Aging & Mental Health Vol. 15, No. 2, March 2011, 232–242

Coping in old age with extreme childhood trauma: Aging Holocaust survivors and their offspring facing new challenges Ayala Fridmanab, Marian J. Bakermans-Kranenburgb, Abraham Sagi-Schwartza* and Marinus H. Van IJzendoornb aCenter for the Study of , University of Haifa, Haifa, ; bCentre for Child and Family Studies, , Leiden, The (Received 21 February 2010; final version received 10 June 2010)

Objective: The Holocaust has become an iconic example of immense human-made 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. Methods: 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 ¼ 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 ¼ 2.39) and less satisfaction with their life (odds ¼ 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. Keywords: Holocaust; early childhood trauma; mental health; dissociative symptomatology; intergenerational transmission of trauma

Introduction dissociative symptoms, and physical health. This study During the last hundred years, numerous devastating is a follow-up of a previous study conducted 11 years wars and genocides have created millions of casualties ago with the same participants, which makes it possible and severe trauma in many more surviving adults and to examine the stability of adaptation of Holocaust children (Burnham, Lafta, Doocy, & Roberts, 2006; survivors over time. Danieli, 1998). The Holocaust that took place during Holocaust survivors who were children during World War II and aimed at the destruction of the World War II are now coping with normal aging Jewish people in Europe has become the most widely processes such as illness, frailty, dependency, and studied example of such immense man-made cata- isolation, which might elicit memories from their past strophes. The study of its long-term effects may help to experience (Shmotkin & Barilan, 2002). Moreover, gain better understanding of the adaptation of victims signs of unresolved trauma or loss might emerge again of recent genocides extended in countries like as an expression of loss of significant others and the Cambodia, Nigeria, Rwanda, Sudan, and former survivors’ own impending death. Their children are Yugoslavia. In the current study we explore the themselves adults now, also facing major challenges (mal-) adaptation of aging Holocaust survivors and such as balancing demanding work and family life their adult offspring in light of the developmental tasks (Erikson, 1950). they have to cope with in old age. Childhood trauma During the Holocaust, adults and children experi- may leave the survivors more vulnerable when they are enced a total disruption of their life experiences. They facing stress related to old age, whereas their offspring were prisoners at work camps or death camps, or were might have a challenging role of protecting their own hidden in hostile territory, and often were exposed to parents from further pain. Here, we examine the death and loss of family members (Safford, 1995). This adaptation of Holocaust survivors and their offspring man-made catastrophe was characterized by an in light of these new challenges, examining satisfaction environment that was extremely threatening and with life (SWL), mental health, cognitive abilities, dangerous with no rational explanation or meaning.

*Corresponding author. Email: [email protected]

ISSN 1360–7863 print/ISSN 1364–6915 online ß 2011 Taylor & Francis DOI: 10.1080/13607863.2010.505232 http://www.informaworld.com Aging & Mental Health 233

