PTSD transmission: a review of secondary traumatization in Holocaust survivor families

Williams-Keeler, Lyn

Abstract

Posttraumatic Stress Disorder (PTSD) provides a common language for diagnoses and assessment of trauma victims, including Holocaust survivors. Many of these survivors established post-war families and it is here that we began to witness the possibility of trauma transmission. Parental communication regarding the Holocaust, often characterized by obsessive re-telling or all-consuming silence, and strong family ties are implicated in the theoretical literature on trauma transmission. Terms such as vicarious, empathic, and secondary traumatization have been used to describe intergenerational trauma transmission. The crucial emergent question is whether a secondary PTSD syndrome, reflected in the current PTSD symptomology, is being transmitted from one generation to the next. There is evidence in the literature to support this hypothesis and a call is made for rigorous empirical studies as the test.

Resume

Le syndrome de stress post-traumatique (SSP) fournit le langage permettant de poser des diagnostics et d'effectuer des evaluations dans le cas de victimes de traumatismes, y compris les survivants de l'Holocauste. Un grand nombre de ces personnes ont fonde des families apres la guerre, et c'est dans ces familles que nous avons commence a constater la possibilite de transmission des traumatismes. Le message des parents sur l'Holocauste, qui consiste souvent a raconter l'experience de facon obsessive ou a garder un silence absolu sur la question, et les liens familiaux serres sont mentionnes comme facteurs dans les documents theoriques sur la transmission des traumatismes. Des termes tels que traumatisme indirect, traumatisme empathique et traumatisme secondaire ont ete utilises pour decrire la transmission des traumatismes entre les generations. Il est maintenant essentiel de savoir si un syndrome de stress post-traumatique secondaire, dont la symptomatologie actuelle du SSP laisse entrevoir l'existence, est transmis d'une generation a la suivante. Les documents sur la question contiennent des renseignements a l'appui de cette hypothese, et on recommande que des etudes empiriques rigoureuses soient effectuees pour la confirmer.

The diagnostic criteria for PTSD established in the DSM-IV provides a standardized means of assessing the effects of trauma. Concentration Camp Syndrome, Survivor Syndrome, Postincarceration Late Injury and Concentration Camp Neurosis among other terms were precursors to what is currently known as Posttraumatic Stress Disorder. In this article, PTSD will be used as an umbrella term encompassing earlier terms such as Survivor Syndrome. Regardless of the term used, extensive evidence exists suggesting that large numbers of Holocaust survivors suffered and continue to suffer from their traumatic experiences. Theories of trauma transmission from survivor to offspring have been proposed in psychological literature, but the exact nature of what is transmitted has gained little attention. Various researchers have suggested that since many Holocaust survivors suffer from PTSD, their offspring will also suffer from a syndrome of similar dimensions with diminished proportions (Barocas & Barocas, 1973, 1979; Solomon, 1990). In the following article, trauma will be described in terms of the PTSD diagnostic criteria from the DSM-IV (APA, 1994). The primary focus of this article is to report upon literature-based evidence of PTSD symptom transmission in the second generation. Secondarily, a case for empirically based research further exploring this topic will be advanced.

PTSD in Holocaust Survivors

Much definitive evidence has become available acknowledging the occurrence of PTSD in large numbers of Holocaust survivors (Berger, 1975; Chodoff, 1970; Eaton, Sigal, & Weinfeld, 1982; Eissler, 1967; Hunter, 1988; Krystal, 1968; Rosenbloom, 1988; Rubenstein, Cutter, & Templer, 1989). In 1962, Eitinger described common effects of concentration camps on 100 prisoners 15 years after liberation. Some survivors were simply unable to feel, while others had the paradoxical response of euphoria mixed with emotional numbness. Remarkably, most survivors resumed work almost immediately after repatriation despite severe physical and emotional impairment. Eitinger used the term "concentration camp syndrome" to describe a series of symptoms notably similar to those currently known as PTSD that he found to be present in approximately 85% of his sample group.

In 1975, Matussek used physical exams and psychiatric interviews to determine the effects of traumatic experiences on Jewish concentration camp survivors. Again, survivors reported a series of symptoms that were akin to the current PTSD constellation. It is likely that up to 52.5% of this sample would have met current PTSD criteria. Kuch and Cox (1992) re-examined 124 German files of Jewish Holocaust survivors. They concluded that 46% would have met the PTSD indicators based on the DSM-III-R criteria. The tattooed survivors of Auschwitz were three times as likely to meet the PTSD diagnostic criteria and had a greater number of symptoms than those surviving the Holocaust as a Jew in Europe suffering Nazi pursuit, but not in a concentration camp.

