The Effects of Transgenerational Violence By Jennifer Cyr NURS 509 8 August 07

The Effects of Transgenerational Violence

By Jennifer CyrNURS 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.


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


HPA Axis

Hypothalamus

Pituitary Adrenal

Stress

(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)


• Results:– Holocaust survivors

with PTSD showed lower mean 24hr urinary cortisol

– Correlations between severity of PTSD, cortisol levels, and scores on the avoidance subscale

– (Yehuda et al., 1995)

Soviet POWs in German Captivity

Polish Women at Ravenbruck

http://en.wikipedia.org/wiki/Image:19558.jpg

http://en.wikipedia.org/wiki/Image:Scan2002.jpg


• 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


http://en.wikipedia.org/wiki/Image:Buchenwald-J-Rouard-12.jpg


• 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)


• 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)


• 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)


• 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


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)


• 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


http://www.ushmm.org/wlc/media_ph.php?lang=en&ModuleId=10005142&MediaId=559

http://www.ushmm.org/wlc/media_ph.php?lang=en&ModuleId=10005144&MediaId=492


• 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)


• 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



• 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)


• 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



• 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)


• 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.

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)


• 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)


• 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


• 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

• Relationship of parental trauma exposure and PTSD with their offspring's (Holocaust survivors) development of PSTD, depression or anxiety disorder


Main entrance to the Auschwitz-Birkenau extermination camp. Poland, date uncertain.

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)


• 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







• 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


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 1-yr-old babies at awakening and at bedtime.– Beck Depression Scale– PTSD checklist


http://en.wikipedia.org/wiki/Image:National_Park_Service_9-11_Statue_of_Liberty_and_WTC_fire.jpg

http://www.september11news.com/USAFlagImages.htm

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.


http://www.september11news.com/AftermathImages.htm

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.


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– Roman Catholic grandfather

survived a Nazi camp• For past six years traveling in

Ukraine• Located 500 mass graves

– 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

German Soldier shooting Ukrainian Jew during mass execution in Vinnitsa, Ukraine (1941-1943)

(Associated Press, 2007)

http://en.wikipedia.org/wiki/Image:Einsatzgruppen_Killing.jpg

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.


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. (1998). Vulnerability to posttraumatic stress disorder in adult offspring of holocaust survivors. The American Journal of Psychiatry, 155(9), 1163-1171.

• 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. The American Journal of Psychiatry, 157(8), 1252-1259.

• Yehuda, R., Halligan, S. L., & Bierer, L. M. (2001). Relationship of parental trauma exposure and ptsd to ptsd, depressive and anxiety disorders in offspring. Journal of Psychiatric Research, 35, 261-270.

• Yehuda, R., Engel, S. M., Brand, S. R., Seckl, J., Marcus, S. M., & Berkowitz, G. S. (2005). Transgenerational effects of posttraumatic stress disorder in babies of mothers exposed to the world trade center attacks during pregnancy. The Journal of Clinical Endocrinology & Metabolism, 90(7), 4115-4118.

• Young, E. A., & Breslau, N. (2004). Saliva cortisol in posttraumatic stress disorder: A community epidemiologic study. Biological Psychiatry, 56, 205-209.

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The Effects of Transgenerational Violence By Jennifer Cyr NURS 509 8 August 07