Chapter 6. General Discussion

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1 Chapter 6 General Discussion

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3 Chapter 6. General Discussion 101 Introduction The set of studies described in this dissertation focus on the influence of Holocaust experiences on child survivors and their adult offspring more than 60 years after the Holocaust. The findings can shed more light on whether early childhood trauma might leave specific psychological and neurophysiological markers in later life of victims of such atrocious experiences and also in that of their offspring. The results might also delineate important issues regarding populations that are likely to be more vulnerable when exposed to severe life circumstances because of genetic predisposition. Results of the first study (chapter 2) show that psychological and cognitive markers of trauma experienced during childhood are observed even 60 years after the trauma when Holocaust child survivors are in the elderly phase of life. Holocaust child survivors (now aging women) report more dissociative symptoms in everyday life, less satisfaction with their lives, and they also perceive their life events as more stressful as compared to a matched group of women, also born in Europe but who migrated with their parents just before the onset of the Holocaust to the country that in 1948 became the State of Israel. Moreover, these survivors show more cognitive impairment than their comparisons. The findings are consistent with recent meta-analytic findings (Barel, Van IJzendoorn, Sagi- Schwartz, & Bakermans-Kranenburg, 2010). Nonetheless, adult offspring of survivors were not different from their comparisons, as was also found in metaanalytic studies that suggest that although first-generation survivors display posttraumatic symptomatology, there is no evidence for intergenerational transmission of the trauma to their offspring in non-convenience samples, unless they are also stressed by psychological or physical adversities unrelated to the Holocaust experiences of their parents (Van IJzendoorn et al., 2003). Nevertheless, traumatic experiences may go under the skin. Below the seemingly unruffled surface of more or less adequate adaptation to post-war conditions, traumatized individuals and their offspring might be more vulnerable to stressful circumstances as a consequence of a somewhat dysregulated neurobiological stress system. In particular the Hypothalamic-Pituitary-Adrenal (HPA) system regulating physiological stress may be affected by negative experiences in early childhood, and such changes may be passed on to the next generation. With regard to n daily cortisol production, our study shows that Holocaust child survivors who immigrated to Israel after the Holocaust showed 60 years post war elevated levels of daily cortisol secretion as compared to their matched controls (chapter 3). Early Holocaust related traumatization is associated with changed HPA-axis functioning 60 years later. These findings are consistent with meta-analytic data (Barel et al., 2010) and with a previous study examining the

4 102 Chapter 6. General Discussion effects of early traumatic stress on the adreno-cortical system during aging in Holocaust child survivors (Van der Hal-Van Raalte et al., 2007). Intergenerational transmission seemed absent for the adult offspring of Holocaust survivors; as a group they did not display a different diurnal cortisol pattern when compared to offspring of the matched controls. However, the first generation s level of dissociation was found to moderate cortisol level in their offspring: Offspring of survivors with more dissociative symptoms showed lower levels of cortisol production over the day. Similar associations between offspring daily cortisol secretion and parental PTSD were found in Yehuda s studies (Yehuda, Halligan, & Bierer, 2002; Yehuda, Halligan, & Grossman, 2001; Yehuda et al., 2000). These findings demonstrate that daughters of Holocaust survivors with more dissociative symptomatology display different stress regulation when compared to daughters of survivors with lower symptomatology. The effects of the Holocaust on HPA-axis functioning was also the focus of our third study. However, here we examined cortisol levels in response to induced stress (chapter 4). Holocaust child survivors displayed elevated levels of cortisol secretion immediately before the onset of the stress procedure, followed by a strong decline of cortisol levels 20 minutes after the onset of the stress procedure. The elevated level of cortisol that was found among survivors prior to the induced stress procedure might point to survivors' increased alertness to anticipated stress. It is possible that the ongoing struggle for survival during childhood forced survivors to be constantly alert and to try to adapt fast to new circumstances, in particular in anticipation of an active session about the Holocaust (Dasberg, 2001). Although such a stress response might promote survival, in the long run though, if activated repeatedly, an overactive HPA axis may exert detrimental effects on ones' health (Denson, Spanovic, & Miller, 2009; Johnson, Kamilaris, Chrousos, & Gold, 1992). We found that comparison participants without Holocaust background showed the expected increase of cortisol levels that is found in most studies (Van IJzendoorn et al., under review, Van der Hal-Van Raalte, Bakermans-Kranenburg, & Van IJzendoorn, 2008) in response to induced stress. Adult offspring of Holocaust survivors did however not display different cortisol reactivity in response to stress when compared to their matched controls. Even though the stress procedure in the current study seemed sufficiently stressful to generate HPA axis responses, it might not have been considered life-threatening to the extent that a hidden vulnerability of survivors' offspring would emerge. The fourth study examined the moderating role of genetics in stress regulation among Holocaust child survivors (chapter 5). The results showed that Holocaust survivors with the wildtype ADRA2B displayed higher cortisol levels than did their comparisons with the same genotype. No difference was found