The possibilities to reduce the threat or stress were very and their grandchildren, we examined posttraumatic limited (E. Kahana, B. Kahana, Harel, & Rosner, stress, attachment, mental health, social adaptation, 1988). Those who were children and survived the and style. Intergenerational transmission extreme inhuman conditions remembered prewar life was absent as no differences were found in the vaguely or even not at all (Krell, Suedfeld, & Soriano, second and third generation offspring of Holocaust 2004). survivors and their comparisons, although the first Studies on the effects of the Holocaust on survivors generation of survivors showed posttraumatic symp- and their families reflect a wide range of perspectives. toms even more than half a century after the Holocaust Accordingly, the conclusions vary, and are sometimes (Sagi-Schwartz et al., 2003). even contradictory (Barel, Van IJzendoorn, Not all efforts made by Holocaust surviving Sagi-Schwartz, & Bakermans-Kranenburg, in press; parents to protect their offspring yielded adaptive Bar-on et al., 1998; Van IJzendoorn, outcomes. Yehuda, Schmeidler, Wainberg, Binder- Bakermans-Kranenburg, & Sagi-Schwartz, 2003). Brynes, and Duvdevani (1998), for example, reported Many studies documented the survivors’ syndrome that although adult children of Holocaust survivors (Niederland, 1968), meaning that Holocaust survivors did not experience more traumatic life events than their suffer from severe and enduring psychological effects comparisons they nevertheless showed higher preva- of the massive trauma, manifested in chronic anxiety lence of current and lifetime PTSD, and they were (de Graaf, 1975), depression, disturbances in cognition more likely to perceive non-life-threatening events as and memory, tendency to isolation (Niederland, 1968), very distressing. Others reported that Holocaust sense of guilt (Chodoff, 1986), low psychological survivors’ offspring were more affected when con- well-being, and difficulties in emotional expression fronted with extreme stress such as cancer (Baider (Amir & Lev-Wiesel, 2003; Nadler & Ben-Shushan, et al., 2000) or combat (Solomon, Kotler, & 1989). In addition, physical health problems have been Mikulincer, 1988) and that daughters of survivors documented (e.g., Antonovsky, Maoz, Dowty, & were more vulnerable to the intergenerational trans- Wijsenbeek, 1971; Landau & Litwin, 2000); in parti- mission of parental trauma (Felsen, 1998). Taken cular cancer morbidity (Keinan-Boker, Vin-Raviv, together, the meta-analytic results suggest that inter- Lipshitz, Linn, & Barchana, 2009). generational transmission of the Holocaust trauma to Alongside studies of maladaptive outcomes and the next generation might be observed in particular in psychopathology of Holocaust survivors, there is a studies with weaker designs using convenience samples growing body of evidence that their psychological and in clinical samples (Van IJzendoorn et al., 2003). adjustment is within the normal range (e.g., Barel As survivors grow old, traumatic experiences may et al., in press; Leon, Butcher, Kleinman, Goldberg, & vary in their impact on life. Trauma may leave the Almagor, 1981). Survivors managed to build families survivors more vulnerable when they are facing stress and to establish social relationships (Harel, B. Kahana, related to old age (e.g., Solomon & Prager, 1992). & E. Kahana, 1993). In a recent meta-analysis Safford (1995) suggested that although many survivors involving 12,746 participants from 71 samples, demonstrated resilience and adaptability (e.g., Leon Holocaust survivors were compared with their counter- et al., 1981), they may be particularly vulnerable to parts on physical health, psychological well-being, changes that are associated with normal aging pro- posttraumatic stress symptoms, psychopathological cesses, because former coping strategies, such as hard symptomatology, cognitive functioning, and stress- work and taking care of the next generation, are no related physiology (Barel et al., in press). Results longer available. Daily coping requires intensive showed that even in non-select samples (i.e., drawn investment in meaningful activities that provide the from population-wide demographic information) opportunity to focus on the present and future, rather Holocaust survivors showed substantially more post- than on the past (Steinitz, 1982). Illness, frailty, traumatic stress symptoms than comparisons. dependency, isolation, and loneliness may disrupt However, they displayed good adaptation in physical such activities, and traumatic memories and unre- health, cognitive functioning, and stress related phy- solved losses might become more dominant. The siology, suggesting also remarkable resilience. absence of social support may contribute to some of The resilience of the first generation of survivors the negative consequences for psychological well-being might explain the unexpected absence of intergenera- (Fening & Levav, 1991; Harel et al., 1993; Landau, & tional transmission of trauma in the set of studies Litwin, 2000). Second-generation Holocaust survivors, involving the second and third generations, respec- now in their 50s and 60s, might have a challenging tively (Sagi-Schwartz, Van IJzendoorn, & Bakermans- role of protecting their own parents from further pain Kranenburg, 2008; Van IJzendoorn et al., 2003). In a (Steinitz, 1982). meta-analytic study on 32 samples with 4418 children The remarkable resilience that in some studies was of Holocaust survivors there was no evidence for found to characterize Holocaust survivors, in particu- secondary traumatization in studies with non-select lar in parenting their offspring, could also serve them recruitment and non-clinical samples (Van IJzendoorn as they are aging. Good health, adequate social et al., 2003). In a quasi-experimental study with resources and satisfactory social relationships are carefully matched Holocaust survivors, their daughters predictors of mental health among aged in general 234 A. Fridman et al.

