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
a
Center for the Study of Child Development, University of Haifa, Haifa, Israel; bCentre for Child and Family Studies,
Leiden University, Leiden, The Netherlands
(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
During the last 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 (SWL), mental health, cognitive abilities,
*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
dissociative symptoms, and physical health. This 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.
Aging & Mental Health
The possibilities to reduce the threat or stress were very
limited (E. Kahana, B. 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, in press;
Bar-on
et
al.,
1998;
Van
IJzendoorn,
Bakermans-Kranenburg, & 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, 1986), 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., Barel
et al., in press; Leon, Butcher, Kleinman, Goldberg, &
Almagor, 1981). Survivors managed to build families
and to establish social relationships (Harel, B. Kahana,
& E. Kahana, 1993). In a recent meta-analysis
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 stressrelated physiology (Barel et al., in press). 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, & BakermansKranenburg, 2008; Van IJzendoorn et al., 2003). In a
meta-analytic study on 32 samples with 4418 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 quasi-experimental study with
carefully matched Holocaust survivors, their daughters
233
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, BinderBrynes, 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
et al., 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 50s and 60s, 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
234
A. Fridman et al.
(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 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 12–15
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.
Methods
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 ¼ 76.98,
SD ¼ 2.99). Of the 104 second-generation 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 ¼ 47.46, SD ¼ 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 complete 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 (Peña, 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 0.86 for
first generation, and 0.83 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 six-point Likert scale the extent
to which they experienced feelings of distress and
Aging & Mental Health
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
0.84 for the first generation, and 0.95 for the second
generation.
Satisfaction with life
SWL scale is a five-item questionnaire designed to
assess SWL as a whole (Pavot & Diener, 1993). Using
seven-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 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
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 ¼ 0.28 for the
first generation ( p 5 0.05), and r ¼ 0.68 for the second
generation ( p 5 0.01).
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, 1994).
235
Life events
The Life Events questionnaire was developed for this
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 threepoint 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 ¼ 0.91 ( p 5 0.01) for the first generation, and r ¼ 0.93 ( p 5 0.01) 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 SD ¼ 3.29 above the mean
or smaller than SD ¼ 3.29 under the mean (Tabachnick
& Fidell, 2007). Physical health, stressful life events,
and dissociation distributions were moderately positively skewed, and square-root transformation was
used for the analysis. The distributions of the variables
SWL 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
log 10 transformation was used since the distribution
was substantially negatively skewed. For the DES 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
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 five-point Likert scale ranging
from 1 ¼ very unhealthy to 5 ¼ 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 ¼ 0.62
( p 5 0.01) for the first generation, and r ¼ 0.27
( p 5 0.05) for the second generation.
Possible differences in mortality between Holocaust
survivors and comparison subjects were tested.
A chi-squared test showed no differences between the
two groups 2 (1, N ¼ 104) ¼ 0.44, p ¼ 0.74. 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) ¼ 2.07, p ¼ 0.04 (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) ¼ 2.99,
p 5 0.05. However, no differences were found for
daughters of Holocaust survivors and comparison
subjects.
236
A. Fridman et al.
Table 1. Holocaust survivors and comparison subjects: between samples analysis.
