The Effects of Transgenerational Violence
By Jennifer Cyr
NURS 509
8 August 07
Outline
• History of PTSD, cortisol, nature vs. nurture,
HPA axis
• Studies
– Holocaust survivors and PTSD
– Cumulative trauma in Holocaust Survivors
– Vulnerability to PTSD in Adult Children of Holocaust
Survivors
– Low Cortisol and the Risk for PTSD in adult offspring
of Holocaust survivors
– Relationship of parental trauma exposure and PTSD
to their children’s psychiatric dx
Outline
• Studies continued
– Effects of PTSD of Mother’s Exposed to the World Trade Center
Attacks
during pregnancy
– Ukraine’s Nazi Past
– Others
• Summary
• Questions or discussion
History of PTSD
• Early studies emphasized the importance of trauma exposure as the
main variable causing PTSD symptoms.
• Since just a portion of trauma victims are diagnosed with PTSD it is
important to look at other contributing factors such as familial risk.
• Prior to 1980 the diagnosis of PTSD was not given.
• Examining the familial link of PTSD in parents and children, means
looking toward the future of possible genetic links.
•
(Yehuda, Halligan & Bierer, 2001)
History of PTSD
• 1918-Wolfsohn demonstrated that 74% of 100 patients
with war neuroses reported a family history of
psychoneurosis compared to none of 100 matched
comparison subjects
• His findings were replicated
– similar associations in World War I and World War II veterans
and their families
– Study of traumatized civilians exposed to disaster
• Increased prevalence of trauma survivors with PTSD that
had a twin that also had PTSD
•
(Yehuda, Bierer, Schmeidler, Aferiat, Breslau, & Dolan, 2000)
History of cortisol
• Low cortisol levels have been found in many
groups of trauma survivors with PTSD
• This finding was thought to be counter-intuitive
because in times of acute and chronic stress
cortisol levels were thought to be high in certain
psychiatric diagnosis where stress is associated
•
(Yehuda et al., 2000)
Theory of nature vs. nurture
• Reside in the environment where one or both parents
suffered from a mental illness.
• Decades after World War II the mother was the primary
caregiver for the children. Psychiatric impairment of the
mother would have greater impact then the father’s
psychiatric impairment.
• In animal models disrupted child rearing of the mother
has been implicated in vulnerability to stress.
• Holocaust survivors’ offspring self-report a higher
amount of physical neglect and emotional abuse when
there is a co-occurrence of parental PTSD.
•
(Yehuda et al., 2001)
HPA Axis Theory
• In cases of chronic stress or illness high levels of cortisol
occur because the HPA axis has stopped responding
• Low levels of cortisol in PTSD occur because the HPA
axis may be overly responsive to cortisol
• This hypothesis is consistent with the increased reaction
to implicit and explicit memories of the trauma as well as
generalized hypervigilance
•
(Yehuda et al., 2000)
HPA Axis
Hypothalamus
Stress
Adrenal
Pituitary
(Young & Breslau, 2004)
HPA Axis
(Kollack-Walker, 1999)
Holocaust Survivors & PTSD
• Compare urinary cortisol of Holocaust survivors
with PTSD vs. Holocaust survivors without PSTD
• Collected 24 hr urine samples
• Following day subject evaluated for the presence
and severity of past and current PTSD symptoms
and other psychiatric disorders
•
(Yehuda, Kahana, Binder-Brynes, Southwick, Mason & Giller, 1995)
Holocaust Survivors & PTSD
• Results:
– Holocaust survivors with
PTSD showed lower mean
24hr urinary cortisol
– Correlations between
severity of PTSD, cortisol
levels, and scores on the
avoidance subscale
Soviet POWs in German Captivity
Polish Women at Ravenbruck
–
(Yehuda et al., 1995)
Holocaust Survivors & PTSD
• Conclusions
– Low urinary cortisol
associated with clinically
significant PTSD symptoms
rather then a result of
experiencing trauma
– Low cortisol levels continue
for decades (50yrs) after
exposure to a trauma
among pts with chronic
PTSD
–
(Yehuda et al., 1995)
Holocaust Survivors & PTSD
• Conclusions
– Neurobiology alterations in cortisol release are associated with
the clinical significance of the symptoms
– Cortisol excretion was associated with the severity of the
trauma-related symptoms
– Severity of avoidance symptoms was predictive for the level of
cortisol excretion
– Hyperarousal and intrusive scores did not correlate with cortisol
excretion
–
(Yehuda et al., 1995)
Holocaust Survivors & PTSD
• Limitations
– The age of the participants could be considered as part of the
reason cortisol levels were low
– 47 subjects, 15 control subjects
– Exclusion of subjects with major medical concerns and certain
psychotropic medications
• First reports of women included in such studies
–
(Yehuda et al., 1995)
Cumulative Trauma, Recent Stress, Current PTSD in
Holocaust Survivors
• Study the relationship of lifetime trauma, recent
stress, and presence & severity of PTSD in
