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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

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the effects of transgenerational violence

The Effects of Transgenerational Violence

By Jennifer Cyr

NURS 509

8 August 07

outline
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
outline1
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
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 ptsd1
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
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
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
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
HPA Axis

Stress

(Young & Breslau, 2004)

hpa axis1
HPA Axis

(Kollack-Walker, 1999)

holocaust survivors ptsd
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 ptsd1
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
    • (Yehuda et al., 1995)

Soviet POWs in German Captivity

Polish Women at Ravenbruck

holocaust survivors ptsd2
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 ptsd3
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 ptsd4
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
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 survivors1
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 survivors2
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
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 survivors1
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 survivors2
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 survivors3
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 survivors4
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 survivors5
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 survivors6
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 survivors7
Vulnerability to PTSD in Adult Children of Holocaust Survivors
  • Limitations
    • Convenience sample of volunteers
    • Moderate size of study group
    • (Yehuda et al., 1998)

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
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 survivors1
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 survivors2
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 survivors3
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

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
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 dx1
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 dx2
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 dx3
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 dx4
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 dx5
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
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
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
  • (Yehuda et al., 2005)
effects of 9111
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 9112
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 9113
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
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)

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)

Other studies….
summary
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
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.
references1
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.