CHAPTER 2. Coping in Old Age with Extreme Childhood Trauma: Aging Holocaust Survivors and Their Offspring Facing New Challenges

Transcription

1 CHAPTER 2 Coping in Old Age with Extreme Childhood Trauma: Aging Holocaust Survivors and Their Offspring Facing New Challenges Ayala Fridman, Marian J. Bakermans-Kranenburg, Abraham Sagi-Schwartz, Marinus H. Van IJzendoorn Aging and Mental Health (in press)

2 24 Chapter 2. Coping in Old Age with Extreme Childhood Trauma Abstract Objective: The Holocaust has become an iconic example of immense humanmade catastrophes, and survivors are now coping with normal aging processes. Childhood trauma may leave the survivors more vulnerable when they are facing stress related to old age, whereas their offspring might have a challenging role of protecting their own parents from further pain. Here we examine the psychological adaptation of Holocaust survivors and their offspring in light of these new challenges, examining satisfaction with life, mental health, cognitive abilities, dissociative symptoms, and physical health. Method: Careful matching of female Holocaust survivors and comparison subjects living in Israel was employed to form a case-control study design with two generations, including four groups: 32 elderly female Holocaust survivors and 47 daughters, and 33 elderly women in the comparison group, and 32 daughters (total N = 174). Participants completed several measures of mental and physical health, and their cognitive functioning was examined. The current study is a follow-up of a previous study conducted 11 years ago with the same participants. Results: Holocaust survivors showed more dissociative symptomatology (odds = 2.39) and less satisfaction with their life (odds = 2.79) as compared to a matched group. Nonetheless, adult offspring of Holocaust survivors showed no differences in their physical, psychological and cognitive functioning as compared to matched controls. Conclusions: Holocaust survivors still display posttraumatic stress symptoms almost 70 years after the trauma, whereas no intergenerational transmission of trauma was found among the second generation.

3 Chapter 2. Coping in Old Age with Extreme Childhood Trauma 25 Introduction During the past hundred years numerous devastating wars and genocides have created millions of casualties and severe trauma in many more surviving adults and children (Burnham, Lafta, Doocy, & Roberts, 2006; Danieli, 1998). The Holocaust that took place during World War II and aimed at the destruction of the Jewish people in Europe has become the most widely studied example of such immense man-made catastrophes. The study of its long-term effects may help to gain better understanding of the adaptation of victims of recent genocides extended in countries like Cambodia, Nigeria, Rwanda, Sudan, and former Yugoslavia. In the current study we explore the (mal-) adaptation of aging Holocaust survivors and their adult offspring in light of the developmental tasks they have to cope with in old age. Childhood trauma may leave the survivors more vulnerable when they are facing stress related to old age, whereas their offspring might have a challenging role of protecting their own parents from further pain. Here we examine the adaptation of Holocaust survivors and their offspring in light of these new challenges, examining satisfaction with life, mental health, cognitive abilities, dissociative symptoms, and physical health. The current study is a follow-up of a previous study conducted 11 years ago with the same participants, which makes it possible to examine the stability of adaptation of Holocaust survivors over time. Holocaust survivors who were children during World War II are now coping with normal aging processes such as illness, frailty, dependency and isolation, which might elicit memories from their past experience (Shmotkin & Barilan, 2002). Moreover, signs of unresolved trauma or loss might emerge again as an expression of loss of significant others and the survivors own impending death. Their children are themselves adults now, also facing major challenges such as balancing demanding work and family life (Erikson, 1950). During the Holocaust, adults and children experienced a total disruption of their life experiences. They were prisoners at work camps or death camps, or were hidden in hostile territory, and often were exposed to death and loss of family members (Safford, 1995). This man-made catastrophe was characterized by an environment that was extremely threatening and dangerous with no rational explanation or meaning. The possibilities to reduce the threat or stress were very limited (Kahana, Kahana, Harel, & Rosner, 1988). Those who were children and survived the extreme inhuman conditions remembered prewar life vaguely or even not at all (Krell, Suedfeld, & Soriano, 2004). Studies on the effects of the Holocaust on survivors and their families reflect a wide range of perspectives. Accordingly, the conclusions vary, and are sometimes even contradictory (Barel, Van IJzendoorn, Sagi-Schwartz, & Bakermans- Kranenburg. 2010; Bar-on et al, 1998; Van IJzendoorn, Bakermans-Kranenburg, &