Measure
Unresolved state of mind
Unusual beliefs
Intrusion
Avoidance
Autonomic anxiety
Cognitive worry
Well-being
Group
Participated in
phase 2 M (SD)
Holocaust survivors
Comparisons
Daughters of Holocaust survivors
Daughters of comparisons
Holocaust survivors
Comparisons
Daughters of Holocaust survivors
Daughters of comparisons
Holocaust survivors
Comparisons
Daughters of Holocaust survivors
Daughters of comparisons
Holocaust survivors
Comparisons
Daughters of Holocaust survivors
Daughters of comparisons
Holocaust survivors
Comparisons
Daughters of Holocaust survivors
Daughters of comparisons
Holocaust survivors
Comparisons
Daughters of Holocaust survivors
Daughters of comparisons
Holocaust survivors
Comparisons
Daughters of Holocaust survivors
Daughters of comparisons
17.93 (7.26)
13.24 (5.61)
15.67 (4.93)
15.54 (7.37)
34.64 (14.09)
26.45 (8.69)
35.53(11.67)
32.90 (9.65)
21.41 (7.98)
18.45 (8.18)
16.28 (6.52)
17.42 (6.47)
22.14 (8.67)
15.35 (6.80)
15.65 (6.91)
14.48 (5.89)
15.83 (6.93)
13.16 (5.57)
12.56 (3.63)
12.55 (3.96)
15.06 (5.01)
14.39 (6.19)
14.30 (4.35)
13.39 (4.69)
56.00 (10.56)
59.23 (9.25)
53.98 (10.18)
56.48 (8.85)
Did not participate
in phase 2 M (SD)
15.28
15.16
17.19
13.35
26.72
29.74
38.20
31.11
20.00
17.84
13.40
17.84
19.50
12.58
13.60
13.95
18.56
12.95
14.00
13.16
15.94
13.63
14.00
13.21
52.06
49.79
52.00
58.53
(4.86)
(4.70)
(5.45)
(4.67)
(8.64)
(11.54)
(11.82)
(10.35)
(8.31)
(8.14)
(3.85)
(7.16)
(7.49)
(3.85)
(3.36)
(6.16)
(7.77)
(4.18)
(4.85)
(5.37)
(7.78)
(4.57)
(2.45)
(5.17)
(14.47)
(11.67)
(15.83)
(9.29)
t
p
1.38
1.24
0.64
1.16
2.07
1.14
0.48
0.62
0.58
0.26
0.98
0.22
1.05
1.84
1.12
0.31
1.24
0.14
0.81
0.46
0.47
0.46
0.15
0.12
1.07
2.99
0.39
0.78
0.18
0.22
0.52
0.25
0.04
0.26
0.63
0.54
0.57
0.80
0.33
0.83
0.30
0.07
0.29
0.76
0.22
0.89
0.42
0.65
0.64
0.65
0.88
0.90
0.29
0.005
0.70
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
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) ¼ 5.36, p 5 0.05 and no
difference in level of well-being, F(1, 58) ¼ 0.86,
p ¼ 0.36. Second-generation participants (both daughters of Holocaust survivors and daughters of comparisons) did not show stability in their mental health F(1,
72) ¼ 1.89, p ¼ 0.17, and no significant differences were
found for the level of mental health between the two
phases F(1, 72) ¼ 0.04, p ¼ 0.85.
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) ¼ 2.19, p 5 0.05, they were less satisfied with
their lives, t (63) ¼ 3.38, p 5 0.01, they suffered from
more cognitive impairments than comparison subjects,
t (63) ¼ 2.08, p 5 0.05, and they perceived their life
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 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 2 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,
SWL (odds ¼ 2.79, p 5 0.05) and dissociative experiences (odds ¼ 2.39, p 5 0.05) 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
237
Aging & Mental Health
Table 2. Holocaust survivors, their daughters, and comparison subjects statistic.
Measure
Dissociation experiences
Mental health
SWL
Cognitive functioning
Perceived physical health
Physical health symptoms
Perceived stress of life events
Number of stressful life events
Group
M (SD)
Holocaust survivors
Comparisons
Daughters of Holocaust survivors
Daughters of comparisons
Holocaust survivors
Comparisons
Daughters of Holocaust survivors
Daughters of comparisons
Holocaust survivors
Comparisons
Daughters of Holocaust survivors
Daughters of comparisons
Holocaust survivors
Comparisons
Daughters of Holocaust survivors
Daughters of comparisons
Holocaust survivors
Comparisons
Daughters of Holocaust survivors
Daughters of comparisons
Holocaust survivors
Comparisons
Daughters of Holocaust survivors
Daughters of comparisons
Holocaust survivors
Comparisons
Daughters of Holocaust survivors
Daughters of comparisons
Holocaust survivors
Comparisons
Daughters of Holocaust survivors
Daughters of comparisons
7.13
5.03
7.23
7.19
54.59
59.15
58.13
60.41
23.91
27.64
26.21
28.41
30.91
34.21
39.15
40.16
3.44
3.61
4.34
4.30
5.94
4.82
1.21
1.09
5.50
3.91
5.38
4.44
2.28
1.69
2.51
2.16
t
(4.46)
(4.89)
(5.52)
(5.73)
(8.17)
(10.63)
(10.16)
(10.29)
(4.81)
(4.79)
(6.16)
(4.54)
(6.67)
(5.21)
(3.85)
(3.09)
(1.04)
(0.93)
(0.74)
(0.89)
(3.03)
(2.95)
(1.41)
(1.39)
(3.63)
(4.14)
(4.93)
(3.58)
(1.65)
(1.65)
(1.98)
(1.82)
p
2.19
0.03
0.07
0.94
1.93
0.06
0.97
0.33
3.38
0.001
1.68
0.09
2.08
0.041
1.23
0.22
0.63
0.53
0.04
0.97
1.57
0.12
0.88
0.38
2.34
0.022
0.79
0.43