5 Chapter 6. General Discussion 103 between these groups among carriers of the deletion variant. Since previous research showed that the deletion variant was associated with the manifestation of more vivid traumatic memories (de Quervain et al., 2007), we propose here that carriers of the deletion variant may have had more vivid traumatic memories in the years after the Holocaust, and therefore were more driven to reflect on these experiences and to resolve them. As a result they may show less stress dysregulation in the long run as evident from their cortisol levels. Taken together, our findings converge with meta-analytic studies of Holocaust child survivors (Barel et al., 2010) and their offspring (Van IJzendoorn et al., 2003) which show respectively that Holocaust survivors display considerably more posttraumatic stress symptoms than comparisons without Holocaust background, and also that intergenerational transmission may be present under the skin, when risk factors such as higher parental posttraumatic symptomatology exist. Theoretical perspective Attachment theory has been suggested as a conceptual framework for explaining variance in the coping strategies of adults who did or did not experience early separation from their prime caregivers (e.g., Bar-on et al., 1998; Cohen, Dekel, & Solomon, 2002; Van der Hal-Van Raalte et al., 2008). Early separation from caregivers and disruption of close and intimate relationships might result in longterm difficulties with coping with stress (Bowlby 1969/ 1982, 1973, 1980). Our studies suggest that such scars that began more than 60 years ago might never fully heal, as apparent from both psychologically and neuro-biologically functioning with regard to stress regulation. Early separation from both parents during World War II was recently found to be related to high levels of cortisol secretion in response to stress (Pesonen et al., 2010). According to attachment theory, offspring's coping styles are related to caregivers' representations of their past and caregivers' behavior, especially in stressful situations (e.g., Belsky, 2005; Van IJzendoorn & Bakermans-Kranenburg, 1997). Surprisingly, in our studies we found that although survivors displayed difficulties in their own adaptation their daughters showed no differences in adaptation compared to daughters of mothers who did not experienced the Holocaust. How might such extraordinary survivors' resilience be understood? First, it is possible that a basic trust, based on the relationship with the attachments figures was already established before the onset of the Holocaust (survivors were 4-14 years old at the time of the war), and that it is these feelings of basic trust in close relationships that was transmitted from Holocaust survivors to their offspring (Van IJzendoorn et al., 2003). Second, a lack of intergenerational transmission in psychological functioning might be related to our participants' immigration to the

6 104 Chapter 6. General Discussion pre-state of Israel after the war. Barel and her colleagues (2010) found in their meta-analysis that living in Israel might serve as a protective factor for some outcome variables, perhaps because immigrants acquired a new sense of meaning, goals, and pride in building the new state of Israel. Limitations and suggestions for future research Several limitations of the current set of studies should be taken into account. First, the sample was restricted to female survivors and their female offspring. Since gender differences exist in the pattern of cortisol secretion (Kirschbaum & Hellhammer, 1994; Otte et al., 2005; Shalev et al., 2009; Van der Hal-Van Raalte et al., 2008) replication in a male or mixed-gender sample is needed. Second, although our sample was a carefully matched non-convenience sample, maximizing the internal validity for drawing conclusions, its external validity might be limited due to the same inclusion criteria. One of the criteria for the first generation was being a mother and a grandmother (Sagi-Schwartz et al., 2003). This might have resulted in a selection of survivors who were able to deal with intimacy and create new generations. Future research might seek to study also Holocaust survivors who did not marry or do not have offspring in order to examine whether lack of marital and family relations are associated with poorer resilience. Another restriction of our sample is the selection of second generation. The offspring were invited to participate in the original sample only if they had a child aged months old (in order to be eligible to participate in the Strange Situation procedure for the observation of their attachment relationship; Sagi-Schwartz et al., 2003). Different selections with a wider range of participants might reveal the vulnerability that has been reported for some Holocaust survivors' offspring (e.g., Wardi, 1992). Our studies add another layer in the complex attempt to understand the long term effects of early separation and trauma. Unfortunately, horrifying genocides still take place around the globe, and many children are separated from their parents and familiar environments. According to our findings, although survivors themselves suffer from post traumatic symptomatology and their offspring may show neurobiological markers of secondary traumatization if their parents still show more dissociative symptomatology, (adult) children of Holocaust survivors show no psychologically signs of their parents' trauma. Considering the horrifying atrocities and early separations that children might be exposed to, sometimes with enduring negative implications for the life of survivors, there is at the same time some comfort in their impressive resilience as manifested in the limited intergenerational transmission of the trauma to the second generation.

