto.

Some of my parents’ history I know from the stories they and their relatives have told over the years, some I know from visiting Lodz, and some I learned from the haunting photographs taken at great risk by Henryk Ross who, with the help of his wife, Steffie, secretly documented life in Lodz under Nazi rule. Hoping to leave behind a record of what happened there, Ross and his wife buried their 6000 negatives in 1944. They returned after the city was liberated by the Russian Army in 1945 and were overjoyed to find that many of the images had survived.

On June 17, I had the honor of speaking about an exhibition of some of Ross’s Lodz photographs, called “Memory Unearthed,” now on display in Boston’s Museum of Fine Arts.

At a time when Nazi and Stalinist photographers were using their cameras to generate cold, impersonal images of dominance and superiority, Ross was using his to create images of everyday life in the ghetto that were brimming with compassion and mutual respect. Even in the midst of the Shoah (Holocaust), Ross helped both the photographer and those photographed share with dignity the horror of humiliation, the fear of oblivion, and the pain of grief.

Is this so different from the photographs that are so freely taken and shared today? They establish what philosopher Martin Buber would call an “I-Thou” relationship between photographer and subject. Even with the selfie, where the photographer and the subject are the same, the intention is still to connect with others.

In Ross’s hands, the camera became a creative, artistic, therapeutic instrument that empowered mental health. Seventy years later, these photographs provide much more than simple forensic documentation. They offer inspiration for anyone who has experienced suffering, hopelessness, and the question that was asked by one of the ghetto inhabitants, “When will this ever end?”

Through Ross’s work we can learn much that is otherwise obscure about ordinary life, trauma, grief, and loss, as well as about our capacity to choose good and evil and continue to be creative and resilient in the midst of life and when facing death. In this vein, his work belongs alongside the work of other creative and therapeutic artists such as Rembrandt, Goya, and Hyman Bloom, all of whom depicted the vital rhythms of life in the face of war, encroaching death, and entropy.

Photography and the visual arts can be therapeutic in everyday life. An adolescent patient of mine, traumatized as a young child by a psychotic parent, sometimes shows me a photograph on his cellphone of the dog he loves, and how beautifully and peacefully the animal sleeps. I thank him for showing it to me, admire this act of sharing what he loves, and then we explore his anguish and fears as well as his hopes. The photograph provides a safe bridge from the present to the past.

A fragile older woman shares with me fading photographs of the great beauty she was as a young woman. I am grateful that she feels safe enough with me to share these images, which deepen our ability to explore together what she fears most -the loss of family members and her youthful vigor -and in doing so her mature beauty shines forth and she feels empowered to face the inevitability of entropy.

The ease of sharing cellphone photos provides a way for people to feel connected in this often disconnected world. People who have been traumatized can use them to create a community of trust between themselves and others. The seemingly doomed Fekalists that Ross photographed shared their experience not only with Ross but also with a future most knew they would not see. Today, the patients who share photographs with those whom they trust transcend the isolation and aloneness that are all too often the handmaidens of suffering.

In my field, forensic psychiatry, we sometimes use the term “therapeutic jurisprudence.” It refers to the process whereby victims of abuse feel empowered as a result of the course of litigation. It’s time we start thinking about “therapeutic photography.”

 This article was originally published as “Photos, Even Selfies, Have the Power to Heal.” It is reproduced with permission from STAT, a national publication focused on finding and telling compelling stories about health, medicine, and scientific discovery. 2017 © STAT. The exhibit -Memory Unearthed: The Lodz Ghetto Photographs of Henryk Ross -at the Museum of Fine Arts, Boston, ran from May 25 through July 30, 2017. We are grateful to Maia Sutnick of the Gallery of Ontario for allowing us to use the photographs reproduced herewith. For more photographs from the exhibit, go to: 

Dr. Bursztajn is Associate Professor of Psychiatry at Harvard Medical School and a co-founder of the Program in Psychiatry and the Law at Beth Israel Deaconess Medical Center; he has also had a private practice in clinical and forensic psychiatry and psychoanalysis. His email address is:

The Healing Power of Photographs

[[{"type":"media","view_mode":"media_crop","fid":"41184","attributes":{"alt":"Young Westerners Drawn to Terrorist Organizations","class":"media-image media-image-right","id":"media_crop_9096784023397","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4310","media_crop_rotate":"0","media_crop_scale_h":"188","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]The relatively sudden rise of the terrorist group ISIS in the Middle East has surprised many in the West. Equally surprising is that financially stable foreigners from the West are over-represented among ISIS fighters.

 As helpless observers of the inhumane and disproportionate violence that ISIS has exacted on the people of the Middle East and the rest of the world, it is easy to wonder: what could possibly be the appeal of such a murderous, intolerant, and authoritarian organization to so many young people in the West?

This question is easier to answer when imagining the motives and rationales of locals in Iraq and Syria. Perhaps these locals join in what they believe to be a righteous cause. They may want to fight their perceived enemy in a global war, just as many Americans join the US Armed Forces to fight ISIS and other perceived enemies. But what could possibly compel otherwise financially stable young Westerners (non-Muslim as well as Muslim) to leave their families, friends, and home culture, and take up an uncertain future by joining a terrorist organization like ISIS?

Clearly, poverty is not causing people to join ISIS, neither is religion. The vast majority of the West’s 50 million Muslims do not join terrorist groups.

 Even among those with radical Islamic beliefs, only a very few act on those beliefs and join a terrorist organization.

 Background beliefs do not explain the motivation that compels people to join such groups-even as fundamentalist organizations go, ISIS is particularly extreme. It has been roundly condemned by many prominent Islamic institutions across the world as illegitimate, in violation of Islamic Law, and as not a part of Islam; it has even been rejected by the quite radical group Al-Qaeda.

The true answer is more disturbing and psychological, and has little to do with evil psychopaths finding their true home in ISIS, or of innocent youths being brainwashed into mindless soldiers. Rather, it involves the interaction of conscious and unconscious processes with unique features of ideologies like ISIS, and existential (but not material) vulnerabilities inherent in contemporary American life. One way to summarize our answer is that as an ideology, ISIS provides existential fast food, and for some of the most spiritually hungry young Westerners, ISIS is like a Big Mac amidst a barren wasteland of an existence. Much of the worldview of ISIS appears intellectually vapid and brittle, even silly when seriously considered as religious or philosophical propositions. Just as a person can get lost, a religious movement can also get lost in a forest of bad ideas. But most people do not get a PhD in philosophy of religion before deciding what to believe. The heart’s longings lead the mind, and the existential filler of ISIS nourishes the desperate and vulnerable soul, however much one is surrounded by material comfort.

Who actually joins ISIS? Not psychopaths or the brainwashed, but rather everyday young people in social transition, on the margins of society, or amidst a crisis of identity. According to anthropologist and psychologist Scott Atran who has studied the motivations and demographics of terrorists, it is mostly youth in transitional stages in their lives-immigrants, students, those between jobs or girlfriends, or those who left their homes and are looking for new families. For the most part they have no traditional religious education and are “born again” to religion. They are self-seekers who have found their way to jihad in myriad ways.

Have you ever purchased junk food when tired, irritable, and jet-lagged at an airport? For lonely young people in transition, ISIS provides a quick fix to the perennial problems of human life. Vulnerable people don’t tend to fact check when existential relief is easily and cheaply attained with little effort. Specifically, the relief in question concerns the human desire for identity, certainty, social connection, meaning, the optimal amount of freedom, and glory.

At crucial developmental periods in adolescence and early adulthood, the formation of one’s identity is a primary concern, and a riddle to be solved. These years are a time for figuring out who one is, where one belongs, what one values and finds meaningful, and what one can become and prove to the world.

 These years are also a time of increasing awareness of an exciting yet frightening internal world with conscious and unconscious conflicts around envy, competition, self-control, and self-esteem.