Holocaust survivors and non-exposed
comparison group
• Paradigm of the subjects
– Maladjustment and impaired functioning
– Terrific coping skills and exceptional well-being
–
(Yehuda, Kahana, Schmeidler, Southwick, Wilson, & Giller, 1995)
Cumulative Trauma, Recent Stress, Current PTSD in
Holocaust Survivors
• Subjects:
– Non-treatment seeking survivors of Nazi concentration camps
• Without axis I disorder, except PTSD
– Comparable age, gender, race, religion, and income who had not
experienced the Holocaust
• Free from lifetime or current axis I disorder, including PTSD
• Method:
– Asked research questions concerning all the variables
–
(Yehuda et al., 1995)
Cumulative Trauma, Recent Stress, Current PTSD in
Holocaust Survivors
• Results:
– Holocaust survivors: PTSD presence and severity are related to
current and lifetime stressors, plus the focal trauma
• Cumulative lifetime trauma = intrusive s/s
• Recent stressful events = hyperarousal s/s
• Psychotherapeutic process should explore the impact of
life stressors other then the focal trauma and look at
how current stressors are viewed through the past
trauma
•
(Yehuda et al., 1995)
Vulnerability to PTSD in Adult Children of
Holocaust Survivors
• Literature review:
– “General fragility and vulnerability to stress”
– High incidence of depression , conduct disorder, anxiety, inadequate
maturity, personality disorders, dependence, poor coping
– Large number of children seeking treatment and the resemblance of
symptoms to that of their parents
– Indirect exposure to traumatic material as described by their parents
– Direct effect of parent(s) inability to provide a nurturing environment
– Learned responses to stress
–
(Yehuda, Schmeidler, Giller, Siever, & Binder-Brynes, 1998)
Vulnerability to PTSD in Adult Children of
Holocaust Survivors
• Objective:
– Examine stress and trauma
exposure, current and
lifetime PTSD, and other
psychiatric diagnosis in a
group of adult children of
Holocaust survivors and
comparison group of
demographic equivalents
– (Yehuda et al., 1998)
Vulnerability to PTSD in Adult Children of
Holocaust Survivors
• Subjects:
– 100 offspring (29 men, 71 women)
• Raised by at least one biological parent who survived the Holocaust
• 11 offspring were raised by two parents who survived the Holocaust
• Recruited from Mount Sinai Specialized Treatment Program
– 44 comparison group (23 men, 21 women)
• Jewish, within the same age group, did not have a parent who survived the
Holocaust
• Volunteers solicited from lists obtained from the Jewish community
•
(Yehuda et al., 1998)
Vulnerability to PTSD in Adult Children of
Holocaust Survivors
• Method:
– Past/current stressful life events- The Trauma History
Questionnaire
– Cumulative stressful events- Antonovksy Life Crisis
Scale
– After completion on both of these scales
• Ranked in order the severity of events meeting the DSM-IV criteria
for PTSD
–
(Yehuda et al., 1998)
Vulnerability to PTSD in Adult Children of
Holocaust Survivors
• Results:
•
– Adult children of Holocaust survivors experienced greater degree of
lifetime cumulative stress
– Two groups did not have significantly different trauma exposure
– For offspring a substantial amount of trauma exposure was related to
the Holocaust
– PTSD prevalence at present was higher among offspring (15%) as
compared to comparison group (2%)
– PTSD lifetime prevalence higher among offspring (31%) then
comparison group (9%)
(Yehuda et al., 1998)
Vulnerability to PTSD in Adult Children of
Holocaust Survivors
• Results:
– ¼ of offspring related that being brought up with Holocaust related
events was their most distressing event
• Volunteered response of subjectively distressing event in the structured
interview portion of the study
• Clarified response: physical and emotional damage to the parent, caring for
the parent at a young age, minimizing of the offspring’s own life experiences
compared to the Holocaust, burden of compensating the parent for past
loss, taught to fear the environment and react with hypervigilance and
distrust
– 1/3 of offspring that reported this as the most distressing event
developed PTSD in response
•
(Yehuda et al., 1998)
Vulnerability to PTSD in Adult Children of
Holocaust Survivors
• Results:
– 7% of offspring reported that Holocaust stories of events caused
them great distress
• Too young to handle the graphic nature and emotional response of the
parent
• Offspring either imagine their parent re-experiencing the event or applied
the event to themselves
– Offspring were more sensitive to stressors
– Offspring had a higher rate of lifetime and current psychiatric
conditions
–
(Yehuda et al., 1998)
Vulnerability to PTSD in Adult Children of
Holocaust Survivors
• Limitations
– Convenience sample of
volunteers
– Moderate size of study
group
–
An emaciated child eats in the streets of the Warsaw
ghetto. Warsaw, Poland, between 1940 and 1943.