4 26 Chapter 2. Coping in Old Age with Extreme Childhood Trauma Sagi-Schwartz, 2003). Many studies documented the survivors' syndrome (Niederland, 1968), meaning that Holocaust survivors suffer from severe and enduring psychological effects of the massive trauma, manifested in chronic anxiety (De Graaf, 1975), depression, disturbances in cognition and memory, tendency to isolation (Niederland, 1968), sense of guilt (Chodoff, 1968), low psychological well-being, and difficulties in emotional expression (Amir & Lev-Wiesel, 2003; Nadler & Ben-Shushan, 1989). In addition physical health problems have been documented (e.g., Antonovsky, Maoz, Dowty, & Wijsenbeek, 1971; Landau & Litwin, 2000); in particular cancer morbidity (Keinan-Boker, Vin-Raviv, Lipshitz, Linn, & Barchana, 2009). Alongside studies of maladaptive outcomes and psychopathology of Holocaust survivors, there is a growing body of evidence that their psychological adjustment is within the normal range (e.g., Leon, Butcher, Kleinman, Goldberg, & Almagor, 1981; Barel et al., 2010). Survivors managed to build families and to establish social relationships (Harel, Kahana, & Kahana, 1993). In a recent metaanalysis involving 12,746 participants from 71 samples, Holocaust survivors were compared with their counterparts on physical health, psychological well-being, posttraumatic stress symptoms, psychopathological symptomatology, cognitive functioning, and stress-related physiology (Barel et al., 2010). Results showed that even in non-select samples (i.e. drawn from population- wide demographic information) Holocaust survivors showed substantially more posttraumatic stress symptoms than comparisons. However, they displayed good adaptation in physical health, cognitive functioning, and stress related physiology, suggesting also remarkable resilience. The resilience of the first generation of survivors might explain the unexpected absence of intergenerational transmission of trauma in the set of studies involving the second and third generations, respectively (Sagi-Schwartz, Van IJzendoorn, & Bakermans-Kranenburg, 2008; Van IJzendoorn et al., 2003). In a meta-analytic study on 32 samples with 4,418 children of Holocaust survivors there was no evidence for secondary traumatization in studies with non-select recruitment and non-clinical samples (Van IJzendoorn et al., 2003). In a quasiexperimental study with carefully matched Holocaust survivors, their daughters and their grandchildren, we examined posttraumatic stress, attachment, mental health, social adaptation and parenting style. Intergenerational transmission was absent as no differences were found in the second and third generation offspring of Holocaust survivors and their comparisons, although the first generation of survivors showed posttraumatic symptoms even more than half a century after the Holocaust (Sagi-Schwartz et al., 2003). Not all efforts made by Holocaust surviving parents to protect their offspring yielded adaptive outcomes. Yehuda, Schmeidler, Wainberg, Binder-

5 Chapter 2. Coping in Old Age with Extreme Childhood Trauma 27 Brynes, and Duvdevani (1998), for example, reported that although adult children of Holocaust survivors did not experience more traumatic life events than their comparisons they nevertheless showed higher prevalence of current and lifetime PTSD, and they were more likely to perceive non-life-threatening events as very distressing. Others reported that Holocaust survivors' offspring were more affected when confronted with extreme stress such as cancer (Baider et al., 2000) or combat (Solomon, Kotler, & Mikulincer, 1988) and that daughters of survivors were more vulnerable to the intergenerational transmission of parental trauma (Felsen, 1998). Taken together, the meta-analytic results suggest that intergenerational transmission of the Holocaust trauma to the next generation might be observed in particular in studies with weaker designs using convenience samples and in clinical samples (Van IJzendoorn et al., 2003). As survivors grow old, traumatic experiences may vary in their impact on life. Trauma may leave the survivors more vulnerable when they are facing stress related to old age (e. g., Solomon & Prager, 1992). Safford (1995) suggested that although many survivors demonstrated resilience and adaptability (e.g., Leon, Butcher, Kleinman, Goldberg, & Almagor, 1981), they may be particularly vulnerable to changes that are associated with normal aging processes, because former coping strategies, such as hard work and taking care of the next generation, are no longer available. Daily coping requires intensive investment in meaningful activities that provide the opportunity to focus on the present and future, rather than on the past (Steinitz, 1982). Illness, frailty, dependency, isolation, and loneliness may disrupt such activities, and traumatic memories and unresolved losses might become more dominant. The absence of social support may contribute to some of the negative consequences for psychological well-being (Fening & Levav, 1991; Harel et al., 1993; Landau, & Litwin, 2000). Second generation Holocaust survivors, now in their fifties and sixties, might have a challenging role of protecting their own parents from further pain (Steinitz, 1982). The remarkable resilience that in some studies was found to characterize Holocaust survivors, in particular in parenting their offspring, could also serve them as they are aging. Good health, adequate social resources and satisfactory social relationships are predictors of mental health among aged in general (Harel, Sollod, & Bognar, 1982). Shmotkin and Lomranz (1998) found that the main explanation for aging Holocaust survivors lower subjective well-being was their poorer capacity to integrate their past experiences and present goals in their lives. Given the advanced age of Holocaust survivors, any examination of the long-term effects of massive trauma during childhood on Holocaust survivors is not only timely but is also very urgent because this population is getting very old and is rapidly dying and disappearing. Research on Holocaust survivors provides an

6 28 Chapter 2. Coping in Old Age with Extreme Childhood Trauma opportunity for studying the enduring effects of massive trauma and extreme life experiences (Carmil & Breznitz, 1991). Here we present findings from the second phase of a study that started 11 years ago, and included female Holocaust survivors (first generation), their adult daughters (second generation), and their 12 to 15 months old children (third generation) as well as carefully matched comparisons (Sagi-Schwartz et al., 2003). In the first phase we found that the first generation showed more posttraumatic symptoms but that their general adaptation and parenting style did not differ from the comparisons. Also, second and third generation participants were similar to comparison offspring of Holocaust survivors in all domains of functioning that we covered in our study (Sagi-Schwartz et al., 2003). We hypothesized that in the current follow-up, almost 70 years after the Holocaust, survivors would show more posttraumatic symptoms, as expressed in dissociative symptomatology (amnesia and other memory symptoms, depersonalization, derealization, and hallucinations), distress and cognitive impairment compared to participants who did not experience the Holocaust. Furthermore, we hypothesized that their offspring, the second generation Holocaust survivors, would not show signs of posttraumatic stress, and would not differ from their counterparts in mental health. Method Participants Participants were recruited from population-wide demographic information provided by the population registry administered by Israeli Ministry of Interior (Sagi-Schwartz et al., 2003). Two groups were compared: The first generation females with Holocaust experiences in their childhood and their daughters (the second generation), and a matched comparison group of first generation female who were born in Europe and migrated with their parents to the (pre-state of) Israel just before the Holocaust, and their daughters (the second generation). For the purpose of the current phase of the study, we contacted the 106 first- generation participants and 104 second- generation participants who took part in the original sample. Ten first-generation participants (9.3%) had passed away, 13 (11.50%) had health problems that prevented them from cooperating (e.g., dementia), two (1.9%) had personal problems (such as mourning), and two (1.9%) could not be located. Of the 79 first-generation participants who were able to cooperate, 65 (82.3%) agreed to take part in the study (32 Holocaust survivors and 33 comparison respondents). The age of the first-generation participants ranged from 71 to 84 years (M = 76.98, SD = 2.99). Of the 104 second-generation