(Harel, Sollod, & Bognar, 1982). Shmotkin and (9.3%) had passed away, 13 (11.50%) had health Lomranz (1998) found that the main explanation for problems that prevented them from cooperating aging Holocaust survivors’ lower subjective well-being (e.g., dementia), two (1.9%) had personal problems was their poorer capacity to integrate their past (such as mourning), and two (1.9%) could not be experiences and present goals in their lives. located. Of the 79 first-generation participants who Given the advanced age of Holocaust survivors, were able to cooperate, 65 (82.3%) agreed to take part any examination of the long-term effects of massive in the study (32 Holocaust survivors and 33 compar- trauma during childhood on Holocaust survivors is not ison respondents). The age of the first-generation only timely but is also very urgent because this participants ranged from 71 to 84 years (M ¼ 76.98, population is getting very old and is rapidly dying SD ¼ 2.99). Of the 104 second-generation participants, and disappearing. Research on Holocaust survivors five (4.7%) had moved out of Israel, one (0.9%) had provides an opportunity for studying the enduring health problems, and two (1.9%) could not be located. effects of massive trauma and extreme life experiences Of the remaining sample, 79 (82.29%) agreed to take (Carmil & Breznitz, 1991). part (47 daughters of Holocaust survivors group and Here we present findings from the second phase of 32 daughters of comparison subjects). The age of the a study that started 11 years ago, and included female second-generation participants ranged from 38 to 59 Holocaust survivors (first generation), their adult years (M ¼ 47.46, SD ¼ 4.41). daughters (second generation), and their 12–15 months old children (third generation) as well as carefully matched comparisons (Sagi-Schwartz et al., Procedure 2003). In the first phase we found that the first Receiving participant’s principal agreement, a research generation showed more posttraumatic symptoms, but assistant visited each participant at home at the that their general adaptation and parenting style did participant’s convenience. The first and second gen- not differ from the comparisons. Also, second and eration subjects were visited on separate occasions. third generation participants were similar to compar- After a brief introduction, the participant signed an ison offspring of Holocaust survivors in all domains of informed consent form and completed some question- functioning that we covered in our study naires. First-generation participants were guided by the (Sagi-Schwartz et al., 2003). research assistant through the entire session, and We hypothesized that in the current follow-up, helped them complete the tasks and questionnaires if almost 70 years after the Holocaust, survivors would they needed clarification. show more posttraumatic symptoms, as expressed in dissociative symptomatology (amnesia and other memory symptoms, depersonalization, derealization, Measures and hallucinations), distress and cognitive impairment Dissociation compared to participants who did not experience the The Dissociative Experiences Scale (DES) was devel- Holocaust. Furthermore, we hypothesized that their oped by Bernstein and Putnam (1986) to assess the offspring, the second-generation Holocaust survivors, frequency of dissociative experiences. It contains 28 would not show signs of posttraumatic stress, and self-report items that ask participants to indicate the would not differ from their counterparts in mental frequency (0–100%) of various dissociative experiences health. such as discontinuities in awareness, imaginative involvement, and amnesia, excluding experiences that occurred when they were under the influence of alcohol Methods or drugs. Translation into Hebrew was done for the Participants purpose of the current study by Hebrew and English native speakers, using a dual-focus approach in order Participants were recruited from population-wide to maintain linguistics equivalence (Pen˜a, 2007). Total demographic information provided by the population scores were calculated by averaging the 28 items scores, registry administered by Israeli Ministry of Interior resulting in a scale score ranging from 0 to 100. (Sagi-Schwartz et al., 2003). Two groups were com- Cronbach’s alpha reliability coefficients were 0.86 for pared: The first-generation females with Holocaust first generation, and 0.83 for second generation. experiences in their childhood and their daughters (the second generation), and a matched comparison group of first-generation female who were born in Europe Well-being and migrated with their parents to the pre-State of Two subscales were used to assess the subjective Israel just before the Holocaust, and their daughters well-being. The adapted version of the Mental Health (the second generation). Inventory (Florian & Drori, 1990) that was used in the For the purpose of the current phase of the study, first phase of Holocaust study consists of 14 items we contacted the 106 first-generation participants and dealing with distress and well-being. Participants were 104 second-generation participants who took part in asked to indicate on a six-point Likert scale the extent the original sample. Ten first-generation participants to which they experienced feelings of distress and Aging & Mental Health 235 well-being during the past month with higher scores Life events reflecting more well-being and less distress. Cronbach’s The Life Events questionnaire was developed for this alpha reliability coefficients in the current study were study. This checklist consists of 18 items describing 0.84 for the first generation, and 0.95 for the second stressful life events, such as marital conflict or illness of generation. family members. Subjects were asked to mark if they had or had not experienced that life event in the past Satisfaction with life year and to rate the accompanying stress on a three- point Likert scale. Participants could add more SWL scale is a five-item questionnaire designed to stressful life events if they wanted, and a list of 35 assess SWL as a whole (Pavot & Diener, 1993). Using possible stressful life events was obtained. The seven-point Likert scales, participants were asked to correlation between the two stressful life events rate their level of agreement with statements on a scale measures was r ¼ 0.91 ( p 5 0.01) for the first genera- of 1 (strongly disagree)to7(strongly agree). The score tion, and r ¼ 0.93 ( p 5 0.01) for the second generation. for the overall scale is the sum of all five items. Higher scores represent more SWL, whereas lower score represent dissatisfaction. Cronbach’s alpha reliability coefficients were 0.65 for the first generation and 0.84 Statistical analysis for the second generation. The Hebrew version has In order to avoid biased results due to extreme values, been used in various studies in Israel (e.g., Cohen & all measures were inspected for outliers, which were Shmotkin, 2007). Intercorrelations between the two defined as values larger than SD ¼ 3.29 above the mean subscales of subjective well-being were r ¼ 0.28 for the or smaller than SD ¼ 3.29 under the mean (Tabachnick first generation ( p 5 0.05), and r ¼ 0.68 for the second & Fidell, 2007). Physical health, stressful life events, generation ( p 5 0.01). and dissociation distributions were moderately posi- tively skewed, and square-root transformation was Cognition used for the analysis. The distributions of the variables The Telephone Instrument for Cognitive Status SWL for both generations and cognition for the Modified (TICS-m) was administered to participants first-generation participants were moderately nega- during an interview. The TICS-m consists of 21 items tively skewed and a reflection of square-root transfor- with a maximum score of 50 points, with lower scores mation was used. For the perceived physical health reflecting more cognitive impairment. The questions measure of second-generation participants, reflected pertain to long– and short-term memory, orientation log 10 transformation was used since the distribution to time and place, attention, language and abstraction. was substantially negatively skewed. For the DES of The Hebrew version is a direct translation of the first-generation participants, one case was deleted since English TICS-m (Beeri, Werner, Davidson, Schmidler, it reflected clinical dissociation (Carlson & Putnam, & Silverman, 2003). Studies have shown convergent 1993; Frischholz et al., 1990), whereas the study validity with other cognitive tests and test–retest focused on a non-clinical sample. validity (e.g., de Jager, Budge, & Clarke, 2003; Desmond, Tatemichi, & Hanzawa, 1994). Attrition Physical health Possible differences in mortality between Holocaust Physical health status was assessed by a questionnaire survivors and comparison subjects were tested. developed by Herczeg Institute on Aging (Tel Aviv A chi-squared test showed no differences between the 2 University) and used in a previous Holocaust study two groups (1, N ¼ 104) ¼ 0.44, p ¼ 0.74. In order to (Van der Hal-Van Raalte, Bakermans-Kranenburg, & test for possible selective attrition, we compared the Van IJzendoorn, 2008). Subjects were asked to rate trauma and well-being data of the participants who their health using a five-point Likert scale ranging continued their participation in the current phase with from 1 ¼ very unhealthy to 5 ¼ very healthy. Also, they those who dropped out. Holocaust survivors who were asked to indicate which of 19 listed health continued to take part in the study reported more problems they suffered. Participants could add more unusual beliefs in the previous phase of the study health conditions if they wanted, and a list of 40 (11 years ago) than those who dropped out, possible health problems was obtained. The total t (44) ¼ 2.07, p ¼ 0.04 (Table 1). No other differences number of health problems ranged from 0 (no health were found for the trauma measures. It was also found problems) to 15 for first generation, and from 0 to 8 for that comparison subjects who continued to participate second generation. This questionnaire is widely used in the study reported higher mental health 11 years ago for socio-demographic research in Israel. The correla- than participants that did not continue, t (48) ¼ 2.99, tion between the two health measures was r ¼ 0.62 p 5 0.05. However, no differences were found for ( p 5 0.01) for the first generation, and r ¼ 0.27 daughters of Holocaust survivors and comparison ( p 5 0.05) for the second generation. subjects. 236 A. Fridman et al.