(Yehuda et al., 1998)
Low Cortisol and the Risk for PTSD in adult offspring of Holocaust
survivors
• 24 hr urine collected to measure cortisol levels in
35 adult offspring and 15 comparison subjects
(no holocaust parents)
• Subjects were evaluated to determine
– Presence or absence of psychiatric diagnosis
– Clinical symptoms
– PTSD present or absent in the parents
–
(Yehuda, Bierer, Schmeidler, Aferiat, Breslau, & Dolan, 2000)
Low Cortisol and the Risk for PTSD in adult offspring of
Holocaust survivors
• Results
– Low cortisol levels were significantly associated with
both PTSD in the parents as well as lifetime PTSD in
the participants
– Current psychiatric diagnosis other then PTSD was
non-significant, but was associated with higher
cortisol levels
–
(Yehuda et al., 2000)
Low Cortisol and the Risk for PTSD in adult offspring of
Holocaust survivors
(Yehuda et al., 2000)
Low Cortisol and the Risk for PTSD in adult offspring of
Holocaust survivors
• Conclusions
– Parental PSTD was a risk
factor and appears to be
associated with low cortisol
levels in the presence/absence
of lifetime PTSD in the
offspring
– Low cortisol levels are a
vulnerability marker
– Low cortisol levels can be
associated with acute and
chronic PTSD
–
(Yehuda et al., 2000)
• Limitations
– Parental PTSD was subjective
assessment by the adult
offspring rather then assessing
the parent directly
Relationship of parental trauma exposure and PTSD to their children’s
psychiatric dx
Main entrance to the
Auschwitz-Birkenau
extermination camp.
Poland, date uncertain.
• Relationship of parental trauma exposure and PTSD with
their offspring's (Holocaust survivors) development of
PSTD, depression or anxiety disorder
•
(Yehuda et al., 2001)
Relationship of parental trauma exposure and PTSD to their children’s
psychiatric dx
• Subjects
– 135 – 55 men & 80 women
– Divided into three groups according to parental
trauma exposure and PTSD
• 60 offspring of Holocaust survivors, having at least one parent with
PTSD
• 33 offspring of Holocaust survivors, having no parent with PTSD
• 42 demographically equivalent subject with parents with no
Holocaust exposure
•
(Yehuda et al., 2001)
Relationship of parental trauma exposure and PTSD to their children’s
psychiatric dx
• Method
– Psychiatric interview – lifetime psychiatric dx and exposure to
traumatic events
• 1st Trauma History Questionnaire
• Clinician administered PTSD scale done if the offspring endorsed at least one
traumatic event
– Participants completed a checklist on the 17 DSM-IV symptoms
of PTSD for their parents, symptom severity rated from 0-4 on
the Likert scale
• Administered to both offspring of Holocaust survivors and comparison group
–
(Yehuda et al., 2001)
Relationship of parental trauma exposure and PTSD to their children’s
psychiatric dx
(Yehuda et al., 2001)
Relationship of parental trauma exposure and PTSD to their children’s
psychiatric dx
(Yehuda et al., 2001)
Relationship of parental trauma exposure and PTSD to their children’s
psychiatric dx
• Results
– There is a strong connection between parental PTSD and the
occurrence of PTSD in the offspring
– Parental trauma exposure rather then PTSD was significantly
predictive for lifetime depressive do of the offspring
– Lifetime psychiatric disorders was found to be substantially
higher in offspring of Holocaust survivors than in comparison
subjects
–
(Yehuda et al., 2001)
Effects of PTSD of Mother’s Exposed to the World Trade
Center Attacks
during pregnancy
• Purpose: Report on the relationship between
maternal PTSD symptoms and salivary cortisol
levels in infants of mothers directly exposed to
the World Trade Center collapse on September
11, 2001 during pregnancy.
•
(Yehuda, Engel, Brand, Seckl, Marcus, & Berkowitz, 2005).
Effects of 911
• Subjects
– Mothers N=38
– Babies N= 38
• Method
– Collected salivary cortisol samples from themselves and their 1yr-old babies at awakening and at bedtime.
– Beck Depression Scale
– PTSD checklist
•
(Yehuda et al., 2005)
Effects of 911
• Results
– Lower cortisol levels noted
in both mothers and babies
of mothers who developed
PTSD in response to 911.