1.54
0.13
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
Predictors
Dissociation experiences
Mental health
SWL
Cognitive functioning
Perceived physical health
Physical health symptoms
Perceived stress of life events
Number of stressful life events
2
Second-generation participants
Wald Odds ratio
95% CI
Wald 2
Odds ratio
95% CI
5.35*
0.51
5.26*
3.07
0.02
0.15
2.39
1.18
2.39
0.97
2.79
1.99
0.81
0.79
4.31
0.49
[1.14, 4.99]
[0.91, 1.05]
[1.16, 6.70]
[0.92, 4.31]
[0.06, 10.97]
[0.24, 2.63]
[0.68, 27.52]
[0.14, 1.75]
0.09
0.41
0.33
1.33
0.13
0.07
0.14
0.28
1.09
0.98
1.25
0.92
1.78
0.89
0.77
1.69
[0.63, 1.88]
[0.91, 1.05]
[0.58, 2.70]
[0.79, 1.06]
[0.08, 36.61]
[0.37, 2.13]
[0.24, 11.85]
[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
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.
Associations between generations
Significant positive correlations were found between
Holocaust survivors and their daughters on the total
sum of stressful life events, r ¼ 0.53, p 5 0.01: the more
stressful life events mothers (first generation) reported,
the more did their daughters (second generation)
238
A. Fridman et al.
Table 4. Correlations between first and second generation.
Holocaust survivors
and their daughters (N ¼ 79)
Comparison subjects and
their daughters (N ¼ 64)
0.21
0.02
0.31
0.29
0.15
0.03
0.58**
0.52**
0.03
0.28
0.03
0.12
0.17
0.04
0.09
0.17
Dissociation experiences
Mental Health Inventory
SWL
Cognitive questionnaire
Perceived physical health
Physical health
Perceived stress of life events
Number of stressful life events
Note: **p 5 0.01.
report such events. Also, when mothers reported more
stress of those life events, their daughters reported
more stress too r ¼ 0.42, p 5 0.05 (Table 4).
Discussion
Holocaust survivors who were children during the
Second World War, now in their 70s and 80s, 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 pre-State
of Israel with their parents just before the onset of the
Holocaust. SWL 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 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 SWL
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 SWL, along with the lack
Aging & Mental Health
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 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
SWL 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
DES (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 well-known 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
239
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 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, SWL, 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 et al. (in press) 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 et al. (1998) in Holocaust offspring.
A limitation of the current study is the use of only selfreport 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
mixed-gender 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
240
A. Fridman et al.
survivors have been studied intensively and some of
our participants might have been included in previous
studies. The effects of repeated testing are unknown.
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.
Acknowledgments
The generous support of the German-Israel Foundation for
Research and Development (GIF 279) and the Koehler
Stiftung (Munich, Germany) to Avi Sagi-Schwartz, Klaus
Grossmann and Marinus van IJzendoorn is deeply appreciated. Marinus van IJzendoorn and Marian BakermansKranenburg were supported by research awards from the
Netherlands Organization for Scientific Research (NWO
SPINOZA prize and VIDI grant no. 452-04-306, respectively). We would like to thank our research assistants Tali
Grossman, Sigal Haimovich and Yamit Ophir Goldstein for
their dedicated and sensitive involvement in the project.
Special thanks go to Sarit Alkalay for her valuable
contribution to the study.
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, 295–299.
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, 186–193.
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, 904–910.
Barel, E., Van IJzendoorn, M.H., Sagi-Schwartz, A., &
Bakermans-Kranenburg, M.J. (in press). Surviving the
Holocaust: A meta-analysis of the long-term sequelae of
genocide. Psychological Bulletin.
Bar-on, D., Eland, J., Kleber, R.J., Krell, R., Moore, Y.,
Sagi,
A., . . . , Von
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, 315–338.
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, 381–386.