Table 1. Holocaust survivors and comparison subjects: between samples analysis.

Participated in Did not participate Measure Group phase 2 M (SD) in phase 2 M (SD) tp

Unresolved state of mind Holocaust survivors 17.93 (7.26) 15.28 (4.86) 1.38 0.18 Comparisons 13.24 (5.61) 15.16 (4.70) 1.24 0.22 Daughters of Holocaust survivors 15.67 (4.93) 17.19 (5.45) 0.64 0.52 Daughters of comparisons 15.54 (7.37) 13.35 (4.67) 1.16 0.25 Unusual beliefs Holocaust survivors 34.64 (14.09) 26.72 (8.64) 2.07 0.04 Comparisons 26.45 (8.69) 29.74 (11.54) 1.14 0.26 Daughters of Holocaust survivors 35.53(11.67) 38.20 (11.82) 0.48 0.63 Daughters of comparisons 32.90 (9.65) 31.11 (10.35) 0.62 0.54 Intrusion Holocaust survivors 21.41 (7.98) 20.00 (8.31) 0.58 0.57 Comparisons 18.45 (8.18) 17.84 (8.14) 0.26 0.80 Daughters of Holocaust survivors 16.28 (6.52) 13.40 (3.85) 0.98 0.33 Daughters of comparisons 17.42 (6.47) 17.84 (7.16) 0.22 0.83 Avoidance Holocaust survivors 22.14 (8.67) 19.50 (7.49) 1.05 0.30 Comparisons 15.35 (6.80) 12.58 (3.85) 1.84 0.07 Daughters of Holocaust survivors 15.65 (6.91) 13.60 (3.36) 1.12 0.29 Daughters of comparisons 14.48 (5.89) 13.95 (6.16) 0.31 0.76 Autonomic anxiety Holocaust survivors 15.83 (6.93) 18.56 (7.77) 1.24 0.22 Comparisons 13.16 (5.57) 12.95 (4.18) 0.14 0.89 Daughters of Holocaust survivors 12.56 (3.63) 14.00 (4.85) 0.81 0.42 Daughters of comparisons 12.55 (3.96) 13.16 (5.37) 0.46 0.65 Cognitive worry Holocaust survivors 15.06 (5.01) 15.94 (7.78) 0.47 0.64 Comparisons 14.39 (6.19) 13.63 (4.57) 0.46 0.65 Daughters of Holocaust survivors 14.30 (4.35) 14.00 (2.45) 0.15 0.88 Daughters of comparisons 13.39 (4.69) 13.21 (5.17) 0.12 0.90 Well-being Holocaust survivors 56.00 (10.56) 52.06 (14.47) 1.07 0.29 Comparisons 59.23 (9.25) 49.79 (11.67) 2.99 0.005 Daughters of Holocaust survivors 53.98 (10.18) 52.00 (15.83) 0.39 0.70 Daughters of comparisons 56.48 (8.85) 58.53 (9.29) 0.78 0.44