The main point to note here is the appropriateness of the PTSD diagnosis, in retrospect, among survivors and the significantly higher rate of occurrence among those exposed to greater traumas. The question of whether some form of PTSD exists in the second generation arises logically from this body of literature.

Theories of Trauma Transmission

The study of how trauma is transmitted from one individual to another is still at an early stage of development. We will limit our focus primarily to trauma transmission from Holocaust survivor to offspring, although there are theories outside of this realm that further support the notion of trauma transmission (Allen & Bloom, 1994; Edwards, 1995; McCann & Pearlman, 1990). Holocaust survivors suffered directly from the injustices of the Nazi regime. The next generation were not directly exposed to the cruel fate of their parents' generation, and yet, there is substantial evidence that many of the offspring suffered from a secondary exposure to the trauma which their parents faced.

Albeck (1994) explains the phenomenon of trauma transmission in Holocaust-survivor offspring as follows: "These offspring, the 'second generation' from the trauma, may thus bear 'the scar without the wound,' since they are significantly, if only indirectly, affected" (p. 106). In response to much of the research that assumes psychopathology in the second generation, Albeck discusses the importance of addressing issues of second-generation psychology (their appropriate psychological response toward the trauma of their parents) rather than psychopathology in the second generation. Based on his view, trauma may be transmitted but the offspring are still able to become healthy effectual adults. Albeck emphasizes the importance of recognizing that if trauma experienced by the survivors is transmitted, it will manifest as a unique entity in the offspring. Albeck uses the term "empathic traumatization" to describe the offsprings' attempts to understand their parents' wartime experiences and pain as a means of establishing a connection with them. In doing so the offspring imagine Holocaust scenes which they attempt to successfully escape or survive. The offspring literally maintain their familial ties by integrating their parents' experiences.

Mor (1990) offers a different but complementary view of trauma transmission. Mor suggests that the children of survivors "adopted" their parents' trauma through one of two types of parental communication. The first possible interchange was through an almost obsessive re-telling of Holocaust stories from survivor to child. The second means of transmission was accomplished through an all-consuming silence. Although the silence was meant to be protective, it led to a fearful reflection of the horrors that befell the parents and the missing grandparents, aunts, uncles, and cousins. Albeck (1994) and Mor's conceptualizations are easily integrated. The offspring learn about the Holocaust through their parents' communication and use these messages to create a bridge between themselves and their parents' past traumas.

Freyberg (1980) offered a psychodynamic explanation of the transmission of trauma from Holocaust survivors to their offspring. She referred to Mahler's developmental work in order to construct her theory of transmission. Freyberg identified "boundary blurring" as being fundamental to the difficulties with separation-individuation seen in second generation offspring as early as 16 to 24 months old. The young child is beginning to feel strong urges to explore one's world and act independently. If the love of the primary caretaker is not maintained in a supportive and encouraging manner toward the child during this phase, development of autonomy will be hindered. Chazan (1992) further supports Freyberg's (1980) conceptualization by suggesting that intergenerational transmission of trauma occurs when the traumatized parent implants their own emotional instability into their children. The child internalizes the parents' stress and social mistrust which in turn leads to enmeshed family relations where the child remains confused about the boundaries between themselves and their parents. This theory further complements Albeck (1994) and Mor's (1990) theories which are both firmly rooted in the existence of close family ties.

Vogel (1994) cites the Jordan et al. (1991) "Self-In-Relation" model to explain how female offspring of trauma victims are more likely to unknowingly adopt the trauma-related symptoms of their mothers. This theory proposes that females develop a sense of self while growing up, through a bond of empathy with their mothers. This increased identification with the parent is the link that enhances the likelihood of trauma transmission. Vogel does not suggest that male offspring invulnerable to trauma transmission, but rather that female offspring are more open and thus more vulnerable to the transmission of trauma from their same-sex caretaker. There is, however, no empirical or clinical evidence to suggest that more female than male survivor offspring are susceptible to their parents' trauma.

