Aging of Child Holocaust Survivors
Numerous studies focus on the influence of Holocaust experiences on child survivors more than 60 years after the Holocaust. Our own treatment and research group investigated issues as diverse as development of dementia, suicide and psychiatric services used by survivors (Ohanna, Golander, & Barak, 2011; Barak, 2007; Barak et al., 2005; Barak, & Szor, 2000; Terno, Barak, Hadjez, Elizur, & Szor, 1998). The findings can shed more light on whether early childhood trauma might leave specific psychological and neurophysiological markers in later life of victims of such atrocious experiences. Since. Dvorjetzky published his seminal work, “Psychociological problems of Jewish children hidden by non-Jews during the Holocaust” in 1966 (Dvorjetzky, 1966), there have been 246 clinical and research publications focusing on the issue.
Results of these studies show that psychological and cognitive markers of trauma experienced during childhood are observed even 60 years after the trauma when Holocaust child survivors are in the elderly phase of life. Holocaust child survivors (now aging adults) report more dissociative symptoms in everyday life, less satisfaction with their lives, and they also perceive their life events as more stressful as compared to a matched group of adults, also born in Europe but who migrated with their parents just before the onset of the Holocaust to the country that in 1948 became the State of Israel. Moreover, these survivors show more cognitive impairment than their peers who were not Holocaust survivors. The findings are consistent and supported by recent meta-analytic findings (Barel, Van IJzendoorn, Sagi-Schwartz, & Bakermans-Kranenburg, 2010).
Nevertheless, traumatic experiences may go under the skin. Below the seemingly unruffled surface of more or less adequate adaptation to post-war conditions, traumatized individuals might be more vulnerable to stressful circumstances as a consequence of a poorly regulated neurobiological stress system. In particular the Hypothalamic-Pituitary-Adrenal (HPA) system regulating physiological stress may be affected by negative experiences in early childhood. Early Holocaust related traumatization is associated with changed HPA-axis functioning 60 years later. Holocaust child survivors display elevated levels of cortisol secretion immediately before the onset of the stress procedure, followed by a strong decline of cortisol levels 20 minutes after the onset of the stress procedure. The elevated level of cortisol that was found among survivors prior to the induced stress procedure might point to survivors’ increased alertness to anticipated stress (van der Hal-Van Raalte, Bakermans-Kranenburg, & van IJzendoorn, 2008; Yehuda, Halligan, & Bierer, 2002).
It is possible that the ongoing struggle for survival during childhood in the shadow of the Holocaust forced survivors to be constantly alert and to try to adapt quickly to new circumstances, in particular in anticipation of any activity signaling weakness or danger. Although such a stress response might promote survival, in the long run, if activated repeatedly, an overactive HPA axis may exert detrimental effects on health.
Taken together, findings published since the 1960’s converge with meta-analytic studies of Holocaust child survivors which show respectively that Holocaust survivors display considerably more posttraumatic stress symptoms than comparisons without Holocaust background (Amir & Lev-Wiesel, 2003).
Attachment theory has been suggested as a conceptual framework for explaining variance in the coping strategies of adults who did or did not experience early separation from their primary caregivers. Early separation from caregivers and disruption of close and intimate relationships might result in long-term difficulties with coping with stress. Studies suggest that such scars that began more than 60 years ago might never fully heal, as apparent from both psychological and neuro-biological functioning with regard to stress regulation. Early separation from both parents during World War II was recently found to be related to high levels of cortisol secretion in response to stress. According to attachment theory, children’s coping styles are related to caregivers’ representations of their past and caregivers’ behavior, especially in stressful situations (Durst, 2003; Krell, 1985).
The effects of the Holocaust on the second and third generations of the offspring of survivors have been discussed extensively in scientific literature in Israel and abroad, particularly with regard to behavioral and mental aspects. However, very little is known about survivors’ physical health. Research suggests that pregnancy in times of hunger and stress, which were an integral part of life during the Holocaust and affected the health of the survivors, may also have affected the health of their offspring, not only in the immediate postnatal period but throughout their adult lives. Of particular interest is the possible emergence of medical problems later in life, such as diabetes and cardiovascular and bone disease. Moreover, there are indications that this effect does not stop at first-generation offspring but continues to affect the second and third generations as well. It is therefore possible that the Holocaust scarred not just the millions of people who lived through it but its stigmata are passed on to their children and children’s children (Sperling, Kreil, & Biermann, 2012).