 For youths on the margins of Western society, and in transition from one community to the next, this process of identity formation can become a hopeless task. When one has become a fringe member of one’s home community in America during crucial phases of identity formation, it is very tempting to join what appears to be a righteous struggle against one’s oppressive community. Even superficial Internet exposure (much less direct marketing) can convince the young that they too may participate in a world-historical narrative in which the enemy of America is a beacon of hope for solidifying their emerging self. This may evolve into a counterphobic attitude toward the society in which they feel helplessness, with a full embrace of a cult of death such as ISIS.

Humans tend to live with a quest for certainty in their hearts, and uncertainty is experienced as aversive.

 Whatever its factual merits, a pluralistic worldview denies its adherents the delights of absolute certainty, and it takes much cognitive effort to maintain. ISIS provides an ideology in which the world is divided into absolute good and evil, no compromises are possible, radical Islam is the solution to all human problems, and any other interpretation of Islam is unthinkable. Why settle for shades of grey in a messy world when “The Truth” is packaged and delivered in under 30 seconds via Internet sound bites? This black and white picture of truth may seem simplistic for the critically minded, but it can provide epistemological crÃ¨me brÃ»lÃ©e for drifting and unanchored Western youths. These youths are looking for answers to existential questions within a home culture perceived to be permissive and relativistic. In the midst of all this, an ideology that does not compromise the quest for certainty can be very appealing to the most vulnerable.

Americans pride themselves on their individualism, but the underside of individualism is loneliness.

 The desire for social connection is a human need as basic as food and sex, and the most obvious source of terrorist seduction for the lonely hearted.

 Social networks construct the web by which individuals are drawn to action, and social connection is a common attraction for everyday wholesome clubs as well as nefarious cults of all persuasions. Terrorist organizations are no exception, and most people join due to the influence of friends, kin, and others in a social network.

Although joining based on the influence of one’s friends and kin is a primary factor, recruitment from ISIS also occurs. ISIS has initiated a number of systematic online efforts to target and respond effectively to young Westerners in transition at the margins of society, who can be easily tempted by the false allure of quick and easy social connections amidst an individualistic society from which they feel alienated.

 Rather than contemplating and deciding whether the ideas within the ideology of ISIS are rational and worthy of assent, the young are more likely to be drawn in by attachments to those already embedded in ISIS as a way to thwart loneliness.

By most accounts, Americans are happy people, and the pursuit of happiness is enshrined in the American Declaration of Independence. But Western definitions of happiness tend toward happiness as present pleasure and self-expression, rather than happiness as meaning, moral struggle and sacrifice, and aligning oneself with sacred purposes beyond the self.

 The latter meaning-oriented definition of happiness is more crucial for mental and physical health, but it is more common in non-secular cultures (and in the religious traditions within secular societies).

 For Western youths drifting between communities and belief systems amidst pluralistic America, the allure of a powerful, simple ideology with a crystal-clear elaboration of the transcendent meaning for their lives and struggles would be akin to an ice cream cone on a hot July afternoon. This desire for meaning-to be a part of something much larger than oneself, especially if it is transcendent-is a very deep wish in human nature, and not the same as routine motivations concerning status or in-group preferences (ethnicity, race, or religion).

 Thus the same need for meaning that propels a youngster to want to join ISIS can also lead an American businessman who achieves financial success to yearn for something beyond the accumulation of wealth, to something more meaningful and significant such as philanthropy, political office, or supporting a war.

Relatedly, as Atran notes, people join ISIS because they seek adventure and want glory. ISIS presents to the bored, secure, and the uninspired in Western liberal democracies a “thrilling cause and call to action that promises glory and esteem in the eyes of friends. Jihad is an egalitarian, equal-opportunity employer: fraternal, fast-breaking, glorious and cool. . . Many are just ‘vacationers’ for jihad, going to Syria over school breaks or holidays for the thrill of adventure and a semblance of glory.”