Danieli (1985) suggests that survivor parents attempt to teach their children how to survive in the event of further persecution; thus, they inadvertently transmit their own wartime experiences. Children of survivors have been observed acting out Holocaust survival behavior adopted by their parents and becoming highly sensitive to Holocaust imagery during same-age anniversaries of their parents' trauma (Axelrod, Schnipper, & Rau, 1980; Krell, 1982).

Overall, survivor parents have been found to be overprotective, limited in their ability to inspire a smooth transition to separation and individuation in their offspring, highly expectant of the aspirations of their children, and burdened with traumatic memories which they pass on to the next generation (Freyberg, 1980; Halik, Rosenthal, & Pattison, 1990; Mor, 1990; Rosenman & Handelsman, 1990). It is important to consider the role of parenting in Holocaust survivors and to question whether the survivor's experience led to impaired parenting. A number of studies have addressed the issue of parenting style and competence (Gross, 1988; Keller, 1988; Weiss, 1988). The study results indicate that Holocaust experience did not lead to extremes in parenting styles, that traumatized adults were adaptable enough to revert back to typical pre-trauma family child-rearing practices, and that family cohesion was not compromised.

Heavily implicated in the theories of trauma transmission is the role of parental communication about the Holocaust as well as the family bond. However, none of the theories reviewed here have been satisfactorily studied. They lead to more questions, one of the most central being: If trauma transmission takes place what exactly is transmitted through the generations?

PTSD Transmission

McCann and Pearlman (1990) brought forward the idea of vicarious traumatization, later coined compassion fatigue by Figley (Edwards, 1995) to describe trauma that is transmitted over the course of therapy from client to counsellor, but not related specifically to Holocaust survivors. An even more dramatic example of the stressful impact of exposure to Holocaust-related material was described by McCarroll, Blank, and Hill (1995). In their study, Holocaust Memorial Museum staff exposed to personal artifacts, survivor histories, and archival materials, reported a range of stress reactions including: states of emotional numbing, social withdrawal, grief reactions, nightmares, and anger. If trauma is so volatile as to leave its mark on a therapist who meets a client for a limited period of time, or museum staff who come in contact with historical material alone, we must ask what happens to the offspring of trauma victims who interact with these individuals on a daily basis.

Bergmann and Jucovy (1982) suggest that the traumatic Holocaust experiences of one's parents pose a mental health risk to the offspring and that:

... so far as our own experience goes, it is not possible for a child to grow up, without becoming scarred, in a world where the Holocaust is the dominant psychic reality. With few exceptions, the mental health of children of survivors is in jeopardy ... (p. 312).

This literature review reflects on the question of whether a secondary PTSD is being transmitted from one generation to the next in significant numbers of Holocaust survivor families, as Bergmann and Jucovy suggest. This is not to say that PTSD symptoms will be identical to the parents, or utterly debilitating in successive generations, but that parentally transmitted PTSD may be manifested in offspring of traumatized parents.

Solomon, Kotler, and Mikulincer (1988) collaborated on a unique research project that specifically set out to measure PTSD in the second generation. This longitudinal study found significant differences on PTSD measures between Israeli soldiers (with survivor parents and those without survivor parents) exposed to combat situations. Offspring of survivors reported a greater number of PTSD symptoms that endured over a longer period of time than soldiers whose parents were not Holocaust survivors. All subjects were reported to be psychologically and physically healthy prior to participation in combat situations. The authors concluded that these results are indicative of a PTSD latency or greater susceptibility to PTSD among the second generation when confronted with major stressors.

Similarly, Solomon (1990) reported that second generation Israeli soldiers exposed to combat situations exhibited PTSD symptomatology remarkably similar to Holocaust survivors. This included "intrusive symptoms, hyperalertness, cognitive impairment, and guilt feelings ... all symptoms ... highly reminiscent of the nightmares and flashbacks so prevalent among Holocaust survivors" (p. 1742). Although these studies are quite revealing, we must keep in mind that the study participants were combat veterans and were thus an unusual sample not directly generalizable to the average North American second generation offspring. Nonetheless, the importance of the research by Solomon et al. (1988) and Solomon (1990) is twofold. First, it provides support for Rosenheck and Nathan's (1985) conceptualization of "secondary transmission." In their paper, secondary transmission was used to suggest the transmission of trauma between Vietnam Veterans suffering from PTSD and their offspring. Second, there is some evidence for the hypothesis that children of survivors will exhibit PTSD significantly more often than matched controls.