Cardiovascular morbidity, particularly death from ischemic heart disease, was inversely related to birth weight. The existence of such a connection is acknowledged nowadays by most investigators, and recent studies fully substantiate it. Risk factors for atherosclerosis are higher in low birth-weight children. In addition, the prevalence of type II diabetes in adults is inversely related to birth weight and Ponderal Index, and the lower the weight the higher the rates of diabetes 50 years later. Epidemiological studies provide ample evidence that low birth weight and hypertension are similarly connected. Follow-up of children born during World War II in hunger-stricken areas corroborates this observation (Cohen, Brom, & Dasberg, 2001; Hazani & Shasha, 2008).
Post-Traumatic Stress Disorder Effects on Brain Aging and Dementia
Forty years ago in a relatively obscure Polish journal, Ryn published his observations on former prisoners of the Nazi concentration camps (Ryn, 1972). He reported being able to distinguish characteristic phases during the life-cycle in the evolution of their suffering, emphasizing premature aging in late life and an organic impairment of the central nervous system. He concluded his clinical testimonial by writing:”…the camp stress has left in human nature traces so painful that they cannot disappear when the generation of former prisoners is gone” (Ryn, 1972). However, the premature aging and organic phase late in the course of post-traumatic stress disorder (PTSD) were not noted or extensively researched. It was only recently that new research showing that PTSD significantly increases the risk for dementia in later life has come to light (Yaffe et al., 2010).
Yaffe and colleagues, in the first study to show the association between PTSD and dementia, found that older veterans with PTSD had nearly a two-fold increased risk for dementia compared to their counterparts without PTSD. Their findings show that veterans with PTSD developed new cases of dementia at a rate of 10.6% over seven years of follow-up, versus 6.6% of those without PTSD. In addition, PTSD did not appear to be associated with a particular dementia type but rather had an across-the-board effect for all dementias, including vascular dementia and Alzheimer’s disease. To examine the question of whether PTSD might carry an increased risk for dementia, these researchers used data from the Department of Veterans Affairs National Patient Care Database. The retrospective cohort study included 181,093 veterans aged 55 years and older without dementia at baseline and compared rates of newly diagnosed dementia or cognitive impairment in 53,155 subjects with a diagnosis of PTSD and 127,938 subjects without PTSD. Subjects’ mean age at baseline was 68.8 years, and the great majority were male. After adjustment for demographics and medical and psychiatric comorbidities, PTSD patients were still nearly twice as likely to develop incident dementia (HR, 1.77; 95% CI, 1.7 – 1.9). The results were similar when investigators excluded subjects with a history of traumatic brain injury, substance abuse, or depression. Because the study is the first to show this association, these findings need to be replicated (Yaffe et al., 2010). Thus, Ryn’s keen clinical observations noted forty years ago have become a major issue for researchers and clinicians treating the elderly as modern research underlines the need to clarify the complex association between PTSD and the risk of dementia.
It is established that persons who have a history of severe and prolonged trauma, such as exposure to genocide, combat, captivity and torture, may continue to experience physical and mental health problems as they age. Given the neurochemical, neurological, and neuropsychological impairments that appear to accompany PTSD, several investigators have suggested that severe and prolonged trauma or a history of PTSD may place aging individuals at increased risk of cognitive decline and inception of dementia. It has been observed that former prisoners of war and survivors of Nazi concentration camps may demonstrate concomitant neuropsychological disorders decades after the traumatic experience, with a possible increase in rate of cognitive decline and risk of dementia. Many investigators have documented deficits in memory performance in trauma survivors with PTSD, although a great variability across studies and questions regarding the associations between memory impairments and trauma exposure remain unanswered. The Traumatic Stress Studies Program research group at Mount Sinai School of Medicine in New York has reported memory changes in PTSD late in life not previously observed in young trauma survivors. Both Holocaust survivors and elderly combat veterans show reductions in performance on performance and total learning in contrast to younger participants with PTSD. The similarity in deficits between combat veterans and Holocaust survivors taken together with a more pronounced negative correlation between age and learning deficits in Holocaust survivors with PTSD may be viewed as supporting evidence for an accelerated age-related decline in aging trauma survivors with PTSD (Yehuda et al., 2007).