Note: Holocaust survivors, N ¼ 48; comparisons, N ¼ 50; daughters of Holocaust survivors, N ¼ 48; and daughters of comparisons, N ¼ 50.

Results Holocaust survivors reported higher frequency of First, we will present the stability across the two phases dissociative experiences than their comparisons, of the study, 11 years apart, for those measures that t (62) ¼ 2.19, p 5 0.05, they were less satisfied with were employed at each point in time. Then, we will test their lives, t (63) ¼3.38, p 5 0.01, they suffered from the associations within each generation, and finally we more cognitive impairments than comparison subjects, will test the associations between the first and second t (63) ¼ 2.08, p 5 0.05, and they perceived their life generation. events as more stressful, t (63) ¼ 2.35, p 5 0.05, than women their age who did not experience the Holocaust. Multivariate logistic regression was con- Stability over the years ducted in order to predict whether a participant Mental health belonged to Holocaust survivors group, or to the comparison group. Results of the logistic regression The Mental Health Inventory for general well-being analysis are presented in Table 3. Wald 2 term was used in both phases of the study. Repeated expresses the added value of each variable in predicting measures ANOVA showed stability of mental health group membership. The odds ratio is larger when the between two phases of the study for first-generation probability of the participant to belong to the group of participants (both for Holocaust survivors and com- Holocaust survivors is higher. As displayed in Table 3, parison subjects) F(1, 58) ¼ 5.36, p 5 0.05 and no SWL (odds ¼ 2.79, p 5 0.05) and dissociative experi- difference in level of well-being, F(1, 58) ¼ 0.86, ences (odds ¼ 2.39, p 5 0.05) were significant predic- p ¼ 0.36. Second-generation participants (both daugh- tors of group membership. Participants who were less ters of Holocaust survivors and daughters of compar- satisfied with their life and who showed more isons) did not show stability in their mental health F(1, dissociative symptomatology were more likely to 72) ¼ 1.89, p ¼ 0.17, and no significant differences were belong to the group of Holocaust survivors. found for the level of mental health between the two phases F(1, 72) ¼ 0.04, p ¼ 0.85. Second generation and comparisons First-generation Holocaust survivors and comparisons Table 2 presents the main outcomes of daughters Table 2 presents the main measures of Holocaust of Holocaust survivors and their counterparts. survivors, their daughters and their comparisons. No significant differences were found between the Aging & Mental Health 237

Table 2. Holocaust survivors, their daughters, and comparison subjects statistic.

Measure Group M (SD) tp

Dissociation experiences Holocaust survivors 7.13 (4.46) Comparisons 5.03 (4.89) 2.19 0.03 Daughters of Holocaust survivors 7.23 (5.52) Daughters of comparisons 7.19 (5.73) 0.07 0.94 Mental health Holocaust survivors 54.59 (8.17) Comparisons 59.15 (10.63) 1.93 0.06 Daughters of Holocaust survivors 58.13 (10.16) Daughters of comparisons 60.41 (10.29) 0.97 0.33 SWL Holocaust survivors 23.91 (4.81) Comparisons 27.64 (4.79) 3.38 0.001 Daughters of Holocaust survivors 26.21 (6.16) Daughters of comparisons 28.41 (4.54) 1.68 0.09 Cognitive functioning Holocaust survivors 30.91 (6.67) Comparisons 34.21 (5.21) 2.08 0.041 Daughters of Holocaust survivors 39.15 (3.85) Daughters of comparisons 40.16 (3.09) 1.23 0.22 Perceived physical health Holocaust survivors 3.44 (1.04) Comparisons 3.61 (0.93) 0.63 0.53 Daughters of Holocaust survivors 4.34 (0.74) Daughters of comparisons 4.30 (0.89) 0.04 0.97 Physical health symptoms Holocaust survivors 5.94 (3.03) Comparisons 4.82 (2.95) 1.57 0.12 Daughters of Holocaust survivors 1.21 (1.41) Daughters of comparisons 1.09 (1.39) 0.88 0.38 Perceived stress of life events Holocaust survivors 5.50 (3.63) Comparisons 3.91 (4.14) 2.34 0.022 Daughters of Holocaust survivors 5.38 (4.93) Daughters of comparisons 4.44 (3.58) 0.79 0.43 Number of stressful life events Holocaust survivors 2.28 (1.65) Comparisons 1.69 (1.65) 1.54 0.13 Daughters of Holocaust survivors 2.51 (1.98) Daughters of comparisons 2.16 (1.82) 0.87 0.41

