Keywords

Introduction

Research of post traumatic mental disorders, especially due to man-made trauma , is often difficult and delicate, being burdened by emotionally and politically charged issues.

The study of the mental consequences of the Holocaust on Jewish survivors and their descendants, was, and still is, loaded with sentiments. In Israel, the general attitude towards the survivors has evolved over the years. This change has contributed in many ways to the research; first of the survivors, and then of their offspring. Also, fundamental differences between the Holocaust of the Jewish people and other genocides were ignored. This may have resulted in a misreading of the state of the survivors and their offspring, and also possibly in misunderstanding the terms “resilience” and “post traumatic growth .”

Early researchers believed they faced a new mental condition in civilians, similar to soldiers’ post traumatic responses, for which they had no accepted definition. Lacking literature on the post-traumatic stress disorder , a term that became widespread only years later, the term Konzentrationslager (concentration camp ) syndrome was coined explaining for the psychological symptoms identified among survivors (Eitinger 1961; Chodoff 1963). This syndrome was attributed to the cumulative effects of traumatic adversity on the individual, the family, and the community (Eitinger 1972).

Most psychotherapists who treated Holocaust survivors , found them as post-traumatic, and this was seen as the common response to experiencing the horrors of the Holocaust. Yolanda Gampel , a leading Israeli psychoanalyst, working with survivors and their offspring, coined the term “radioactive identification” of the victims – a mental radioactivity emerging from the social violence that penetrated the victims, and that was transferred subconsciously to the next generation (Gampel 1996).

Over the years, Holocaust survivors have been studied as examples of genocide survivors, however, many of these studies did not take into account the fact that the Holocaust was a different kind of genocide. As opposed to other genocides, the Holocaust did not result out of a civil war, or a national or political conflict – since the Jews did not attack or harm Nazi Germany in any way; Jews in occupied Nazi territory during the last years of WWII were all subject to a specific death threat, just because they were Jewish; most of them suffered famine and starvation, poor hygiene, inflammatory diseases, slave labor, severe trauma and grief. Jews who survived such horrors had to have special personal traits, physical and psychological, which enabled them to adjust and persevere through a long-lasting horrific experience. For almost 50 years this plain truth – that the survivors were a selected group of people – was not confronted, partly because of the pejorative nature of the term “selection,” the infamous Nazi practice performed in death camps selecting who would live or die. Thus the positive traits of the survivors, traits that they could inherit to their offspring, were not addressed. Ironically, the selection procedure was done by Nazi doctors, most notably the notorious Dr. Mengele , as if it were a standard medical practice.

Studies on Concentration Camp Survivors in Poland

Polish non-Jewish prisoners in Nazi concentration camps are a remarkable comparison population to the Jewish Holocaust survivors, and such a comparison is possible due to the extensive research done in Poland. Polish non-Jews were also victims of genocide; about 3,000,000 of the 6,000,000 Poles who were killed by the Nazis during WWII-about 10% of the Polish population at that time-were Catholics. However, they did not face the same absolute life-threatening destiny of Jews in the Holocaust, and in concentration camps they did not face the same continuous and certain death threat. A leading group of physicians, most of them psychiatrists from the Medical Academy of the Jagellonian University in Krakow, led by Antony Kepinski, studied Polish Auschwitz survivors from the end of the 1950s, and published their findings in the “Medical Review – Auschwitz” (Ryn 2005). These studies revealed extensive psychopathology, as well as chronic physical conditions among the survivors. One of the groups, studied by Adam Szymusik , consisted of a hundred individuals, examined during the years 1959–1961. Psychological disturbances were found in 64 examinees, and 48 of these cases were clearly related to incarceration in the concentration camp. The psychiatrist Maria Orwid (1930–2009) studied the post-war problems experienced by these survivors (Bomba and Orwid 2010). She found that their main reference group for the survivors was their co-prisoners, and that their post-war adjustment seemed to be more difficult than their adjustment to the camp. The Krakow Auschwitz study concluded that surviving the extreme stress of imprisonment in a concentration camp required specific adaptation mechanisms, and that these resulted in a chronic disorder of adaptation mechanisms to life after liberation accompanied by a severe deterioration in health.

Another longitudinal study was a retrospective study carried out in Wroclaw (Poland), looking at medical records of 250 former prisoners in 1950, and 120 records in 1975, and compared them with medical records of a control group (Jablonski et al. 2015a, b). Compared with the control group, former prisoners manifested multi-comorbidity, premature aging, and a dramatic increase in mortality rate. The multi-morbidity mostly affected older prisoners who stayed at a camp for a longer time period (Jablonski et al. 2015a). The interrelated somatic and psychological symptoms profile – “concentration camp syndrome” – was found among 58.8% of former prisoners 5 years after leaving the camp, and in 77.5% after 30 years (Jablonski et al. 2015b).