There are a number of plausible explanations for the association besides the obvious one of head trauma causing both PTSD and vulnerability to subsequent cognitive impairment. Many of the protective factors we acquire during development are not available to victims of mass violence, prolonged war or Holocaust survivors, while they accumulate risk factors. The lack of education, severe hunger, exposure to central nervous system infections, elevated homocysteine levels and chronic activation of glucocorticoid secretion are all involved in the excessive risk. As these victims of massive trauma become adults and then age, many acquire so-called secondary risk factors for dementia such as diabetes, cardiovascular disease, nicotine and alcohol abuse, depression and reduced social networks.
There are several major studies that form the scientific infrastructure to the claim put forward that PTSD – especially exposure to massive prolonged trauma – constitutes a risk factor to the development of dementia. First, Hasegawa proposed the following hypothesis: the physiological functions of amyloid beta and amyloid precursor protein have been greatly clarified in the last decade (Hardy & Selkoe, 2002). In particular, one of its functions is of importance for synaptic plasticity. Extracellular amyloid beta may suppress synaptic plasticity or inhibit long-term potentiation (LTP) from outside the cell. LTP is considered one of the major molecular bases of memory. Amyloid beta may induce the inhibition or loss of memory (Hasegawa, 2007). If indeed amyloid beta has a truly physiological function such as to suppress LTP, then how does this physiological function of amyloid beta induce Alzheimer’s disease? Recent observations document that homocysteic acid is part of the cascade leading to accumulation of amyloid beta into neurons, suggesting that its physiological function is inhibited by homocysteic acid through this very accumulation. In addition, these researchers observed that homocysteic acid induced hypermethylation of the alpha-synuclein protein in the presence of excess methionine, and this hypermethylation is overexpressed with aging process (Hardy & Selkoe, 2002). Thus, Hasegawa hypothesized that prolonged stress induces pathological changes in the elderly typical of Alzheimer’s disease (Hasegawa, 2007).
Early in 2008, Levine and colleagues demonstrated the presence of elevated serum homocysteine levels in male patients with PTSD. The group tested total serum homocysteine levels in 28 male patients with PTSD compared to those of 223 healthy controls. The effects of PTSD diagnosis and duration of illness on serum homocysteine level were significant (Levine et al., 2008). Second, Sutker and colleagues evaluated former prisoners of war from both the Korean Conflict and World War II with special focus on confinement weight losses. High weight-loss subjects performed more poorly than combat veterans on a wide battery of cognitive tests including IQ. The authors conclude that their findings support the hypothesis that severity of stress reflected by trauma-induced weight loss is predictive of long-term compromise in cognitive performance (Sutker, Galina, West, & Allain, 1990).
Finally, smaller hippocampal volume has been observed in young and middle-aged adults with chronic PTSD. These alterations may put trauma survivors with PTSD at greater risk for cognitive decline in later life. One postmortem and one MRI study support this contention. Bracha and colleagues investigated whether war-related PTSD is associated with a postmortem change in neuronal counts in the locus coeruleus, relying on the demonstrations that enhanced central nervous system noradrenergic postsynaptic responsiveness has been shown to contribute to PTSD. Three veterans with PTSD were found to have substantially lower locus coeruleus neuronal counts compared to four comparison subjects. The very small sample size warrants larger neuromorphometric studies in veterans and other victims of mass trauma (Bracha, Garcia-Rill, Mrak, & Skinner, 2005). Nevertheless, an MRI study undertaken by Yehuda and colleagues examined whether there are PTSD-related differences in hippocampal volume in middle-aged and elderly veterans. Seventeen veterans with chronic PTSD and 16 veterans without chronic PTSD agreed to an MRI scan. Veterans with PTSD did not differ from those without PTSD in hippocampal volume, but smaller left hippocampal volumes were observed in veterans who developed PTSD in response to their first reported traumatic exposure. The authors concluded that although hippocampal volume was not found to differ between subjects with and without PTSD, smaller hippocampal volumes in PTSD may be associated with specific risk and resilience factors (Yehuda et al., 2007).
Coping in Old Age with Extreme Childhood Trauma
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. Child Holocaust survivors show more dissociative symptomatology (odds ratio 2.4) and less satisfaction with their life (odds ratio 2.8) as compared to matched groups. Holocaust survivors still display post-traumatic stress symptoms almost seventy years after the trauma (Lis-Turlejska, Luszczynska, Plichta, & Benight, 2008).