– Lower cortisol levels were
noted in babies of mothers
born with PTSD and
exposed to 911 in there
third trimester.
–
(Yehuda et al., 2005)
Effects of 911
• The current findings suggest that extrinsic environmental
conditions occurring in offspring later in life cannot fully
account for transgenerational transmission of cortisol
related to parental PTSD.
• The similarity between correlations observed in the
current study of 1-yr-old offspring and adult offspring of
Holocaust survivors should not preclude longitudinal
investigation of these effects because even effects
related to in utero programming and/or early stress can
change over time.
•
(Yehuda et al., 2005)
Effects of 911
• “The current cohort provides an opportunity to examine
the longitudinal development in cortisol over time in
relation to both remitted or ongoing maternal symptoms
and factors related to child development.” (Yehuda et al., 2005, p.
4117)
• “Disentangle the contributions of genetic, prepregnancy,
in utero, and postpartum influences on offspring cortisol
levels in a sample where the intensity, frequency, and
duration of the stressor is clearly defined, and the
symptoms are clearly quantified in a prospective
manner.” (Yehuda et al., 2005, p. 4117)
Ukraine’s Nazi Past
•
Father Patrick Desbois
•
For past six years traveling in
Ukraine
Located 500 mass graves
•
•
•
•
•
•
– Roman Catholic grandfather
survived a Nazi camp
– Estimated sites 726
1.5 million Jews
Most by machine gun, some never
recorded
Eye witness testimony of “stirring”
graves,
Jewish women who acted as sex
slaves and servants
Children shot after failed attempt
to gas them in trucks
(Associated Press, 2007)
German Soldier shooting Ukrainian
Jew during mass execution in
Vinnitsa, Ukraine (1941-1943)
Other studies….
•
•
•
Salivary Cortisol in PTSD-Community
sample
– 516 subjects
– Morning and evening salivary
sample
Results
– Lifetime PTSD-elevated evening
cortisol
– Comorbidity-only those persons
w/PTSD & MDD showed elevated
evening cortisol levels
– Either MDD or PTSD only, no
changes in cortisol level
Conclusion
– Neither PTSD or trauma alone
alters cortisol levels,
– Comorbidity of PTSD & MDD show
elevations in cortisol
– (Young & Breslau, 2004)
•
•
24H Cortisol & NE in subjects seeking
tx after 911 attacks
– 42 subjects
– 24H urine samples
Results
– PTSD subjects 24H cortisol was
lower then non-PTSD group
– 24H cortisol was negatively
correlated with WTC attacks, and
with self-rated avoidance and total
score on the PTSD symptom scale
(PSS)
– 24H NE excretion not associated
with the development of PTSD or
with PTSD related symptoms
– 24H NE was negatively correlated
with days since 911 attacks
– (Bierer et al., 2006)
Summary
• Depressive Do and PTSD are associated with different
neurobiological responses to stress. It makes it difficult
to explain why some trauma results in depression as
opposed to PTSD or the co-occurrence of the two
disorders. In the absence of other vulnerabilities and
exposure to trauma, PTSD will more likely develop in
persons with pre-existing history of familial patterns.
•
(Yehuda et al., 2001)
References
•
•
•
•
•
•
Bierer, L. M., Tischler, L., Labinsky, E., Cahill, S., Foa, E., & Yehuda, R. (2006). Clinical
correlates of 24-H cortisol and norepinephrine excretion among subjects seeking
treatment following the world trade center Attacks on 9/11. Annals New York
Academy of Sciences, 1071, 514-520.
Kollack-Walker, S. (1999). Stress. Unpublished Presentation. University of Michigan.
Press, A. (2007). Ukraine's nazi past revealed. Herald, p. A4.
Yehuda, R., Kahana, B., Karen-Binder-Brynes, Southwick, S. M., Mason, J. W., & Giller,
E. L. (1995). Low urinary cortisol excretion in holocaust survivors with posttraumatic
stress disorder. The American Journal of Psychiatry, 152(7), 982-986.
Yehuda, R., Kahana, B., Schmeidler, J., Southwick, S. M., Wilson, S., & Giller, E. L.
(1995). Impact of cumulative lifetime trauma and recent stress on current
posttraumatic stress disorder symptoms in holocaust survivors. The American Journal
of Psychiatry, 152(12), 1815-1818.
Yehuda, R., Schmeidler, J., Earl L. Giller, J., Siever, L. J., & Binder-Brynes, K. (1998).
Relationship between posttraumatic stress disorder characteristics of holocaust
survivors and their adult offspring. American Journal of Psychiatry, 15(6), 841-843.
References
•
•
•
•
•
Yehuda, R., Schmeidler, J., Wainberg, M., Karen-Binder-Brynes, & Duvdevani, T.
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