Unfortunately, studies that address secondary transmission of PTSD from survivors of major trauma to their offspring in a cohesive, empirically based manner, using valid and reliable measures of PTSD are sparse. The available literature generally skirts the PTSD transmission issue, and instead considers only one or two PTSD criteria indirectly. Further complicating research in this field is the lack of a PTSD measure modified to fit offspring of trauma survivors not directly exposed to the stressor. Nonetheless, in order to further our discussion of trauma transmission, we will now consider the possibility of the transmission of actual PTSD symptoms from those described in the DSM-IV (APA, 1994). The primary focus at this point will be on studies that provide evidence for the relevance of a given criteria when referring to survivor offspring.

PTSD Criteria

There are six criteria that need to be met in part or whole in order to establish PTSD as a diagnosis based on the diagnostic criteria in the DSM-IV (APA, 1994). Psychological literature will be reviewed as a source of data to determine if there is evidence that a given criteria could be used to refer to the second generation and to strengthen the case for further research.

Criterion A: The Traumatic Stressor. Criterion A has two parts, both of which must be met prior to proceeding with a diagnosis based on the following 17 core symptoms described in Criteria B, C, and D. The first part states that the individual has had personal involvement in a life or death event or threat, that is seen as compromising to personal safety or that of friends, associates, or family. The second part focuses on the person's response to the stressor. This response is to be assessed for components of horror, terror or helplessness. The wording of Criterion A is interpreted here as allowing for generalizations to the offspring of trauma survivors. While offspring of Holocaust survivors did not directly suffer through the Holocaust themselves, they may have shared the horrific memories, fears, and losses of their parents. The messages passed on from parent to offspring, whether verbal or nonverbal, can create an atmosphere of keen awareness of a frightening past. Jucovy (1983) very succinctly points out that trauma is very much a part of the Holocaust survivor's family environment: "the child of a survivor is, after all, exposed to the Holocaust as filtered through the experiences of the parents" (p.19).

In 1974, Kestenberg brought together a study group whose purpose was to discuss the relevance of the Holocaust on second generation therapy patients (Jucovy, 1983). Kestenberg believed that parents' Holocaust experience had such an impact on the offspring that dealing with the Holocaust was essential to the therapeutic process of recovery in the second generation (Kestenberg, 1973). Similarly, psychologists suggest that psychotherapy with survivor offspring may be inadequate if the traumatic experiences of their parents are not considered (Axelrod, Schnipper, & Rau, 1980; Krell, 1982). Therefore, clinical observations suggest that the impact of the Holocaust on survivor offspring is real and traumatic enough to affect the offspring's psychological well-being.

As early as 1966, Rakoff, Sigal, and Epstein noted that survivor offspring were over-represented in proportion to the number of survivor parents in the local Jewish population serviced at a psychiatry department of a Montreal Hospital. More than 20 years later, Sigal, DiNicola, and Buonvino (1988) reported the same phenomenon among grandchildren of Holocaust survivors. This suggests that the effects of exposure to massive trauma may persist through secondary transmission and as far as a third generation (Epstein, 1979; Sigal, DiNicola, & Buonvino, 1988). In Sigal et al. (1988) the grandchildren of survivors were reported showing "signs of fears or nervousness in everyday ordinary situations" (p.209) significantly more often than controls.

Feelings of fear and helplessness in survivor offspring were noted by Rosenman and Handelsman (1990) in their clinical practice. In 1979, Barocas and Barocas presented some of their clinical findings on the second generation. They reported that the offspring exhibited many symptoms commonly found among the survivor population. These included fear of further persecution and alarm over their vulnerability to death. Sigal, Silver, Rakoff, and Ellin (1973) found children of Holocaust survivors to have significantly less adequate coping abilities and greater behavioral and personality disturbances than offspring in a control group.

In summary, there is some support for the presence of Criterion A-1 (threat to personal safety or that of friends, family or associates) and A-2 (feelings of horror, helplessness, or extreme fear related to the stressor) among survivor offspring. However, the studies cited were not directly focused on the presence of Criterion A among the second generation and so may not have been sensitive enough to reflect precisely on this question.