7 Chapter 2. Coping in Old Age with Extreme Childhood Trauma 29 participants, five (4.7%) had moved out of Israel, one (0.9%) had health problems and two (1.9%) could not be located. Of the remaining sample, 79 (82.29%) agreed to take part (47 daughters of Holocaust survivors group, and 32 daughters of comparison subjects). The age of the second-generation participants ranged from 38 to 59 years (M = 47.46, SD = 4.41). Procedure Receiving participant's principal agreement, a research assistant visited each participant at home at the participant s convenience. The first and second generation subjects were visited on separate occasions. After a brief introduction, the participant signed an informed consent form and completed some questionnaires. First-generation participants were guided by the research assistant through the entire session, and helped them completing the tasks and questionnaires if they needed clarification. Measures Dissociation. The Dissociative Experiences Scale (DES) was developed by Bernstein and Putnam (1986) to assess the frequency of dissociative experiences. It contains 28 self report items that ask participants to indicate the frequency (0% - 100%) of various dissociative experiences such as discontinuities in awareness, imaginative involvement, and amnesia, excluding experiences that occurred when they were under the influence of alcohol or drugs. Translation into Hebrew was done for the purpose of the current study by Hebrew and English native speakers, using a dual-focus approach in order to maintain linguistics equivalence (Pena, 2007). Total scores were calculated by averaging the 28 items scores, resulting in a scale score ranging from 0 to 100. Cronbach's alpha reliability coefficients were.86 for first generation, and.83 for second generation. Well-Being. Two subscales were used to assess the subjective well-being. The adapted version of the Mental Health Inventory (Florian & Drori, 1990) that was used in the first phase of Holocaust study consists of 14 items dealing with distress and well-being. Participants were asked to indicate on a 6-point Likert scale the extent to which they experienced feelings of distress and well-being during the past month with higher scores reflecting more well-being and less distress. Cronbach's alpha reliability coefficients in the current study were.84 for the first generation, and.95 for the second generation. Satisfaction With Life (SWL) scale is a 5-item questionnaire designed to assess satisfaction with life as a whole (Pavot & Diener, 1993). Using 7-point Likert scales, participants were asked to rate their level of agreement with statements on a scale of 1 ("strongly disagree") to 7 ("strongly agree"). The score for the overall scale is the sum of all 5 items. Higher scores represent more satisfaction with life, whereas

8 30 Chapter 2. Coping in Old Age with Extreme Childhood Trauma lower score represent dissatisfaction. Cronbach's alpha reliability coefficients were.65 for the first generation, and.84 for the second generation. The Hebrew version has been used in various studies in Israel (e.g. Cohen & Shmotkin, 2007). Intercorrelations between the two subscales of subjective well-being were r =.28 for the first generation (p <.05), and r =.68 for the second generation (p <.01). Cognition. The Telephone Instrument for Cognitive Status- Modified (TICS-m) was administered to participants during an interview. The TICS-m consists of 21 items with a maximum score of 50 points, with lower scores reflecting more cognitive impairment. The questions pertain to long and short-term memory, orientation to time and place, attention, language and abstraction. The Hebrew version is a direct translation of the English TICS-m (Beeri, Werner, Davidson, Schmidler, & Silverman, 2003). Studies have shown convergent validity with other cognitive tests and test-retest validity (e.g., de Jager, Budge, & Clarke, 2003; Desmond, Tatemichi, & Hanzawa, 1993). Physical Health. Physical health status was assessed by a questionnaire developed by Herczeg Institute on Aging (Tel Aviv University) and used in a previous Holocaust study (Van der Hal-Van Raalte, Bakermans-Kranenburg, & Van IJzendoorn, 2008). Subjects were asked to rate their health using a 5-point Likert scale ranging from 1 = very unhealthy to 5 = very healthy. Also, they were asked to indicate which of 19 listed health problems they suffered. Participants could add more health conditions if they wanted, and a list of 40 possible health problems was obtained. The total number of health problems ranged from 0 (no health problems) to 15 for first generation, and from 0 to 8 for second generation. This questionnaire is widely used for socio-demographic research in Israel. The correlation between the two health measures was r =.62 (p <.01) for the first generation, and r =.27 (p <.05) for the second generation. Life Events. The Life Events questionnaire was developed for the present study. This checklist consists of 18 items describing stressful life events, such as marital conflict or illness of family members. Subjects were asked to mark if they had or had not experienced that life event in the past year and to rate the accompanying stress on a 3-point Likert scale. Participants could add more stressful life events if they wanted, and a list of 35 possible stressful life events was obtained. The correlation between the two stressful life events measures was r =.91 (p <.01) for the first generation, and r =.93 (p <.01) for the second generation. Statistical Analysis In order to avoid biased results due to extreme values, all measures were inspected for outliers, which were defined as values larger than 3.29 SD above the mean or smaller than 3.29 SD under the mean (Tabachnick & Fidell, 2007). Physical health, stressful life events, and dissociation distributions were moderately