The Holocaust that took place during World War II and was 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 in countries like Cambodia, Nigeria, Rwanda, Sudan, and former Yugoslavia.
Childhood trauma may leave survivors more vulnerable when they are facing stress related to old age. 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 experiences. Moreover, signs of unresolved trauma or loss might emerge again as an expression of loss of significant others and the survivors’ own impending death. 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. This man-made catastrophe was characterized by an environment that was extremely threatening and dangerous with no rational explanation or meaning.
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. Many studies documented the survivors’ syndromes, meaning that Holocaust survivors suffer from severe and enduring psychological effects of the massive trauma, manifested as chronic anxiety, depression, disturbances in cognition and memory, tendency to isolation, guilt, low psychological well-being, and difficulties in emotional expression. In a recent meta-analysis involving 12,746 participants from 71 samples, Holocaust survivors were compared to their counterparts on physical health, psychological well-being, post-traumatic stress symptoms, psychopathological symptomatology, cognitive functioning, and stress-related physiology. Results showed that even in non-select samples (i.e., drawn from population-wide demographic information) child Holocaust survivors showed substantially more post-traumatic stress symptoms than comparisons (Barel, Van IJzendoorn, Sagi-Schwartz, & Bakermans-Kranenburg, 2010).
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. Many researchers demonstrate that although many survivors demonstrated resilience and adaptability, 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. 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. Already in the 1990s it was found that the main explanation for aging child Holocaust survivors’ lower subjective well-being was their poorer capacity to integrate their past experiences and present goals. Given the advancing age of child 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 rapidly dying and disappearing.
Holocaust survivors who were children during the Second World War and are now in their 70s and 80s show more dissociative symptomatology, less satisfaction with their lives, more cognitive impairment, and they report more stress associated with their recent life events as compared to matched groups of adults their age who were also born in Europe but who migrated to what became the State of Israel with their parents just before the onset of the Holocaust. Child Holocaust survivors show markers of the traumatic experiences even almost seven decades after the Holocaust. 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 negative experiences. Failure to reach that end in this phase of life may result in despair or depression. 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 many child survivors lost their parents during the war, leaving them confused, isolated, and full of despair. Furthermore, perhaps integrating Holocaust atrocities is not only impossible, but not even adaptable. For child 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. Alongside the difficulty of integrating past and present experiences, higher levels of dissociative symptomatology among child Holocaust survivors is found. Dissociative markers, defined as the failure to integrate experiences such as memories and perceptions of reality that are normally associated, characterize many psychological disorders, and it has been suggested to be the mechanism that underlies the relation between early childhood trauma and later psychopathology.
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 to integrate past experiences with current life circumstances. Maybe the core of post-traumatic stress of child 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. 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 possible 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 child 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 child survivors show, they are unable to integrate their past and present challenges (Brom, 2001; Valent, 1998).
The surviving children of the Holocaust are now elderly and attempting to integrate their horrid life experiences into a semblance of sanity. The papers herein translated and the studies reviewed in the introduction all emphasize one truth: the Holocaust deprived the child survivors of a peaceful legacy. The aging of child survivors is a period of severe emotional and psychiatric impairment. It is my clinical and research experience, as well as studies reported widely in the scientific literature, that establishes the life-long damages caused to child survivors of the Holocaust (Barak, 2007; (Barak et al., 2005; Barak, & Szor, 2000; Terno, Barak, Hadjez, Elizur, & Szor, 1998; Robinson, Rapaport-Bar-Sever, & Rapaport, 1994).
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, 16,295-299.
Barak, Y., & Szor, H. (2000). Lifelong posttraumatic stress disorder: evidence from aging Holocaust survivors. Dialogues in Clinical Neuroscience,2,57-62.
Barak, Y., Aizenberg, D., Szor, H., Swartz, M., Maor, R., & Knobler, H.Y. (2005). Increased risk of attempted suicide among aging Holocaust survivors. American Journal of Geriatric Psychiatry, 13,701-704.
Barak, Y. (2007). The aging of Holocaust survivors: myth and reality concerning suicide. Israel Medical Association Journal, 9,196-198.
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 a genocide. Psychological Bulletin, 136,677-698.
Bracha, H.S., Garcia-Rill, E., Mrak, R.E., & Skinner, R. (2005). Postmortem locus coeruleus neuron count in three American veterans with probable or possible war-related PTSD. Journal of Neuropsychiatry and Clinical Neuroscience, 17,503-509.