Psychiatric studies of Jewish Holocaust survivors living in Poland and their children started with the founding of the Association of Children of the Holocaust in Poland in 1991. Children of Holocaust survivors reported a high rate of anxiety states in early childhood, and almost all had identity difficulties, due to the “double taboo “they experienced – the Holocaust and their Jewish origin (Bomba and Orwid 2010).

“Second Generation ” as a Psychological-Cultural Phenomenon

Studies on the influence of the trauma of the Holocaust on the survivors ‘children have been published in Israel since the 1960s. Most of these studies described the “Second Generation” by illustrating their parents’ behavior; their inability to grieve over their lost loved family members, their guilt feelings, their longings, and their feelings of abandonment. All these affected the construction of their post-Holocaust families and their attitudes towards raising their children (Rakoff 1961; Nathan et al. 1964; Klein 1972; Kellerman 2001).

However, many such studies described populations in clinical situations or in mental treatment – survivors and “Second Generation” patients – and therefore were selection-biased. One of the principal researchers in the field was Hillel Klein (1923–1985), a leading Israeli psychiatrist and psychoanalyst, and a survivor himself. Lately, his studies of Holocaust survivors and their families in Israel and the Diaspora were re-published (Klein 2012). In a study among Second Generation subjects in a kibbutz of many survivors, Klein found that the survivors’ children were not interested in the history of the Holocaust more than other children in their group (Klein 1972). This finding, however, was not given emphasis at the time.

A pivotal study that focused on the Second Generation was published in the Children of the Holocaust, written by the Second Generation writer, Helen Epstein (Epstein 1979). In this study, survivors ’ children talked about their views on the influence of the Holocaust on them. They talked about the influence of their parents’ silence, on their responsibility to cherish the memory of the lost relatives, and on topics that were not discussed until then; their shame in their parents who were different from other parents, their parents’ over-protection, their anger toward Nazi crimes and their anger in becoming a “replacement” instead of the lost relatives for the parents. Some of them identified with the Holocaust victims , and felt as if they were in the Holocaust themselves.

Mental Difficulties Among Second Generation Holocaust Survivors , or “Transgenerational Transmission of the Holocaust Survivor Syndrome”

Mental health therapists who treated members of the Second Generation tended to attribute the mental health problems of their patients to having been raised by mentally afflicted parents and to the “transgenerational transmission” of symptoms related to their parents’ trauma during the Holocaust. Thus, the research literature was based mostly on few clinical cases, not representative of the Second Generation, but rather only representing the clinical sub-group which sought psychiatric help . This led to a tendency to focus on the pathology of the few, rather than examining more representative cohorts of offspring of survivors. van Ijzendoorn et al. (2003) tested the hypothesis of secondary traumatization in Holocaust survivor families, through a series of meta-analyses on 32 samples involving 4418 participants. In a set of adequately designed studies, no evidence for the influence of the parents’ traumatic Holocaust experiences on their children was found. Sagi-Schwartz et al. (2008) did not find tertiary traumatization (of the third generation ) in a meta-analysis of 13 non-clinical studies involving 1012 participants.

The primary “clinical” approach of “Transgenerational Transmission” also reflects the emphasis of most therapist-researchers, who focused on the psychiatric symptoms of a minority of survivors rather than on the success of the majority, who managed to survive the Holocaust, and establish a social and professional life . Only a few scholars, such as Hillel Klein , stressed these “healthy” areas (Knobler et al. 2015).

Only later did the literature begin to concentrate not on the negative effect of trauma and the vulnerability of those who survived the Holocaust, but rather on their resilience in the face of overwhelming traumatic events , and on their ability to overcome the trauma and grief – their post-traumatic growth (Sigal 1995; Baron et al. 1996).

Survivor Resilience as an Inspiration for the Salutogenic Theory

Aaron Antonovsky (1923–1994), a medical sociologist , studied Holocaust survivors in Israel and found that many of them did not demonstrate overt psychopathological signs (Antonovsky et al. 1971). This finding led him to coin the term “salutogenesis ” (as opposed to pathogenesis), involving the description and examination of factors responsible for the formation and the maintaining of health. For that purpose, individuals and communities need “a sense of coherence”, consisting of three factors: a sense of comprehensibility , a sense of manageability, and a sense of meaningfulness (Antonovsky 1979, 1987). For empirical studies he formed the Sense of Coherence Scale , that has since been used in hundreds of studies (Eriksson and Lindstrom 2006). Shamay Davidson , a leading Israeli psychiatrist, was also among the few who pointed out the ability of the survivors to outlive the Holocaust and its aftermath helped by their group’s support, during the Holocaust and later in Israel (Davidson 1973).

