Parental PTSD, health behaviors and successful aging among offspring of Holocaust survivors

Highlights

• Study examined Holocaust survivors' and offspring health behaviors and aging.

• Holocaust survivors with probable PTSD reported more unhealthy behaviors.

• Offspring of these survivors also reported more unhealthy behaviors.

• Parental PTSD linked with offspring aging via parental and offspring behaviors.

Abstract

Unhealthy behaviors and physical morbidity are more common among trauma survivors, especially those who suffer from posttraumatic stress disorder (PTSD). This study looked at the underexplored relationships between parental PTSD, unhealthy behaviors and aging of trauma survivors' offspring. Dyads of parents (mean age = 82.42) and offspring (mean age = 55.48) reported PTSD symptoms, health behaviors and completed indices of successful aging. Dyads were divided into three groups: Holocaust survivors (HS) with probable PTSD (n = 28 dyads), HS without PTSD (n = 86 dyads) and comparison parents without PTSD (n = 73 dyads). Relative to the other groups, HS parents with probable PTSD and their offspring reported more unhealthy behaviors. Serial mediation models showed that the effect of parental PTSD on offspring successful aging was mediated by both parental and offspring unhealthy behaviors. Findings remained significant after controlling for background characteristics and offspring PTSD. This study provides preliminary evidence that PTSD is related to unhealthy behaviors across generations in HS families. Possible mechanisms for such intergenerational effect and its clinical implication are discussed.

Introduction

Myriad studies have identified traumatic exposure and especially posttraumatic stress disorder (PTSD) as risk factors for unhealthy behaviors including smoking, alcohol abuse and low frequency of physical activity (Rheingold et al., 2004). These behaviors comprise an important path to increased physical morbidity seen among traumatized individuals (Schnurr, 2017). As engagement in health behaviors tend to continue across generations (e.g., Pugliese and Tinsley, 2007), it is possible that parental trauma exposure and PTSD not only relate to parental behavior, but also linger on to associate with health behaviors and physical status of offspring. This latter possibility is underexplored. To address this issue, the current study assessed health behaviors and indices of successful aging among Holocaust survivors (HS) and their adult offspring.

Exposure to traumatic events, and especially PTSD, increase the risk for a variety of health-risk behaviors such as substance abuse (Rheingold et al., 2004). PTSD is also related to less preventive health behaviors (e.g., physical activity, diet and regular utilization of medical care), although this relationship is less consistent across studies (Lee and Park, 2018). Traumatized individuals may turn to substance use with the attempt to rapidly minimize discomfort linked with trauma-related losses, PTSD symptoms and related negative emotions (Rheingold et al., 2004). Decreased preventive health behaviors among traumatized victims associate with dampened motivation for proactive measures, low self-efficacy, and foreshortened future orientation (Lee and Park, 2018).

Relatedly, theoretical models and empirical works suggest that unhealthy behaviors mediate the effect of trauma exposure and PTSD on various markers of aging among survivors (Schnurr, 2017). Utilizing an extensive outlook at the aging of trauma survivors, scholars began to assess the relationship of behaviors with multiple indices of health usually clustered under the concept of successful aging (e.g., Pietrzak et al., 2014, Bodner et al., 2018).

Successful aging was originally described as the combination between freedom from disease and disability and active engagement with life (Rowe and Kahn, 1987). Criticized for depicting an extraordinary or exceptional aging, rather than successful aging (Martin et al., 2015), scholars recently suggested to move from the prior dichotomous operationalization (i.e., either successful or unsuccessful aging) to a continuous one, as individuals experience limitations in one functional domain may perform relatively well in other domains (Kok et al., 2017). Not surprisingly, substance abuse history is among the factors related to less successful aging among trauma survivors (Pietrzak et al., 2014). The current study followed this broad-scope view and assessed the link between health behaviors and successful aging from an intergenerational perspective.

There is a fairly large and consistent literature demonstrating moderate resemblance between parents' and offspring health behaviors. For example, parental alcohol consumption is positively associated with drinking in offspring (Rossow et al., 2016). Similarly, parents' smoking is related to their children's smoking (Leonardi-Bee et al., 2011), and parental modeling behavior, as well as parental support for physical activity, are associated with offspring physical activity (Pugliese and Tinsley, 2007). The correlation between parents' health behaviors and their offspring behaviors can extend for decades (e.g., Hemmingsson et al., 2017).

The link between parents' and offspring health behaviors can reflect the latter tendency to emulate parental behaviors (Bandura, 1986). This link can also result from parents engaging in unhealthy behaviors being more lenient towards children's risky behaviors, or being unable to fulfil their responsibilities and take adequate care of their offspring. Poor parenting accompanying parental negative health behaviors could also associate with mental health and later health-risk behaviors among offspring (Reczek et al., 2017).

Despite the abovementioned findings, the intergenerational association of unhealthy behaviors among trauma survivors and their family members is underexplored. As this study focuses on HS and their offspring, the next section will briefly review the health behaviors and aging in these groups.

Most of the literature suggests that the behaviors and health of HS and their offspring are not an inevitable consequence of exposure per se, but rather, relate to an unresolved attempt to cope with the trauma mainly manifested by parental PTSD (Yehuda et al., 2008, Shrira et al., 2017). Accordingly, large-scale studies on community-dwelling individuals did not find HS (Shmotkin et al., 2003) or their offspring (Levav et al., 2007, Shrira et al., 2011) to differ from comparisons in health behaviors. However, other studies with samples coping with stress, or with samples characterized by significant clinical features, did allude to the possibility of higher rates of unhealthy behaviors among HS and offspring. For example, Kimron and Cohen (2012) showed that HS used more emotional-focused coping (including alcohol use) when being hospitalized. Emotional-focused coping further explained the greater psychological distress seen among HS relative to other hospitalized older adults. In another sample characterized with an extraordinarily high rates of parental PTSD (77.0%), Yehuda et al. (2008) found a slightly higher frequency of substance abuse disorder among offspring of HS relative to comparisons, yet they did not find parental PTSD (as reported by offspring themselves) to be related to an increased risk of such disorder.

With regard to successful aging and its indices, there is evidence that physical morbidity is higher among HS who suffer from PTSD (Brodaty et al., 2004), and burgeoning evidence suggests that their offspring also manifest less successful aging (Shrira et al., 2017) and perceive their aging in less favourable terms (Shrira, 2016). Therefore, the current study will separate HS to those with and without probable PTSD, with an attempt to point at unhealthy behaviors as one possible factor associating with less successful aging in families of HS with PTSD.

The study compared health behaviors and indices of successful aging among HS and comparison parent-offspring dyads. The first hypothesis was that relative to the other dyads (comparison and HS without PTSD), HS with probable PTSD and their offspring would report more unhealthy behaviors. Offspring of HS with probable PTSD will also show less successful aging relative to their counterparts. The second hypothesis maintained that the relationship between parental PTSD and offspring successful aging would be mediated by parents' health behaviors and the health behaviors of the offspring themselves.