Criterion B: Re-experiencing Trauma. Criterion B focuses on recurrent, intrusive, re-experiencing of the trauma by the individual. In Axelrod, Schnipper, and Rau's (1980) clinical observations, they recognized the occurrence of an "anniversary reaction" (p. 5) among the second generation where survivor offsprings' psychiatric hospitalization coincided with the major Holocaust trauma experienced by one or both parents. They point out that this reaction in the offspring suggests a persistent reexperiencing of trauma in subsequent generations. As an example of how salient the parents' Holocaust experiences can be for the offspring, Axelrod et al. illustrates an anniversary reaction that reconstructed the parents' Holocaust internment in the survivor offspring's lifetime.

[A] patient inexplicably left his pregnant wife, returned to his parents, and behaved suspiciously. As a result of his suspicious behavior, he was twice imprisoned for robberies he did not commit. His confinement, first in jail, and then in the hospital, occurred at the same age at which both parents were interned by the Nazis (p. 5).

Axelrod et al. (1980) noted that hospitalized survivor offspring often acted as if the hospital was a concentration camp. They concluded that patients seemed to be preparing for a second Holocaust by the following: testing the limitations and freedoms of the hospital setting, feeling isolated, feeling persecuted and in need of rescue. Although these actions and characteristics can be seen in other psychotic patients, virtually all the survivor offspring reported being burdened by distressing Holocaust imagery. In contrast, Zlotogorski's (1985) research resulted in no significant correlations between age of parental internment and ego functioning in the offspring.

As early as 1968, Winnik reported that survivor offspring were afflicted by nightmares featuring terrifying Holocaust imagery as a direct result of stories told to the offspring by the survivor parent. Furthermore, Barocas and Barocas' (1973, 1979) clinical findings suggest that the negative effects of concentration camp exposure is passed down through the generations leaving the successive generation with symptomatology very similar to that of the survivor generation. These include common PTSD symptomatology of intrusive images (B-1), nightmares (B-2), difficulty containing anger (D-2), restricted emotional range (C-6), fear of death (A-2), and other associated symptoms such as depressive tendency and guilt over surviving the Holocaust. The studies cited above provide some evidence of the persistent nature of the parents' trauma on the next generation.

Criterion C: Avoidance and Withdrawal. According to Criterion C, the individual has a tendency to avoid trauma-related cues and experiences emotional numbing. In 1966, psychologists were noting apathy and a "lack of appropriate involvement in the world" (Rakoff, Sigal, & Epstein, 1966, p. 24) among offspring of survivors. This appears to fit within criteria C, particularly items C-4 "markedly diminished interest or participation in significant activities (APA, 1994, p. 428)" and C-5 "feeling of detachment or estrangement from others (APA, 1994, p. 428)."

Rubenstein, Cutter, and Templer (1989) reported Jewish offspring of survivors to have greater death anxiety scores than non-clinical non-Jewish populations. This death anxiety may be a reflection of the sense of a foreshortened future referred to in item C-7. Interestingly, death anxiety scores among survivor offspring were not significantly greater than Jewish non-survivor offspring controls. Jewish people around the world share a common history of persecution which may account for the elevations in death anxiety scores among both the Jewish survivor and non-survivor offspring. The "anniversary reaction" noted by Krell (1982) and Axelrod, Schnipper, and Rau (1980) can also be used to further strengthen the case for the appearance of item C-7 among the second generation. The crucial point is that the survivor offspring are identifying with their parents' trauma and do not assume a normal life span.

Leventhal and Ontell (1989) reported that survivor offspring rated a number of adjectives as being significantly descriptive (p

Criterion D: Hyperawareness. Criterion D can be described as a "hyperawareness" manifested as sleep disturbance, irritability, poor concentration, and heightened vigilance and alarm. A tendency towards repressed aggression among survivor offspring was noted by Krystal in 1968. He suggested, based on clinical findings, that this repression eventually leads to aggressive outbursts. Krell (1982) also reported on the clinical progress of a survivor offspring showing signs of depression and outbursts of anger. This would provide support for Criterion D-2 (flares of anger and irritability) among survivor offspring.