9 Chapter 2. Coping in Old Age with Extreme Childhood Trauma 31 positively skewed, and square-root transformation was used for the analysis. The distributions of the variables satisfaction with life for both generations and cognition for the first generation participants were moderately negatively skewed and a reflection of square-root transformation was used. For the perceived physical health measure of second generation participants, reflected log10 transformation was used since the distribution was substantially negatively skewed. For the dissociative experiences scale of first generation participants, one case was deleted since it reflected clinical dissociation (Carlson & Putnam, 1993; Frischholz et al., 1990), whereas the study focused on a non-clinical sample. Attrition Possible differences in mortality between Holocaust survivors and comparison subjects were tested. A chi-square test showed no differences between the two groups χ² (1, N = 104) =.44, p =.74. In order to test for possible selective attrition, we compared the trauma and well-being data of the participants who continued their participation in the current phase with those who dropped out. Holocaust survivors who continued to take part in the study reported more unusual beliefs in the previous phase of the study (11 years ago) than those who dropped out, t (44) = 2.07, p =.04 (Table 1). No other differences were found for the trauma measures. It was also found that comparison subjects who continued to participate in the study reported higher mental health 11 years ago than participants that did not continue, t (48) = 2.99, p <.05. However, no differences were found for daughters of Holocaust survivors and comparison subjects. Results First, we will present the stability across the two phases of the study, 11 years apart, for those measures that were employed at each point in time. Then, we will test the associations within each generation, and finally we will test the associations between the first and second generation. Stability over the years Mental Health. The mental health inventory for general well-being was used in both phases of the study. Repeated measures ANOVA showed stability of mental health between two phases of the study for first generation participants (both for Holocaust survivors and comparison subjects) F (1, 58) = 5.36, p <.05 and no difference in level of well-being, F (1, 58) = 0.86, p =.36. Second generation participants (both daughters of Holocaust survivors and daughters of comparisons)

10 32 Chapter 2. Coping in Old Age with Extreme Childhood Trauma Table 1. Holocaust Survivors and Comparison Subjects: Between Samples Analysis Measure Group Participated in phase 2 M (SD) Unresolved state of mind Did not participate in phase 2 M (SD) Holocaust survivors (7.26) (4.86) 1.38 =.18 Comparisons (5.61) (4.70) Daughters of Holocaust survivors (4.93) (5.45) Daughters of comparisons (7.37) (4.67) t p Unusual beliefs Holocaust survivors (14.09) (8.64) Comparisons (8.69) (11.54) Daughters of Holocaust survivors 35.53(11.67) (11.82) Daughters of comparisons (9.65) (10.35) Intrusion Holocaust survivors (7.98) (8.31) Comparisons (8.18) (8.14) Daughters of Holocaust survivors (6.52) (3.85) Daughters of comparisons (6.47) (7.16) Avoidance Holocaust survivors (8.67) (7.49) Comparisons (6.80) (3.85) Daughters of Holocaust survivors (6.91) (3.36) Daughters of comparisons (5.89) (6.16) Autonomic anxiety Holocaust survivors (6.93) (7.77) Comparisons (5.57) (4.18) Daughters of Holocaust survivors (3.63) (4.85) Daughters of comparisons (3.96) (5.37) Cognitive Holocaust survivors (5.01) (7.78) worry Comparisons (6.19) (4.57) Daughters of Holocaust survivors (4.35) (2.45) Daughters of comparisons (4.69) (5.17) Well being Holocaust survivors (10.56) (14.47) Comparisons (9.25) (11.67) Daughters of Holocaust survivors (10.18) (15.83) Daughters of comparisons (8.85) (9.29) Note. N (Holocaust survivors) = 48; N (Comparisons) = 50; N (Daughters of Holocaust survivors) = 48; N (Daughters of comparisons) = 50

11 Chapter 2. Coping in Old Age with Extreme Childhood Trauma 33 Table 2. Holocaust Survivors, Their Daughters and Comparison Subjects Statistic Measure Group M (SD) t p Dissociation experiences Holocaust survivors 7.13 (4.46) Comparisons 5.03 (4.89) Daughters of Holocaust survivors 7.23 (5.52) Daughters of comparisons 7.19 (5.73) Mental health Holocaust survivors (8.17) Comparisons (10.63) Daughters of Holocaust survivors (10.16) Daughters of comparisons (10.29) Satisfaction with Holocaust survivors (4.81) life Comparisons (4.79) Daughters of Holocaust survivors (6.16) Daughters of comparisons (4.54) Cognitive Holocaust survivors (6.67) functioning Comparisons (5.21) Daughters of Holocaust survivors (3.85) Daughters of comparisons (3.09) Perceived physical Holocaust survivors 3.44 (1.04) health Comparisons 3.61 (0.93) Daughters of Holocaust survivors 4.34 (0.74) Daughters of comparisons 4.30 (0.89) Physical health Holocaust survivors 5.94 (3.03) symptoms Comparisons 4.82 (2.95) Daughters of Holocaust survivors 1.21 (1.41) Daughters of comparisons 1.09 (1.39) Perceived stress Holocaust survivors 5.50 (3.63) of life events Comparisons 3.91 (4.14) Daughters of Holocaust survivors 5.38 (4.93) Daughters of comparisons 4.44 (3.58) Number of stress- Holocaust survivors 2.28 (1.65) ful life events Comparisons 1.69 (1.65) Daughters of Holocaust survivors 2.51 (1.98) Daughters of comparisons 2.19 = Note. N (Holocaust survivors) = 32; N (Comparisons) = 33; N (Daughters of Holocaust survivors) = 47; N (Daughters of comparisons) = 33