Brom, D. (2001). The consequences of the Holocaust on child survivors and children of survivors. Israel Journal of Psychiatry and Related Sciences, 38,1-2.
Cohen, M., Brom, D., & Dasberg, H. (2001). Child survivors of the Holocaust: symptoms and coping after fifty years. Israel Journal of Psychiatry and Related Sciences, 38,3-12.
Durst, N. (2003). Child-survivors of the Holocaust: age-specific traumatization and the consequences for therapy. American Journal of Psychotherapy, 57,499-518.
Dvorjetzky, M. (1966). Psychociological problems of Jewish children hidden by non-Jews during the Holocaust. Dapim Refuiim, 25,244-250.
Hardy, J., & Selkoe, D.J. (2002). The amyloid hypothesis of Alzheimer’s disease: progress and problems on the road to therapeutics. Science, 19(5580), 353-356.
Hasegawa, T. (2007). Prolonged stress will induce Alzheimer’s disease in elderly people by increased release of homocysteic acid. Medical Hypotheses, 69,1135-1139.
Hazani, E., & Shasha, S.M. (2008). Effects of the Holocaust on the physical health of the offspring of survivors. Israel Medical Association Journal, 10,251-255.
Krell, R. (1985). Child survivors of the holocaust: 40 years later. Introduction. Journal of the American Academy of Child Psychiatry, 24,378-380.
Levine, J., Timinsky, I., Vishne, T., Dwolatzky, T., Roitman, S., Kaplan, Z., Kotler, M., Sela, B.A, & Spivak, B. (2008). Elevated serum homocysteine levels in male patients with PTSD. Depression and Anxiety, 25,154-157.
Lis-Turlejska, M., Luszczynska, A., Plichta, A., & Benight, C.C. (2008). Jewish and non-Jewish World War II child and adolescent survivors at 60 years after war: effects of parental loss and age at exposure on well-being. American Journal of Orthopsychiatry, 78,369-377.
Ohanna, I., Golander, H., & Barak, Y. (2011). Does late onset depression predispose to dementia? A retrospective, case-controlled study. Comprehensive Psychiatry. 52,659-661.
Robinson, S., Rapaport-Bar-Sever, M., & Rapaport, J. (1994). The present state of people who survived the Holocaust as children. Acta Psychiatrica Scandinavia, 89,242-245.
Ryn, Z. (1972). Is Auschwitz still a reality? Psychiatric reflections. Przegl Lek, 29(1), 206-210.
Sperling, W., Kreil, S., & Biermann, T. (2012). Somatic diseases in child survivors of the Holocaust with posttraumatic stress disorder: a comparative study. Journal of Nervous and Mental Disorders, 200,423-428.
Sutker, P.B., Galina, Z.H., West, J.A., & Allain, A.N. (1990). Trauma-induced weight loss and cognitive deficits among former prisoners of war. Journal of Consulting Clinical Psychology, 8(3),323-328.
Terno, P., Barak, Y., Hadjez, J., Elizur, A., & Szor, H. (1998). Holocaust survivors hospitalized for life: the Israeli experience. Comprehensive Psychiatry, 39,364-367.
Valent, P. (1998). Resilience in child survivors of the Holocaust: toward the concept of resilience. Psychoanalytical Review, 85,517-535.
van der Hal-Van Raalte, E.A., Bakermans-Kranenburg, M.J., & van IJzendoorn, M.H. (2008). Diurnal cortisol patterns and stress reactivity in child Holocaust survivors reaching old age. Aging and Mental Health, 12,630-638.
Yaffe, K., Vittinghoff, E., Lindquist, K., Barnes, D., Covinsky, K.E., Neylan, T., Kluse, M., & Marmar, C. (2010). Posttraumatic stress disorder and risk of dementia among US veterans. Archives of General Psychiatry, 67,608-613.
Yehuda, R., Halligan, S.L., & Bierer, L.M. (2002). Cortisol levels in adult offspring of Holocaust survivors: relation to PTSD symptom severity in the parent and child. Psychoneuroendocrinology, 27,171-180.
Yehuda, R., Golier, J.A., Tischler, L., Harvey, P.D., Newmark, R., Yang, R.K., & Buchsbaum, M.S. (2007). Hippocampal volume in aging combat veterans with and without post-traumatic stress disorder: relation to risk and resilience factors. Journal of Psychiatry Research, 41,435-445.