Bergmann and Jucovy (1982) found that children of Holocaust survivors tend to suffer from superego impairments. This clinical finding was later supported by Gross' (1988) empirical study. Survivor offsprings' 16 Personality Factor Inventory scores were low on ego strength and superego strength scales based on norms. According to Gross, low ego strength scores signal sleep difficulty (D-1), irrational fears (A-2) and the tendency to become irritated (D-2) by others. In another study, survivor offspring rated cautiousness as being significantly descriptive of themselves at the p

Criterion E: Symptom Duration. Criterion E states that the PTSD symptoms (referred to in criteria B, C, D) must be present for longer than one month. There is evidence that survivor offspring carry the emotional burden of their parents for many years (Barocas & Barocas, 1973, 1979; Epstein, 1979; Sigal, DiNicola, & Buonvino, 1988). Some researchers report that adult survivor offspring attend group therapy and seek out other forms of mental health support in numbers that surpass Jewish non-survivor offspring (Axelrod, Schnipper, & Rau, 1980; Rakoff, Sigal, & Epstein, 1966). However, more recently, Sigal and Weinfeld (1989) reported no significant differences between children of survivors and non-survivor offspring in seeking mental health support. Nonetheless, other researchers suggest that the trauma is even carried to a third generation suggesting a long-term psychological sequelae of the Holocaust on future generations (Rakoff, Sigal, & Epstein, 1966; Rubenstein, Cutter, & Templer, 1989; Sigal, DiNicola, & Buonvino, 1988).

Social and Occupational Impairment. Finally, Criterion F asserts that the symptoms must be clinically significant enough to impair functioning of life skills. This relatively new criterion, incorporated as an explicit criterion only since the DSM-IV, plays a lessor diagnostic role than those symptoms captured in criterion B, C, and D. Criterion F was mainly established to reflect upon the impact of combat exposure on war veterans. Although there is some controversy regarding the life-skills functioning of military veterans, a number of studies do suggest that, among this population, we see the tendency for high divorce rates, and occupational unemployment or underemployment (Anderson & Mitchell, 1992; Pavalko & Elder, 1990). In contrast, among Holocaust survivors and their offspring a very different pattern of behavior is displayed, characterized by high educational and occupational aspirations and achievements, as well as stable family and marital lives, and social achievements (Davidson, 1981; Eitinger, 1962; Epstein, 1979; Leventhal & Ontel, 1989; Rosenman & Handelsman, 1990; Sigal & Weinfeld, 1989).

Interestingly, according to Rose and Garske's (1987) study, children of survivors reported being significantly more achievement-oriented than non-Jewish control groups, but not significantly different from non-Jewish children of immigrants. This suggests that the Holocaust did not deter survivor offspring from achieving success in areas equal to their same-age Jewish Canadian peers. However, Leventhal and Ontell (1989) suggested that the offspring are struggling with issues of personal contentment and identify strongly with their parents' expectations. Others have reported separation difficulties among survivor families as well as second generation struggles with developing intimacy and trust of others (Freyberg, 1980; Mor, 1990; Podietz et al, 1984; Rose & Garske, 1987; Shoshan, 1989).

Sigal and Weinfeld's (1989) research is the most thorough and appropriately sampled study of its kind, with findings that suggest a well-integrated and psychologically undisturbed second generation. This is not to say that significant numbers of the second generation do not have some form of secondary traumatization, as this question was not directly addressed by Sigal and Weinfeld. In fact, aside from Solomon's work (1988, 1990) there are no studies that use empirical methods to directly test the hypothesis of the transmission of PTSD from Holocaust survivor to offspring. What we can conclude from Sigal and Weinfeld's study is that if the second generation does suffer from some secondary form of PTSD, it does not manifest in significant numbers on the level of impaired life skills.

Discussion

Theories of trauma transmission suggest that children of survivor(s) had to face overt or subliminal Holocaust messages while growing up. Each responded in a unique manner to this material. Some lived in comfortable loving homes where their parents' Holocaust experience was not the dominant theme; others lived in homes of mourning where Holocaust imagery was a constant. Subsequently, in survivor families the trauma of the parent may have become the trauma of the child. The PTSD diagnostic criteria takes the transmission theories one step further by providing a guideline for determining whether trauma is transmitted through generations and if so, what exactly, in terms of the PTSD symptomology, is transmitted. This knowledge may help illustrate both the nature of the perceived stressor and how symptoms of PTSD might manifest in the second generation.

In reviewing the literature in terms of secondary PTSD, the severity of each case is important to consider as some offspring show secondary traumatization while others may manifest a latent PTSD or none at all. The literature does point to a tendency toward latent vulnerability, where offspring exposed to trauma respond with a greater number of PTSD symptoms which last for a longer duration (Solomon, 1990; Solomon, Kotler, & Mikulincer, 1988). Unfortunately, much of the evidence in support of the transmission of PTSD in the second generation has been pieced together from numerous peripheral studies.