Resilience is understood today as the process of overcoming rather than succumbing to the effects of adverse experiences such as genocides and mass atrocities (Rutter 1987; Masten and Narayan 2012; Reed et al. 2012). “Post traumatic growth ” is the term coined by Calhoun and Tedeschi (Calhoun and Tedeschi 2014) for the development of positive outcome following trauma : better interpersonal relationships, making changes in one’s life , gaining a higher appreciation of life, building resilience and self-empowerment, and spiritual/religious growth.

Progress in Research: Community-Based Epidemiological Studies

The early studies, conducted at a time when psychiatric epidemiology was in its infancy, suffered from a number of weaknesses, including selection bias, unmeasured confounding , and limited analysis of sub-groups (Solkoff 1992).

The first large scale population based study was carried out in Israel in the early 1980s, not on survivors , but on their offspring. This pioneering study, by Schwartz et al. (1994) was conducted by a research group from Columbia University in New York , represented in Israel by Itzhak Levav . This extensive community-based epidemiological study analyzed a representative sample of second generation offspring of two parent survivors of the death camps, compared to descendants of former Europeans who had not been in the Holocaust.

No evidence of higher symptom scale scores or higher rates of current psychiatric disorders were found among the children of Holocaust survivors . Moreover, in their report, the authors began with the obvious: Holocaust survivors undoubtedly experienced severe trauma over a lengthy period, and growing in the shadow of such parents left its mark on their children’s characters. However, Holocaust survivors were also clearly gifted with unique characteristics which helped them survive. Since a significant part of these characteristics was passed on to their children, this should also be taken into consideration when evaluating the personality and the mental state of the second generation .

Today it has become clear that this evaluation is even more complex than previously believed, in light of recent data on epigenetic heredity whereby it is not only genetic qualities determined by one’s genome that are passed on to future generations, but also acquired characteristics that can be inherited. [Transgenerational epigenetic inheritance is the transmittance of traits from one generation to the offspring without alteration of the primary structure of DNA.] Epigenetic studies have the potential to improve our understanding of the etiology of human behavior and mental disorders by bridging the gap in knowledge between the exogenous environmental exposures and behavior and pathophysiology. The current literature on epigenetic regulation of anxiety , depression, and post-traumatic stress disorders , possibly relevant in this discussion of survivors , is just emerging, and is not reliable yet (El-Sayed et al. 2012; Mahgoub and Monteggia 2013). Additionally, these studies need control groups to better understand what might be the epigenetic effect.

It may not be surprising, due to the delicacy of the research topic, that unbiased large scale epidemiological community-based studies of Holocaust survivors were not done at all, until the beginning of the twenty-first century. A first such study conducted during the years 2002–2004 was led in Israel by Itzhak Levav , as part of the Israel World Mental Health Survey . It included a similar comparison, this time of the two generations: survivors vs. non-survivors, and second generation of survivors vs. others. The findings among the second generation resembled those of the first study: no statistical differences were elicited on several measures of psychopathology between a group of offspring of Holocaust survivors (N = 430) to a comparison group of 417 offspring of Europe-born parents who did not reside in Nazi-occupied countries (Levav et al. 2007). The findings among the survivors were quite surprising; the survivors ‘lifetime and 12-month prevalence rates of anxiety disorders, their current sleep disorders, and their emotional distress were higher than the control. In spite of this, they did not have higher rates of depressive disorders or post-traumatic stress disorder (Sharon et al. 2009).

This finding is exceptional, considering the unique trauma and grief the Holocaust survivors had suffered in contrast to all other victims of genocide and mass trauma. It is even more outstanding comparing the rates of PTSD symptoms and depressive symptoms with other victims. Whenever and wherever other genocide survivors were evaluated, an (expected) high rate of such symptoms was found. Such findings were manifest in the effects of war that included genocide: in Rwanda (Pham et al. 2004), in Cambodia (Marshal et al. 2005; Sonis et al. 2009), or in former Yugoslavia (Basoglu et al. 2005).

Indeed, high rates of PTSD and depression are always found among populations exposed to mass conflict and displacement: Steel (Steel et al. 2009) found in a meta-analysis of 5904 studies of surveys involving refugees, conflict-affected populations, or both, that after adjusting for methodological factors, exposure to torture and other potentially traumatic events account for higher rates of reported prevalence of PTSD and depression. Another population with reported high rates of PTSD and depression are prisoners of war. Former prisoners of war (ex-POWs) are at high risk of developing psychiatric disorders (Ursano and Rundell 1990). Among them the prevalent disorders are PTSD (e.g. Solomon et al. 2008) and depression (e.g. Page et al. 1991). This discrepancy is even more remarkable taking into account the incomparable degree of horrors and atrocities experienced by the Holocaust survivors , who were apart from everything else, both prisoners of war, and civilians, not trained soldiers.