Note: Holocaust survivors, N ¼ 32; comparisons, N ¼ 33; daughters of Holocaust survivors, N ¼ 47; and daughters of comparisons, N ¼ 33.

Table 3. Predictors of Holocaust versus comparison group.

First-generation participants Second-generation participants Predictors Wald 2 Odds ratio 95% CI Wald 2 Odds ratio 95% CI

Dissociation experiences 5.35* 2.39 [1.14, 4.99] 0.09 1.09 [0.63, 1.88] Mental health 0.51 0.97 [0.91, 1.05] 0.41 0.98 [0.91, 1.05] SWL 5.26* 2.79 [1.16, 6.70] 0.33 1.25 [0.58, 2.70] Cognitive functioning 3.07 1.99 [0.92, 4.31] 1.33 0.92 [0.79, 1.06] Perceived physical health 0.02 0.81 [0.06, 10.97] 0.13 1.78 [0.08, 36.61] Physical health symptoms 0.15 0.79 [0.24, 2.63] 0.07 0.89 [0.37, 2.13] Perceived stress of life events 2.39 4.31 [0.68, 27.52] 0.14 0.77 [0.24, 11.85] Number of stressful life events 1.18 0.49 [0.14, 1.75] 0.28 1.69 [0.20, 2.97]

Notes: CI, confidence interval. First generation, N ¼ 64, and second generation, N ¼ 73. *p 5 0.05.

two groups on any of the variables measured. Here too multivariate logistic regression was conducted in order Associations between generations to predict whether a participant belonged to the Significant positive correlations were found between offspring of Holocaust survivors, or to the compar- Holocaust survivors and their daughters on the total isons. As displayed in Table 3, none of the variables sum of stressful life events, r ¼ 0.53, p 5 0.01: the more that were included in the logistic regression analysis stressful life events mothers (first generation) reported, predicted group membership of the second generation. the more did their daughters (second generation) 238 A. Fridman et al.

Table 4. Correlations between first and second generation.

Holocaust survivors Comparison subjects and and their daughters (N ¼ 79) their daughters (N ¼ 64)

Dissociation experiences 0.21 0.03 Mental Health Inventory 0.02 0.28 SWL 0.31 0.03 Cognitive questionnaire 0.29 0.12 Perceived physical health 0.15 0.17 Physical health 0.03 0.04 Perceived stress of life events 0.58** 0.09 Number of stressful life events 0.52** 0.17

Note: **p 5 0.01.