Bernstein, E.M., & Putnam, F.W. (1986). Development,
reliability and validity of a dissociation scale. Journal of
Nervous and Mental Disease, 174, 727–735.
Boals, A. (2008). Short communication: Intrusive thoughts
and everyday cognitive failures in Holocaust survivors.
Stress and Health, 24, 401–405.
Breznitz, S. (1982). Denial of stress. New York, NY:
International Universities Press.
Burnham, G., Lafta, R., Doocy, S., & Roberts, L. (2006).
Mortality after the 2003 invasion of Iraq: A cross-sectional
cluster sample survey. Lancet, 368, 1421–1428.
Carlson, E.B., & Putnam, F.W. (1993). An update on the
Dissociative Experiences Scale. Dissociation, 6, 16–27.
Carmil, D., & Breznitz, S. (1991). Personal trauma and world
view – Are extremely stressful experiences related to
Aging & Mental Health
political attitudes, religion beliefs, and future orientation?
Journal of Traumatic Stress, 4, 393–405.
Chodoff, P. (1986). Survivors of the Nazi Holocaust.
In R.H. Moos (Ed.), Coping with life crises: An integrated
approach (pp. 407–415). New York: Plenum Press.
Cohen, K., & Shmotkin, D. (2007). Emotional ratings of
anchor periods in life and their relations to subjective wellbeing among Holocaust survivors. Personality and
Individual Differences, 43, 495–506.
Danieli, Y. (1981). On the achievement of integration in
aging survivors of the Nazi Holocaust. Journal of Geriatric
Psychiatry, 14, 191–210.
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, 335–363.
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, 318–324.
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 2b-adrenoceptor is related to
emotional memory in Europeans and Africans. Nature
Neuroscience, 10, 1137–1139.
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, 803–807.
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. 43–67).
New York: Plenum Press.
Fening, S., & Levav, I. (1991). Demoralization and social
supports among Holocaust survivors. Journal of Nervous
and Mental Disease, 179, 167–172.
Florian, V., & Drori, Y. (1990). Mental Health Inventory
(MHI): Psychometric characteristics and normative data
regarding the Israeli population. Psychology, 1, 26–35
(Hebrew).
Frischholz, E.J., Braum, B.G., Sachs, R.G., Hopkins, L.,
Shaeffer, D.M., Lewis, J., . . . , Schwartz, D.R. (1990).
The Dissociative Experiences Scale: Further replication
and validation. Dissociation, 3, 151–153.
Goodman, G.S., Quas, J.A., & Ogle, C.M. (2009). Child
maltreatment and memory. Annual Review of Psychology,
61, 325–351.
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. 241–252). New York: Plenum Press.
Harel, Z., Sollod, R.N., & Bognar, B.J. (1982). Predictors of
mental health among semi-rural aged. The gerontologist,
22, 499–504.
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,
39–47.
Kahana, E., Kahana, B., Harel, Z., & Rosner, T. (1988).
Coping with extreme trauma. In J. Wilson, Z. Harel, &
241
B. Kahana (Eds.), Human adaptation to human stress:
From Holocaust to Vietnam (pp. 55–79). 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, 1489–1500.
Kennedy, F., Clarke, S., Stopa, L., Bell, L., Rouse, H.,
Ainsworth, C., . . . , Waller, G. (2004). Towards a cognitive
model and measure of dissociation. Journal of Behavior
Therapy and Experimental Psychiatry, 35, 25–48.
Krell, R., Suedfeld, P., & Soriano, E. (2004). Child
Holocaust survivors as parents: A transgenerational
perspective. American Journal of Orthopsychiatry, 74,
502–508.
Krystal, H. (1981). Integration and self-healing in posttraumatic states. Journal of Geriatric Psychiatry, 14, 165–189.
Landau, R., & Litwin, H. (2000). The effects of extreme early
stress in very old age. Journal of Traumatic Stress, 13,
473–487.
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, 503–516.
McGowan, P., Sasaki, A., D’Alessio, A.C., Dymov, S.,
Labonté, B., Szyf, M., . . . , Meaney, M.J. (2009).
Epigenetic regulation of the glucocorticoid receptor in
human brain associates with childhood abuse. Nature
Neuroscience, 12, 342–348.
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,
287–293.
Niederland, W.G. (1968). Clinical observations on the
‘‘Survivor Syndrome’’. The International Journal of
Psychoanalysis, 49, 313–315.