12 34 Chapter 2. Coping in Old Age with Extreme Childhood Trauma did not show stability in their mental health F(1, 72) = 1.89, p =.17, and no significant differences were found for the level of mental health between the two phases F (1, 72) = 0.04, p =.85. First Generation Holocaust Survivors and Comparisons. Table 2 presents the main measures of Holocaust survivors, their daughters and their comparisons. Holocaust survivors reported higher frequency of dissociative experiences than their comparisons, t (62) = 2.19, p <.05, they were less satisfied with their lives, t (63) = -3.38, p <.01, they suffered from more cognitive impairments than comparison subjects, t (63) = 2.08, p <.05, and they perceived their life events as more stressful, t (63) = 2.35, p <.05, than women their age who did not experience the Holocaust. Multivariate logistic regression was conducted in order to predict whether a participant belonged to Holocaust survivors group, or to the comparison group. Results of the logistic regression analysis are presented in Table 3. Wald χ² term expresses the added value of each variable in predicting group membership. The odds ratio is larger when the probability of the participant to belong to the group of Holocaust survivors is higher. As displayed in Table 3, satisfaction with life (odds = 2.79, p <.05) and dissociative experiences (odds = 2.39, p <.05) were significant predictors of group membership. Participants who were less satisfied with their life and who showed more dissociative symptomatology were more likely to belong to the group of Holocaust survivors. Second Generation and Comparisons. Table 2 presents the main outcomes of daughters of Holocaust survivors and their counterparts. No significant differences were found between the two groups on any of the variables measured. Here too multivariate logistic regression was conducted in order to predict whether a participant belonged to the offspring of Holocaust survivors, or to the comparisons. As displayed in Table 3, none of the variables that were included in the logistic regression analysis predicted group membership of the second generation.

13 Chapter 2. Coping in Old Age with Extreme Childhood Trauma 35 Table 3. Predictors of Holocaust versus Comparison Group Predictors First generation participants Second generation participants Wald χ² Odds Ratio 95% CI Wal d χ² Odds Ratio 95% CI Dissociation experiences 5.35* 2.39 [1.14, 4.99] [0.63, 1.88] Mental health [0.91, 1.05] [0.91, 1.05] Satisfaction with life Cognitive functioning Perceived physical health Physical health symptoms Perceived stress of life events Number of stressful life events 5.26* 2.79 [1.16, 6.70] [0.58, 2.70] [0.92, 4.31] [0.79, 1.06] [0.06, 10.97] [0.08, 36.61] [0.24, 2.63] [0.37, 2.13] [0.68, 27.52] [0.24, 11.85] [0.14, 1.75] [0.20, 2.97] Note: CI = confidence interval. N (First generation) = 64, N (Second generation) = 73 * p <.05 Associations Between Generations Significant positive correlations were found between Holocaust survivors and their daughters on the total sum of stressful life events, r =.53, p <.01: the more stressful life events mothers (first generation) reported, the more did their daughters (second generation) report such events. Also, when mothers reported more stress of those life events, their daughters reported more stress too r =.42, p <.05 (Table 4).

14 36 Chapter 2. Coping in Old Age with Extreme Childhood Trauma Table 4. Correlations between First and Second Generation Holocaust survivors and their daughters (N = 79) Comparison Subjects and their daughters (N = 64) Dissociation Experiences Mental health inventory Satisfaction With Life Cognitive Questionnaire Perceived Physical Health Physical Health Perceived Stress of Life Events.58**.09 Number of Stressful Life Events.52**.17 **p <.01 Discussion Holocaust survivors who were children during the Second World War, now in their seventies and eighties, showed more dissociative symptomatology, less satisfaction with their life, more cognitive impairment, and they reported more stress associated with their recent life events as compared to a matched group of women their age, also born in Europe but who migrated to the pre-state of Israel with their parents just before the onset of the Holocaust. Satisfaction with life and dissociative symptomatology were associated with the Holocaust experiences in the multivariate analysis as well. Hence, Holocaust survivors show markers of the traumatic experiences even almost seven decades after the Holocaust. Nonetheless, adult offspring of Holocaust survivors showed no differences in their physical, psychological and cognitive functioning as compared to matched controls. Our current findings are consistent with the finding of the first phase of the study (Sagi- Schwartz et al., 2003), suggesting that Holocaust survivors still display posttraumatic stress symptoms, but that they do not lag behind in their mental health as compared to their counterparts. Furthermore, the remarkable resilience of first generation participants was manifested in the absence of intergenerational transmission of trauma to the second generation. The adult offspring of survivors are not different from their comparisons on any of the assessments. Our findings