7 Chapter 6. General Discussion 105 References Barel, E., Van IJzendoorn, M.H., Sagi-Schwartz, A., & Bakermans-Kranenburg, M.J. (2010). Surviving the Holocaust: A meta-analysis of the long-term sequelae of genocide. Psychological Bulletin, 136, Belsky, J. (2005). The development and evolutionary psychology of intergenerational transmission of attachment. In C. S. Carter, L. Ahnhert, K. E. Grossmann, S. B. Hrdy, M. E. Lamb, S. W. Porges, & N. Sachser (Eds.), Attachment and Bonding: A new synthesis (pp ). Cambridge, MA: The MIT Press Bowlby, J. (1969/ 1982). Attachment and Loss, vol. 1, Attachment. London:Hogarth Press. Bowlby, J. (1973). Attachment and Loss, vol. 2. Separation and Anger. New York: Basic Books. Bowlby, J. (1980). Attachment and Loss, vol. 3. Loss: Sadness & Depression. London: Hogarth Press. Cohen, E., Dekel, R., & Solomon, Z. (2002). Long-term adjustment and the role of attachment among Holocaust child survivors. Personality and Individual Differences, 33, Dasberg, H. (2001). Adult child survivor syndrome: On deprived childhoods of aging Holocaust survivors. Israeli Journal of Psychiatry and Related Science, 38, de Quervain, D. J. F., Kolassa, I. T., Ertl, V., Onyut, P. L., Neuner, F., Elbert, T., & Papassotiropoulos, A. (2007). A deletion variant of the α2b-adrenoceptor is related to emotional memory in Europeans and Africans. Nature Neuroscience 10, Denson, T. F., Spanovic, M., & Miller, N. (2009). Cognitive appraisals and emotions predict cortisol and immune responses: A meta-analysis of acute laboratory social stressors and emotion inductions. Psychological Bulletin, 135, Johnson, E. O., Kamilaris, T. C., Chrousos, G. P., & Gold, P. W. (1992). Mechanisms of stress: A dynamic overview of hormonal and behavioral homeostasis. Neuroscience and Biobehavioral Reviews, 16, Kirschbaum, C., & Hellhammer, D. H. (1994). Salivary cortisol in psychoneuroendocrine research: recent developments and applications. Psychoneuroendocrinology, 19, Otte, C., Hart, S., Neylan, T. C., Marmar, C. R., Yaffe, K., & Mohr, D.C. (2005). A meta-analysis of cortisol response to challenge in human aging: importance of gender. Psychoneuroendocrinology, 30,

8 106 Chapter 6. General Discussion Pesonen, A. K., Räikkönen, K., Feldt, K., Heinonen, K., Osmond, C., Phillips, D. I. W., Barker, D. J. P., Eriksson, J. G., & Kajantie, E. (2010). Childhood separation experience predicts HPA axis responses in late adulthood: A natural experiment of World War II. Psychoneuroendocrinolog, 35, Sagi-Schwartz, A., Van IJzendoorn, M. H., Grossmann, K. E., Joels, T., Grossmann, K., Scharf, M., Koren-Karie, N., & Alkalay, S. (2003). Attachment and traumatic stress in female Holocaust child survivors and their daughters. American Journal of Psychiatry, 160, Shalev, I., Lerer, E., Salomon, I., Uzefovsky, F., Gritsenko, I., Mankuta, D., Ebstein, R. P., & Kaitz, M. (2009). BDNF Val66Met polymorphism is associated with HPA axis reactivity to psychological stress characterized by genotype and gender interactions. Psychoneuroendocrinology, 34, Van der Hal-Van Raalte, E. A. M., Bakermans-Kranenburg, M. J.,& Van IJzendoorn, M. H. (2008). Diurnal cortisol patterns and stress reactivity in child Holocaust survivors reaching old age. Aging & Mental Health, 12, Van der Hal-Van Raalte, E. A. M., Van IJzendoorn, M. H., & Bakermans- Kranenburg, M. J. (2007). Quality of care after early childhood trauma and well-being in later life: Child Holocaust survivors reaching old age. American Journal of Orthopsychiatry, 77, Van IJzendoorn, M. H., Fridman, A., Bakermans-Kranenburg, M. J., & Sagi- Schwartz, A. (under review). Aftermath of genocide: Elevated levels of diurnal cortisol in Holocaust survivors but not in their adult offspring? Van IJzendoorn, M. H., Bakermans-Kranenburg, M. J. (1997). Intergenerational transmission of attachment: A move to contextual level. In: L. Atkinson and J.K. Zucker, (Eds.), Attachment and psychopathology (pp ). New York: Guilford Press. Van IJzendoorn, M. H., Bakermans-Kranenburg, M. J., & Sagi-Schwartz, A. (2003). Are children of Holocaust survivors less well-adapted? A meta-analytic investigation of secondary traumatization. Journal of Traumatic Stress, 16, Wardi, D. (1992). Memorial Candles: The Children of the Holocaust. London: Rouledge. Yehuda, R., Halligan, S. L. & Bierer, L. M. (2002). Cortisol levels in adult offspring of Holocaust survivors: Relation to PTSD symptom severity in the parent and child. Psychoneuroendocrinology, 27, Yehuda, R., Halligan, S. L., & Grossman, R. (2001). Childhood trauma and risk for PTSD: Relationship to intergenerational effects of trauma, parentsl PTSD, and cortisol excretion. Development and Psychopathology, 13,

9 Chapter 6. General Discussion 107 Yehuda, R., Bierer, L. M., Schmeidler, J., Aferiat, D. H., Breslau, I., & Dolan, S. (2000). Low cortisol and risk for PTSD in adult offspring of Holocaust survivors. American Journal of Psychiatry, 157,

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CHAPTER 1. General Introduction

CHAPTER 1 General Introduction 14 Chapter 1. General Introduction Chapter 1. General Introduction 15 In this dissertation I address various aspects associated with the influence of the Holocaust experiences