Pavot, W., & Diener, E. (1993). Review of the
satisfaction with life scale. Psychological Assessment, 5,
164–172.
Peña, E.D. (2007). Lost in translation: Methodological
consideration
in
cross-cultural
research.
Child Development, 78, 1255–1264.
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, 131–153.
Sagi-Schwartz, A., Van IJzendoorn, M.H., & BakermansKranenburg, M.J. (2008). Does intergenerational transmission of trauma skip a generation? No meta-analytic
evidence for tertiary traumatization with the third generation of Holocaust survivors. Attachment and Human
Development, 10, 1–17.
Sagi-Schwartz, A., Van IJzendoorn, M.H., Grossmann, K.E.,
Joels, T., Grossmann, K., Scharf, M., . . . , Alkalay, S.
(2003). Attachment and traumatic stress in female
Holocaust child survivors and their daughters. American
Journal of Psychiatry, 160, 1086–1092.
Shmotkin, D., & Barilan, Y.M. (2002). Expression of
Holocaust experience and their relationship to mental
symptoms and physical morbidity among Holocaust
survivors patients. Journal of Behavioral Medicine, 25,
115–134.
242
A. Fridman et al.
Shmotkin, D., & Lomranz, J. (1998). Subjective well-being
among Holocaust survivors: An examination of overlooked differentiations. Journal of Personality and Social
Psychology, 75, 141–155.
Solomon, Z., Kotler, M., & Mikulincer, M. (1988).
Combat-related posttraumatic stress disorder among
second-generation Holocaust survivors: Preliminary findings. American Journal of Psychiatry, 145, 865–868.
Solomon, Z., & Prager, E. (1992). Elderly Israeli Holocaust
survivors during the Persian Gulf War: A study of
psychological distress. The American Journal of
Psychiatry, 149, 1707–1710.
Steinitz, L.Y. (1982). Psycho-social effects of the Holocaust
on aging survivors and their families. Journal of
Gerontological Social Work, 4, 145–152.
Tabachnick, B.G., & Fidell, L.S. (2007). Using multivariate
statistics. Boston: Pearson Education.
Van der Hal-Van Raalte, E.A.M., Bakermans-Kranenburg,
M.J., & Van IJzendoorn, M.H. (2008). Diurnal cortisol
patterns and stress reactivity in child Holocaust survivors
reaching old age. Aging and Mental Health, 12, 631–639.
Van der Linden, D., Keijsers, G.P.J., Eling, P., & Van
Schaijk, R. (2005). Work stress and attentional difficulties:
An initial study on burnout and cognitive failure. Work
and Stress, 19, 23–36.
Van IJzendoorn, M.H., Bakermans-Kranenburg, M.J., &
Sagi-Schwartz, A. (2003). Are children of Holocaust
survivors less well-adapted? A meta-analytic investigation
of secondary traumatization. Journal of Traumatic Stress,
16, 459–469.
Van IJzendoorn, M.H., & Schuengel, C. (1996). The measurement of dissociation in normal and clinical populations:
Meta-analytic validations of the Dissociative Experiences
Scale (DES). Clinical Psychology Review, 16, 365–382.
Yehuda, R., Bierer, L.M., Schmeidler, J., Aferiat, D.H.,
Breslau, I., & Dolan, S. (2000). Low cortisol and risk for
PTSD in adult offspring of Holocaust survivors. American
Journal of Psychiatry, 157, 1252–1259.
Yehuda, R., Golier, J.A., Halligan, S.L., & Harvey, P.D.
(2004). Learning and memory in Holocaust survivors with
posttraumatic stress disorder. Biological Psychiatry, 55,
291–295.
Yehuda, R., Golier, J.A., & Kaufman, S. (2005). Circadian
rhythm of salivary cortisol in Holocaust survivors with
and without PTSD. American Journal of Psychiatry, 162,
998–1000.
Yehuda, R., Schmeidler, J., Wainberg, M., Binder-Brynes,
K., & Duvdevani, T. (1998). Vulnerability to posttraumatic stress disorder in adult offspring of Holocaust
survivors. American Journal of Psychiatry, 155, 1163–1171.
Copyright of Aging & Mental Health is the property of Routledge and its content may not be copied or emailed
to multiple sites or posted to a listserv without the copyright holder's express written permission. However,
users may print, download, or email articles for individual use.