15 Chapter 2. Coping in Old Age with Extreme Childhood Trauma 37 therefore correspond with the meta-analytic studies, which indicate that although survivors display posttraumatic symptomatology, there is no evidence of intergenerational transmission of the trauma to their offspring in non-convenience samples like our sample (Van IJzendoorn et al., 2003). Concerning the association between first and second generation we found that only the number of recent life events and the subjective stress as a result of these events seemed to be converging. The more stressful life the first generation reported, the more life events their daughters had experienced, and when the first generation reported more stress because of those life events, their daughters reported more stress too. Some of the stressors reported by the two generations referred to family stressors such as sickness or divorce in the family, which might explain at least part of the association. From a human life-span perspective, the main developmental task of old age is to achieve ego integrity through acceptance of one's life experiences, and by integrating and balancing the positive and the negative experiences. Failure to reach that end in this phase of life may result in despair or depression (Erikson, 1987). The resolution of this developmental task depends, however, on the successful mastering of previous transitions through childhood, adolescent and adulthood, such as establishing trust in caring persons and the wider social context, and achieving the capacity for intimate relationships. It is clear that the Holocaust experiences destroyed the trajectory of normal psychological development as all survivors in our study lost their parents during the war (which was a condition for participation), leaving the child survivors confused, isolated and despaired (Safford, 1995). Furthermore, maybe integrating the Holocaust atrocities is not only impossible, but even not adaptable (Danieli, 1981). For Holocaust survivors, integrating and in a sense accepting their traumatic experiences may appear antithetical to the justification for their survival which is to serve as angry witnesses of the outrage of the Holocaust (Krystal, 1981). Therefore ego integrity might be at least partially achieved through the role of being a "historian" rather than being a "victim" (Safford, 1995), especially when survivors share their personal testimony with family and others. The difficulties in integrating past experiences with present challenges were indicated in the lower satisfaction with life that Holocaust survivors displayed as compared to women who did not experience the Holocaust. However, in contrast to studies that found that Holocaust survivors display more mental health difficulties compared to comparisons (e.g., Amir & Lev-Weisel, 2003; Joffe, Brodaty, Luscombe, & Ehrlich, 2003), we did not find such differences in our study. The differences in satisfaction with life, along with the lack of differences in mental health, might be explained by the differences between the measures: Life satisfaction is a conscious cognitive judgment of one's life, according to a personal

16 38 Chapter 2. Coping in Old Age with Extreme Childhood Trauma set of criteria, and it reflects a global long-term perspective rather than specific, unconscious and affective ratings (Pavot & Diener, 1993). In contrast, the mental health index refers to the prevalence of specific feelings and behavior experienced during the last month (Florian, & Drori, 1990). As we are studying the long-term effects of childhood trauma in general and the challenges of coping with this past trauma in old age, the differences found in satisfaction with life may indicate more clearly the co-existence of disturbing traumatic memories and the remarkable strength that Holocaust survivors demonstrate in their everyday life, leading normal and creative lives, and successfully raising non-traumatized next generations. Alongside integrating past and present, we found higher levels of dissociative symptomatology among Holocaust survivors. Dissociative markers, defined as the failure to integrate experiences such as memories and perceptions of reality that are normally associated (Kennedy et al., 2004), characterize many psychological disorders, and it has been suggested to be the mechanism that underlies the relation between early trauma and later psychopathology (Putnam, 1997). In a meta-analytic study, dissociation, as measured by the Dissociation Experiences Scale (Bernstein & Putnam, 1986), was found to be strongly associated with traumatic experiences (Van IJzendoorn & Schuengel, 1996). Dissociation serves as a psychological defense mechanism as it prevents further processing of raw materials so that memories are stored in a fragmented way (Kennedy et al., 2004), and therefore traumatic memories appear to differ from non-traumatic memories in terms of vividness, intrusiveness and amnesias. Dissociative symptoms might be indexed by amnesia and memory symptoms, and by processing symptoms (Putnam, 1997). Amnesia and other memory problems can be manifested as forgetfulness for wellknown information, unexplainable gaps in autobiographical recall, and problems with identifying the source of information. Dissociative process symptoms may include depersonalization, derealization, and hallucinations. It is not surprising therefore, that cognitive functioning is significantly affected by traumatic experiences as evidenced in the assessment of impairments in cognitive performance within the Holocaust survivors group. The observed impairment cannot be due to normal aging processes, since their same-age comparisons showed higher cognitive functioning. Our findings are consistent with studies that found cognitive failures to be related to stress, for example through employee exhaustion (Van Der Linden, Keijsers, Eling, & Van Schaijk, 2005), and related to posttraumatic stress because of child maltreatment (Goodman, Quas, & Ogle, 2009). Boals (2008) recently found that Holocaust survivors with higher levels of posttraumatic symptoms (i.e., intrusiveness and avoidance of traumatic thoughts) were more likely to suffer from cognitive failures in everyday life such as forgetting appointments. Yehuda, Golier, Halligan, and Harvey (2004) also found that Holocaust survivors still suffering from posttraumatic stress showed

17 Chapter 2. Coping in Old Age with Extreme Childhood Trauma 39 impairments in learning and short-term memory as compared to survivors without PTSD and to comparisons that were not exposed to the Holocaust atrocities. Taken together, satisfaction with life, dissociative symptomatology and cognitive functioning appear to be related to one another, and indicate a lack of cognitive-emotional ability of integrating past experiences in current life circumstances. Maybe the core of posttraumatic stress of Holocaust survivors resides in their fragmented past. This might be because their safe and known environment suddenly became extremely threatening and hostile without rational explanation or meaning, and because the duration of this situation was unpredictable (Kahana et al., 1988). Therapies and treatment may particularly address survivors integration capacity, to create a more coherent life history (Krystal, 1981; Van der Hal-Van Raalte et al., 2008). In contrast to studies that reported more physical morbidity among Holocaust survivors (e.g., Amir & Lev-Weisel, 2003) we did not find such differences. This discrepancy might be explained by differences in sampling and design, as Barel and her colleagues (2010) discuss in their meta-analysis. Amir and Lev-Weisel (2003) for example relied on a convenience sample which was recruited through Holocaust survivors' organizations in Israel. One of the strengths of the current study also is the comparability of post-holocaust life conditions of survivors and comparisons who might both have suffered from traumatic events in Israel after the Second World War in comparable ways. Holocaust survivors reported higher stress related to recent life events, even though they did not experience more stressful life events. This subjective stress was also found by Yehuda and her colleagues in Holocaust offspring (1998). A limitation of the current study is the use of only self report measures. It should be noted however that the findings are in line with other studies that used other measures such as interviews (Sagi-Schwartz et al., 2003), and clinical diagnostic tools (Joffe et al., 2003), and also with meta-analytic studies. A larger sample would have increased the power of the statistical analyses to find more differences, but the power was sufficient to detect medium size effects. Furthermore, the current study was limited to female survivors and their female offspring, and replication in a male or mixedgender sample is needed. Also, it has been suggested that Holocaust survivors would constitute a specific selection of resilient individuals who have shown to be able to cope with the most extreme traumatic events. However, we would like to stress the fact that perishing in the Holocaust by no means can be seen as indicative of lesser resilience. In most likelihood it was impossible to escape or survive such an industrially planned and conducted genocide without sheer luck, especially when we think about infants and children. A last limitation is that Holocaust survivors have been studied intensively and some of our participants might have been included in previous studies. The effects of repeated testing are unknown.