A seemingly paradoxical reason some Westerners join ISIS and other totalitarian organizations is that too much freedom can be experienced as burdensome. In 1941, the psychologist Erich Fromm in 

 explained why so many were attracted to the Nazi ideology in Germany by pointing to a feature of human nature that is afraid of being free and thus would rather submit to authority than be responsible for creating a life of one’s own. As in 1941 for Nazism, so also in 2015 for ISIS. Clearly, being a slave is no fun. But maximal freedom may also not be ideal, and humans vary in the degree to which additional freedom is experienced as beneficial. For someone who is socially integrated and stable, and more willful by nature, more autonomy can be a liberating means to self-create a life amidst hospitable institutions. In contrast, young adults in transition or on the margins of society may experience freedom as oppressive, since they lack the personal or social means for actually using a high degree of freedom to improve their lives. A totalitarian cult such as ISIS, which promises a strict ideology, rules, and a social order to which one can bind and submerge oneself, appeals to youths, especially those on the fringes of Western society for whom high amounts of freedom do not feel liberating but instead, oppressive.

Finally, these many vulnerabilities to joining terrorist organizations are combined with a deep but selective empathy. For example, an Iraqi-American youngster who perceives that Iraqis are persecuted by Americans might expand his empathy for suffering Iraqis over Americans and decide to join ISIS. Alternatively, a 5th-generation Italian-American youngster could find himself on the fringe of American society and start to develop deep empathy with the sufferings of America’s perceived enemies. Empathy is indeed a source of joining terrorist groups. The same empathy we may feel for the cherished victims of our favorite causes, others may feel for non-Americans. Empathy can be free of this paradoxical effect and fulfill its ethical possibilities only when empathy is generalized to all humans who suffer, not just to those in our in-group.

The reasons that youths join terrorist organizations such as ISIS have little to do with being poor, brainwashed, a Muslim, or a psychopath, and more to do with vulnerabilities in human nature exacerbated by aspects of Western societies. This diagnosis is echoed by journalists who have interviewed many ISIS fighters; a recent analysis of ISIS fighters remarks that “what draws people to ISIS could easily bring them to any number of cults or totalitarian movements, even those ideologically contradictory to Salafist Jihadism.”

If we Westerners are lucky, we have identities, certainties, social connections, meanings, generalized empathies, freedoms, and individual pursuits of glory that can be taken for granted. However, for those Westerners in transition, marginalized, lonely, lost, bored, uncertain, spiritually or existentially dispossessed, burdened by too much freedom, and empathically selective, ISIS and other shallow but contagious ideologies will remain tempting as quick fixes for the deep predicaments inherent to the human condition.

We would like to thank Dan Jones for helping us find some of the sources quoted in this article.

Dr Haque is Co-Director, UNESCO Chair in Bioethics, American Unit; Department of Psychiatry and Human Behavior, Brown University, Providence, RI; Program in Psychiatry and the Law and Department of Psychology, Harvard University, Cambridge, MA. Ms Choi is Associate at Nonprofit Finance Fund, Boston; Harvard Mediation Program, Harvard Law School. Mr Phillips is Co-Founder of Beyond Conflict, Cambridge, MA. Dr Bursztajn is President, UNESCO Chair in Bioethics, American Unit; Associate Clinical Professor of Psychiatry and Co-Founder of the Program in Psychiatry and the Law, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston. The authors report no conflicts of interest concerning the subject matter of this article.

The Missing Martyrs: Why There Are So Few Muslim Terrorists?

 Neumann PR. The trouble with radicalization. 

 Hassaballa HA. Think Muslims haven’t condemned ISIS? Think again. 

http://www.beliefnet.com/columnists/commonwordcommonlord/2014/08/think-muslims-havent-condemned-isis-think-again.html

The authors explore possible reasons why young people in the West leave their families, friends, and home culture to join terrorist organizations.

Author | Harold J. Bursztajn, MD