Most of the research on survivors and their children is based predominantly on clinical analyses of self-referred mental health clients. The lack of controls in these studies certainly poses a dilemma when drawing conclusions and limits the ability to generalize to a larger survivor and survivor offspring population. Although the case studies presented in the clinical literature do not fall within the realm of strong scientific evidence, they do provide an exceedingly rich source of suggestive material.

At times, empirical studies have shone a more positive light on the subsequent functioning of survivors and their families. However, these studies (cited throughout this document) do not completely account for the complex trauma transmission issues, and in some cases are compromised through non-random samples, measures lacking appropriate sensitivity, unreliable and inadequately validated measures, poorly configured or non-existent control groups, and small sample sizes. Furthermore, these empirical studies often fail to tap the abundant resource gained in extensive clinical interviews or case studies. Subsequently, the absence of pathology in these studies does not adequately reassure the reader that, in fact, no psychological problems exist.

In an attempt to address earlier flaws, some studies have increased sample size significantly and incorporated random sampling techniques (Gross, 1988; Sigal & Weinfeld, 1087, 1080; Weiss, 1088). More recent studies attempt to address earlier flaws such as the acculturation issue by including non-Jewish immigrant and Jewish immigrant control groups (Rose & Garske, 1087; Weiss, 1088). However, there are a number of problems that are common to all Holocaust survivor studies, including the impossibility of random assignment dictated by the historical events and the difficulty of connecting an antecedent event such as the Holocaust with current behavior (i.e., separation difficulties) when so many other factors may have led to this end.

Immigrant status further complicates the Holocaust survivor and survivor offspring literature. Children of Holocaust survivors often report "feeling different" and alienated from their peers (Winik, 1088). This feeling of being alien to one's environment is not unique to survivor families. Obermeyer and Lukoff (1988) suggest that "feeling different" is also reported as being common to children born to immigrant non-survivor families. In fact, a number of researchers suggest that parents' immigrant status rather than Holocaust experience is a stronger factor in predicting significant differences between survivor offspring, non-survivor immigrant offspring and controls in studies measuring psychological, educational, occupational, and familial coping and interpersonal adjustment (Baron, Reznikoff, & Glenwick, 1992; Leon, Butcher, Kleinman, Goldberg, & Almagor, 1981; Rose & Garske, 1987; Rubenstein, Cutter, & Templer, 1989; Weiss, O'Connell, & Siiter, 1986). This raises the issue of the impact of immigration on the second generation and the problem of unravelling the effects of immigration from the effects of the Holocaust.

However, none of the studies related to immigrant status cited above considered the presence of PTSD directly nor the possibility of trauma transmission. Second, there is no evidence based on these articles to refute the relevance of any PTSD symptom criteria. Third, the measures used may not have been adequately sensitive enough to differentiate between survivor and non-survivor immigrant offspring on PTSD criteria. Finally, immigration, in some cases, may simply act to compound the survivor offspring experience of secondary PTSD.

Since the field of secondary transmission of PTSD is in its infancy, the most critical studies have yet to be conducted. There is a great need for research using modified measures of PTSD on survivor offspring and controls (e.g., Jewish immigrant, Jewish non-immigrant, and non-Jewish immigrant controls). It would be best to randomly sample from a non-clinical second generation population to avoid a sampling bias. PTSD measures must be modified to reflect the fact that the second generation did not directly face the traumas of their parents' generation. Multi-method assessment techniques have been demonstrated to produce the greatest success in accurate assessment and diagnosis and are the recommended means of measuring PTSD (Litz, Penk, Gerardi, & Keane, 1992; Malloy, Fairbank, & Keane, 1983; Peterson, Prout, & Schwarz, 1991; Watson, 1990).

There appears to be enough support in the literature to advocate the exploration of secondary traumatization with second generation Holocaust survivors. Awareness of secondary transmission may bring even greater resources into the hands of those who need it -- the second and third generation of survivors and those who will treat them. This research has an important place in both the Holocaust literature and the field of traumatology and may teach us about the possibility of trauma transmission among other traumatized populations.

Send correspondence regarding this article to the first author. E-mail: chai@travelin.com

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