report such events. Also, when mothers reported more the first generation reported more stress because of stress of those life events, their daughters reported those life events, their daughters reported more stress more stress too r ¼ 0.42, p 5 0.05 (Table 4). 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. Discussion From a human life-span perspective, the main Holocaust survivors who were children during the developmental task of old age is to achieve ego Second World War, now in their 70s and 80s, showed integrity through acceptance of one’s life experiences, more dissociative symptomatology, less satisfaction and by integrating and balancing the positive and the with their life, more cognitive impairment, and they negative experiences. Failure to reach that end in this reported more stress associated with their recent life phase of life may result in despair or depression events as compared to a matched group of women their (Erikson, 1987). The resolution of this developmental age, also born in Europe but who migrated to pre-State task depends, however, on the successful mastering of of Israel with their parents just before the onset of the previous transitions through childhood, adolescent, Holocaust. SWL and dissociative symptomatology and adulthood, such as establishing trust in caring were associated with the Holocaust experiences in the persons and the wider social context, and achieving the multivariate analysis as well. Hence, Holocaust survi- capacity for intimate relationships. It is clear that the vors show markers of the traumatic experiences even Holocaust experiences destroyed the trajectory of almost seven decades after the Holocaust. Nonetheless, normal psychological development as all survivors in adult offspring of Holocaust survivors showed no our study lost their parents during the war (which was differences in their physical, psychological, and cogni- a condition for participation), leaving the child tive functioning as compared to matched controls. Our survivors confused, isolated, and despaired (Safford, current findings are consistent with the finding of the 1995). Furthermore, maybe integrating the Holocaust first phase of the study (Sagi-Schwartz et al., 2003), atrocities is not only impossible, but even not suggesting that Holocaust survivors still display post- adaptable (Danieli, 1981). For Holocaust survivors, traumatic stress symptoms, but that they do not lag integrating and in a sense accepting their traumatic behind in their mental health as compared to their experiences may appear antithetical to the justification counterparts. Furthermore, the remarkable resilience for their survival which is to serve as angry witnesses of of first-generation participants was manifested in the the outrage of the Holocaust (Krystal, 1981). absence of intergenerational transmission of trauma to Therefore, ego integrity might be at least partially the second generation. The adult offspring of survivors achieved through the role of being a ‘historian’ rather are not different from their comparisons on any of the than being a ‘victim’ (Safford, 1995), especially when assessments. Our findings therefore correspond with survivors share their personal testimony with family the meta-analytic studies, which indicate that although and others. survivors display posttraumatic symptomatology, The difficulties in integrating past experiences with there is no evidence of intergenerational transmission present challenges were indicated in the lower SWL of the trauma to their offspring in non-convenience that Holocaust survivors displayed as compared to samples like our sample (Van IJzendoorn et al., 2003). women who did not experience the Holocaust. Concerning the association between first and However, in contrast to studies that found that second generation we found that only the number of Holocaust survivors display more mental health recent life events and the subjective stress as a result of difficulties compared to comparisons (e.g., Amir these events seemed to be converging. The more & Lev-Weisel, 2003; Joffe, Brodaty, Luscombe, stressful life the first generation reported, the more & Ehrlich, 2003), we did not find such differences in life events their daughters had experienced, and when our study. The differences in SWL, along with the lack Aging & Mental Health 239 of differences in mental health, might be explained by cognitive failures in everyday life such as forgetting the differences between the measures: Life satisfaction appointments. Yehuda, Golier, Halligan, and Harvey is a conscious cognitive judgment of one’s life, (2004) also found that Holocaust survivors still according to a personal set of criteria, and it reflects suffering from posttraumatic stress showed impair- a global long-term perspective rather than specific, ments in learning and short-term memory as compared unconscious and affective ratings (Pavot & Diener, to survivors without PTSD and to comparisons that 1993). In contrast, the mental health index refers to the were not exposed to the Holocaust atrocities. prevalence of specific feelings and behavior experi- Taken together, SWL, dissociative symptomatol- enced during the last month (Florian & Drori, 1990). ogy and cognitive functioning appear to be related to As we are studying the long-term effects of childhood one another, and indicate a lack of cognitive– trauma in general and the challenges of coping with emotional ability of integrating past experiences in this past trauma in old age, the differences found in current life circumstances. Maybe the core of post- SWL may indicate more clearly the co-existence of traumatic stress of Holocaust survivors resides in their disturbing traumatic memories and the remarkable fragmented past. This might be because their safe and strength that Holocaust survivors demonstrate in their known environment suddenly became extremely threa- everyday life, leading normal and creative lives, and tening and hostile without rational explanation or successfully raising non-traumatized next generations. meaning, and because the duration of this situation Alongside integrating past and present, we found was unpredictable (Kahana et al., 1988). Therapies and higher levels of dissociative symptomatology among treatment may particularly address survivors’ integra- Holocaust survivors. Dissociative markers, defined as tion capacity, to create a more coherent life history the failure to integrate experiences such as memories (Krystal, 1981; Van der Hal-Van Raalte et al., 2008). and perceptions of reality that are normally associated In contrast to studies that reported more physical (Kennedy et al., 2004), characterize many psychologi- morbidity among Holocaust survivors (e.g., Amir & cal disorders, and it has been suggested to be the Lev-Weisel, 2003) we did not find such differences. mechanism that underlies the relation between early This discrepancy might be explained by differences in trauma and later psychopathology (Putnam, 1997). In sampling and design, as Barel et al. (in press) discuss in a meta-analytic study, dissociation, as measured by the their meta-analysis. Amir and Lev-Weisel (2003) for DES (Bernstein & Putnam, 1986), was found to be example relied on a convenience sample which was strongly associated with traumatic experiences (Van recruited through Holocaust survivors’ organizations IJzendoorn & Schuengel, 1996). Dissociation serves as in Israel. One of the strengths of the current study also a psychological defense mechanism as it prevents is the comparability of post-Holocaust life conditions further processing of raw materials so that memories of survivors and comparisons who might both have are stored in a fragmented way (Kennedy et al., 2004), suffered from traumatic events in Israel after the and therefore traumatic memories appear to differ Second World War in comparable ways. Holocaust from non-traumatic memories in terms of vividness, survivors reported higher stress related to recent life intrusiveness, and amnesias. Dissociative symptoms events, even though they did not experience more might be indexed by amnesia and memory symptoms, stressful life events. This subjective stress was also and by processing symptoms (Putnam, 1997). Amnesia found by Yehuda et al. (1998) in Holocaust offspring. and other memory problems can be manifested as A limitation of the current study is the use of only self- forgetfulness for well-known information, unexplain- report measures. It should be noted, however, that the able gaps in autobiographical recall, and problems findings are in line with other studies that used other with identifying the source of information. Dissociative measures such as interviews (Sagi-Schwartz et al., process symptoms may include depersonalization, 2003), and clinical diagnostic tools (Joffe et al., 2003), derealization, and hallucinations. and also with meta-analytic studies. A larger sample It is not surprising therefore, that cognitive would have increased the power of the statistical functioning is significantly affected by traumatic analyses to find more differences, but the power was experiences as evidenced in the assessment of impair- sufficient to detect medium size effects. Furthermore, ments in cognitive performance within the Holocaust the current study was limited to female survivors and survivors group. The observed impairment cannot be their female offspring, and replication in a male or due to normal aging processes, since their same-age mixed-gender sample is needed. Also, it has been comparisons showed higher cognitive functioning. Our suggested that Holocaust survivors would constitute a findings are consistent with studies that found cogni- specific selection of resilient individuals who have tive failures to be related to stress, for example through shown to be able to cope with the most extreme employee exhaustion (Van der Linden, Keijsers, Eling, traumatic events. However, we would like to stress the & Van Schaijk, 2005), and related to posttraumatic fact that perishing in the Holocaust by no means can stress because of child maltreatment (Goodman, Quas, be seen as indicative of lesser resilience. In most & Ogle, 2009). Boals (2008) recently found that likelihood it was impossible to escape or survive such Holocaust survivors with higher levels of posttrau- an industrially planned and conducted genocide with- matic symptoms (i.e., intrusiveness and avoidance of out sheer luck, especially when we think about infants traumatic thoughts) were more likely to suffer from and children. A last limitation is that Holocaust 240 A. Fridman et al. survivors have been studied intensively and some of the way for a more balanced life of generations to our participants might have been included in previous come. studies. The effects of repeated testing are unknown. Future studies may further investigate the under- lying mechanisms of protective and risk factors of Acknowledgments developing posttraumatic symptoms after extreme experiences. Such mechanisms could reside in the The generous support of the German-Israel Foundation for Research and Development (GIF 279) and the Koehler epigenetics of trauma (McGowan et al., 2009) or in Stiftung (Munich, Germany) to Avi Sagi-Schwartz, Klaus gene-environment interactions underlying the emer- Grossmann and Marinus van IJzendoorn is deeply appre- gence of posttraumatic stress reactions. A study ciated. Marinus van IJzendoorn and Marian Bakermans- examining Rwandan survivors (de Quervain et al., Kranenburg were supported by research awards from the 2007) supports the claim for a genetic role in the Netherlands Organization for Scientific Research (NWO predisposition to develop post-traumatic symptoma- SPINOZA prize and VIDI grant no. 452-04-306, respec- tively). We would like to thank our research assistants Tali tology. Also, the effect of trauma on neurobiological Grossman, Sigal Haimovich and Yamit Ophir Goldstein for functioning (e.g., cortisol secretion) should be further their dedicated and sensitive involvement in the project. examined. Diurnal cortisol patterns were explored Special thanks go to Sarit Alkalay for her valuable among Holocaust survivors showing dysregulation in contribution to the study. 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., References 2000; Yehuda, Golier, & Kaufman, 2005) in partici- pants suffering from PTSD. Dissociation is generally Amir, M., & Lev-Wiesel, R. (2003). Time does not heal all considered to be a disorder, but an important question wounds: Quality of life and psychological distress of for future investigations is whether developing some people who survived the Holocaust as children 55 years form of amnesia for the extreme traumatic experiences later. Journal of Traumatic Stress, 16, 295–299. of the Holocaust is adaptive as for example Breznitz Antonovsky, A., Maoz, B., Dowty, N., & Wijsenbeek, H. (1982) argued. Removing traumatic memories from (1971). Twenty-five years later: A limited study of the one’s mind may result in reduced hyper vigilance, sequelae of the concentration camp experience. Social normal cortisol levels, and reduced fight or flight , 6, 186–193. Baider, L., Peretz, T., Hadani, P.E., Perry, S., Avramov, R., responses, all of which might be adaptive. Perhaps the & De-Nour, A.K. (2000). Transmission of response to concept of ‘ego integration’ as applied to survivors of trauma? Second generation Holocaust survivors’ reaction extreme trauma may be less feasible than currently to cancer. American Journal of Psychiatry, 157, 904–910. thought. Alternatively, dissociation of traumatic mem- Barel, E., Van IJzendoorn, M.H., Sagi-Schwartz, A., & ories might have short-term benefits (for raising the Bakermans-Kranenburg, M.J. (in press). Surviving the next generation) and at the same time long-term Holocaust: A meta-analysis of the long-term sequelae of damage (to the individual’s neurobiological genocide. 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