18 40 Chapter 2. Coping in Old Age with Extreme Childhood Trauma Future studies may further investigate the underlying mechanisms of protective and risk factors of developing posttraumatic symptoms after extreme experiences. Such mechanisms could reside in the epigenetics of trauma (McGowan et al., 2009) or in gene-environment interactions underlying the emergence of posttraumatic stress reactions. A study examining Rwandan survivors (De Quervain et al., 2007) supports the claim for a genetic role in the predisposition to develop post-traumatic symptomatology. Also, the effect of trauma on neurobiological functioning (e.g., cortisol secretion) should be further examined. Diurnal cortisol patterns were explored among Holocaust survivors showing dysregulation in cortisol secretion resulting in elevated cortisol levels (Van der Hal-Van Raalte et al., 2008) as well as lowered levels of cortisol production (Yehuda et al., 2000; Yehuda, Golier, & Kaufman, 2005) in participants suffering from PTSD. Dissociation is generally considered to be a disorder, but an important question for future investigations is whether developing some form of amnesia for the extreme traumatic experiences of the Holocaust is adaptive as for example Breznitz (1982) argued. Removing traumatic memories from one s mind may result in reduced hyper vigilance, normal cortisol levels, and reduced fight or flight responses, all of which might be adaptive. Perhaps the concept of ego integration as applied to survivors of extreme trauma may be less feasible than currently thought. Alternatively, dissociation of traumatic memories might have short-term benefits (for raising the next generation) and at the same time long-term damage (to the individual s neurobiological functioning). In sum, Holocaust survivors showed higher frequency of dissociative symptomatology in old age, less satisfaction with their life, more cognitive impairment, and more stress as a result of stressful life events, as compared to a matched control group. Their adult daughters however did not differ from their comparisons. The basic human desire to reach old age with acceptance of past life experiences and accomplishments regardless of traumatic life events might not always be adaptable personally and socially, or remain without psychological costs. The Holocaust and by implication other genocides seem to leave their intractable imprints on the survivors many decades after the end of the traumatic events. Can we expect Holocaust survivors to resolve the loss of family members, friends and other attachment figures during childhood in a coherent framework and to accept these inhuman facts? As the survivors in our study showed, they were unable to integrate their past and present challenges, but they nevertheless successfully managed to keep their children emotionally unharmed. Perhaps dissociation instead of resolution of extreme, incomprehensible trauma is the desirable solution as it paves the way for a more balanced life of generations to come.

19 Chapter 2. Coping in Old Age with Extreme Childhood Trauma 41 References Amir, M., & Lev-Wiesel, R. (2003). Time does not heal all wounds: Quality of life and psychological distress of people who survived the Holocaust as children 55 years later. Journal of traumatic Stress, 16, Antonovsky, A., Maoz, B., Dowty, N., & Wijsenbeek, H. (1971). Twenty-five years later: A limited study of the sequelae of the concentration camp experience. Social Psychiatry, 6, Baider, L., Peretz, T., Hadani, P. E., Perry, S., Avramov, R., & De-Nour, A. K. (2000). Transmission of response to trauma? Second generation Holocaust survivors reaction to cancer. American Journal of Psychiatry 157, 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, Bar-On, D., Eland, J., Kleber, R. J., Krell, R., Moore, Y., Sagi, A., Soriano, E., Suedfeld, P., Van der Velden, P. G., & Van IJzendoorn, M. H. (1998). Multigenerational perspectives on coping with the Holocaust experience: An attachment perspective for understanding the development sequelae of trauma across generations. International Journal of Behavioral Development, 22, Beeri, M.S., Werner, P., Davidson, M., Schmidler, J., & Silverman, J. (2003). Validation of the modified telephone interview for cognitive status (TICS-m) in Hebrew. International Journal of Geriatric Psychiatry, 18, Bernstein, E. M & Putnam, F. W. (1986). Development, reliability and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174, Boals, A. (2008). Short communication: Intrusive thoughts and everyday cognitive failures in Holocaust survivors. Stress and Health, 24, Burnham, G., Lafta, R., Doocy, S., & Roberts, L. (2006). Mortality after the 2003 invasion of Iraq: A cross-sectional cluster sample survey. Lancet, 368, Breznitz, S. (1982). Denial of stress. New York: International Universities Press. Carlson, E. B., & Putnam, F. W. (1993). An update on the dissociative experiences scale. Dissociation, 6, Carmil, D., & Breznitz, S. (1991). Personal trauma and world view-are extremely stressful experiences related to political attitudes, religion beliefs, and future orientation? Journal of Traumatic Stress, 4, Chodoff, P. (1986). Survivors of the Nazi Holocaust. In R. H. Moos (Ed.), Coping with Life Crises: An Integrated Approach (pp ). New-York: Plenum Press.