The Longevity of Holocaust Survivors

Poor health, including poor mental health, is ultimately associated with a shorter life span. Since both were reported extensively on Holocaust survivors, the common logic was that they perished earlier than non-survivors. However, for a long time this conception was never examined even though this could be easily done in Israel using existing state records.

Two separate studies done in Jerusalem , each study populations comprising several hundreds of elderly people in protected housing, found that Holocaust survivors did not have a shorter life span (Collins et al. 2004; Stessman et al. 2008).

A first population-based retrospective cohort study of the Holocaust, based on the entire population of immigrants from Poland to Israel either before or after the Second World War , was published by Sagi-Schwartz et al. (Sagi-Schwartz et al. 2013). Holocaust survivors lived on average 6.5 months longer than non-survivors. Male survivors who were aged 10–15 at the onset of the Holocaust lived 10 months more, while male survivors who were 16–20 lived 18 months longer. The authors suggested two explanations to the surprising findings: “differential mortality” during the Holocaust (i.e. the selection process by the Nazis during the holocaust determining many of the survivors), and “Post-traumatic Growth ,” associated with protective factors inherent in the survivors or in their environment after the Holocaust.

Another remarkable comparison in Israel is with Israeli prisoners of war (POW’s). Solomon et al. (Solomon et al. 2014) studied 154 Israeli ex-prisoners of war and a matched control group (N = 161) of combat veterans 18 years after the 1973 war, and 35 years after the war. Captivity was associated with premature mortality, more health-related conditions and worse self-rated health. The relative risk for mortality in the ex-POWs group was 2.95 times higher than that of controls: 9.2% died from various causes up until 2008, compared with 3.1% of controls.

Studies in which Polish concentration camps survivors and Israeli prisoners of war had shortened life expectancies, whereas Holocaust survivors in Israel live longer, may strengthen Sagi-Schwartz’s (Sagi-Schwartz et al. 2013) selection hypothesis, namely that Holocaust survivors are a unique group of people that had special characteristics that enabled them to endure extreme atrocities and constant stressful conditions such as slave labor, torture, mental trauma and humiliation, starvation, cold, and infectious disease.

As Schwartz (Schwartz et al. 1994) pointed out, Jews who suffered from acute post traumatic reaction or disorder during the Holocaust perhaps could not survive. The uniqueness of the Holocaust survivors was emphasized by Yoram Hazan (1949–2011), a leading Israeli psychoanalyst and a favorite student of Hillel Klein , by the expression “there is no second generation of the Holocaust” (Hazan 1987) and later “there will not be any next generations of the Holocaust”: the generation of the Holocaust survivors will be remembered forever as those who survived – similar to the generation of the Jewish people during the exodus from Egypt, or the expulsion from Spain in 1492.

Further Implications for Research and Treatment

Studies on Holocaust survivors must be done nowadays without delay, due to their sadly dwindling number. The living survivors at the present time are mostly those who were child survivors and grew up and developed their mature personality during the Holocaust. Therefore, the impact of the Holocaust on them could be different, and their resilience could be different and worth studying. Even today, psychopathology oriented research is still prevalent, finding excessive psychopathology among these survivors . For example: a recent study in Israel displayed a higher rate of psychiatric admissions due to schizophrenia among patients who were child survivors (Levine et al. 2016). This study used the Israeli national psychiatric admissions registry as a “national psychiatric case registry,” disregarding the fact that child survivors of the Holocaust who immigrated to Israel must have had lesser family support, leading to higher rates of psychiatric hospitalization, as seen (even in higher rates) among other immigrant communities.

Future research on resilience and post traumatic growth must consider the difference between the outcomes of Holocaust survivors , especially in Israel, with that of survivors of other genocides. Scales that were formed using the experience of Holocaust survivors, such as Antonovsky’s sense of coherence scale (Eriksson and Lindstöm 2006) must be used accordingly.

The surprisingly positive outcome of Holocaust survivors in Israel requires further exploration. The opportunity of the survivors in Israel to be in contact with survivors like themselves, thus getting social support, and their ability to be a part of the building of the state of Israel, may be one of the reasons for their resilience. One result of this understanding was helpful in planning PTSD prevention programs in the IDF (Israeli Defence Forces) ; the fact that survivors could discuss their past freely with other survivors and the help they gained by that, pointed to the need to treat post traumatic soldiers inside their units taking advantage of the cohesion.

And finally, when Holocaust survivors are studied together with post-traumatic populations, the erroneous opinion that similar findings are expected must be discounted. The differences between the Holocaust and other genocides are obvious, forming the difference between such groups. Even though this subject is sensitive, delicate and painful – we propose that it must be confronted.