20 42 Chapter 2. Coping in Old Age with Extreme Childhood Trauma Cohen, K., & Shmotkin, D. (2007). Emotional ratings of anchor periods in life and their relations to subjective well-being among Holocaust survivors. Personality and Individual Differences, 43, Danieli, Y. (1981). On the achievement of integration in aging survivors of the Nazi Holocaust. Journal of Geriatric Psychiatry, 14, Danieli, Y. (1998). International Handbook of Multigenerational Legacies of Trauma. New- York: Plenum Press. de Graaf, T. (1975). Pathological patterns of identification in families of survivors of the Holocaust. Israel Annals of Psychiatry, 13, de Jager, C. A., Budge, M. M., & Clarke, R. (2003). Utility of the TICS-M for the assessment of cognitive function in older adults. Journal of Geriatric Psychiatry, 18, 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, Desmond, D. W., Tatemichi, T.K., & Hanzawa, L. (1994). The telephone interview for cognitive status (TICS): Reliability and validity in stroke sample. Journal of Geriatric Psychiatry, 9, Erikson, E. H. (1950). Child and Society. New-York: Norton. Erikson, E. H. (1987). The Life Cycle Completed. New-York: Norton. Felsen, I. (1998). Transgenerational transmission of effect of the Holocaust. In Y Danieli (Ed.), International Handbook of Multigenerational Legacies of Trauma (pp ). New-York: Plenum Press. Fening, S., & Levav, I. (1991). Demoralization and social supports among Holocaust survivors. Journal of Nervous and Mental Disease, 179, Florian, V., & Drori, Y. (1990). Mental health inventory (MHI): Psychometric characteristics and normative data regarding the Israeli population. Psychology, 1, (Hebrew). Frischholz, E. J., Braum, B. G., Sachs, R. G., Hopkins, L. Shaeffer, D. M., Lewis, J., Leavitt, F., Pasquotto, J. N., & Schwartz, D. R. (1990). The dissociative experiences scale: Further replication and validation. Dissociation, 3, Goodman, G. S., Quas, J. A., & Ogle, C. M. (2009). Child maltreatment and memory. Annual Review of Psychology, 61, Harel, Z., Kahana, B., & Kahana, E. (1993). Social resources and the mental health aging Nazi Holocaust survivors and immigrants. In J. P. Wilson, & B. Raphael (Eds.), International Handbook of Traumatic Stress Syndromes. (pp ). New-York: Plenum Press. Harel, Z., Sollod, R.N., & Bognar, B. J. (1982). Predictors of mental helath among semi-rural aged. The gerontologist, 22,

21 Chapter 2. Coping in Old Age with Extreme Childhood Trauma 43 Joffe, C., Brodaty, H., Luscombe, G., & Ehrlich, F. (2003). The Sydney Holocaust study: Posttraumatic stress disorder and other psychological morbidity in an aged community sample. Journal of Traumatic Stress, 16, Kahana, E., Kahana, B., Harel, Z., & Rosner, T. (1988). Coping with extreme trauma. In J. Wilson, Z. Harel, & B. Kahana (Eds.), Human Adaptation to Human Stress: From Holocaust to Vietnam (pp ). New-York: Plenum press. Keinan-Boker, L., Vin-Raviv, N., Lipshitz, I., Linn, S., & Barchana, M. (2009). Cancer incidence in Israeli Jewish survivors of World War II. The Journal of National Cancer Institute, 101, Kennedy, F. Clarke, S., Stopa, L., Bell, L., Rouse, H., Ainsworth, C., Fearon, P., & Waller, G. (2004). Towards a cognitive model and measure of dissociation. Journal of Behavior Therapy and Experimental Psychiatry, 35, Krell, R., Suedfeld, P., & Soriano, E. (2004). Child Holocaust survivors as parents: A transgenerational perspective. American Journal of Orthopsychiatry, 74, Krystal, H. (1981). Integration and self-healing in posttraumatic states. Journal of Geriatric Psychiatry, 14, Landau, R., & Litwin, H. (2000). The effects of extreme early stress in very old age. Journal of Traumatic Stress, 13, Leon, G. R., Butcher, J. N., Kleinman, M., Goldberg, A., & Almagor, M. (1981). Survivors of the Holocaust and their children: Current status and adjustment. Journal of Personality and Social Psychology, 4, McGowan, P., Sasaki, A., D'Alessio, A. C., Dymov, S., Labonte', B., Szyf, M., Turecki, G., & Meaney, M. J. (2009). Epigenetic regulation of the glucocorticoid receptor in human brain associates with childhood abuse. Nature Neuroscience, 12, Nadler, A., & Ben-Shushan, D. (1989). Forty years later: Long term consequences of massive traumatization as manifested by Holocaust survivors from city and the Kibbutz. Journal of Consulting and Clinical Psychology, 57, Niederland, W. G. (1968). Clinical observations on the "Survivor Syndrome". The International Journal of Psychoanalysis, 49, Pavot, W., & Diener, E. (1993). Review of the satisfaction with life scale. Psychological Assessment, 5, Pena, E. D. (2007). Lost in translation: Methodological consideration in crosscultural research. Child Development, 78, Putnam, F. W. (1997). Dissociation in Children and Adolescents: A Developmental Perspective. New York: Guilford press. Safford, F. (1995). Aging stressors for Holocaust survivors and their families. Journal of Gerontological Social Work, 24,