Journal of Traumatic Stress. Vol. 14, No. 4, 2001

Does Everyone Have a Name? Psychological Distress and Quality of Life Among Child Holocaust Survivors With Lost Identity

Marianne Amir’.3 and Rachel Lev-Wiese12

Knowing one’s identity, name, and biological parents is considered essential to personality development and psychological well-being. This study assessed post- traumatic stress disorder (PTSD) symptoms, subjective quality of life (QoL), psy- chological distress, and potency in a group of adults who were children during the Holocaust (child Holocaust survivors) and who did not know their true iden- tity. Twenty-three such survivors were compared to 23 child Holocaust survivors who knew their identity. Results showed that survivors with lost identity had lower physical, psychological, and social QoL and higher somatization, depression, and anriety scores than did survivors with known identity. The findings suggest that the psychological consequences of not knowing one’s identity are long-lasting. KEY WORDS: child holocaust survivors; lost identity; PTSD; quality of life.

“Who am I? Who are my parents? Do I look like either of them? I would give my entire current life for a moment with my parents.. .just to see them once.. . to hug my mother, to be kissed by her, to know my real name. I lost my childhood. Why did I have to lose my identity as well?’

C, a child Holocaust survivor from Poland, was handed by her parents to a Catholic family at the age of 6 months to be hidden from the Nazis during the Second World War. She was baptized and given a new name by her foster family. Her name was again changed 5 years later by the Jewish Agency by whom she

‘Department of Behavioral Sciences and Department of Social Work, Ben-Gunon University of the Negev, Beer-Sheva, Israel.

’Department of Social Work, Ben-Gunon University of the Negev, Beer-Sheva. Israel. 3T0 whom correspondence should be addressed at Department of Behavioral Sciences. Ben-Gunon University of the Negev, 84105 Beer-Sheva, Israel; e-mail: mamir@bgumail.bgu.ac.il.

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was brought to Israel. All her adult life C has been searching in vain for members of her original family.

Situations such as this raise questions regarding the psychological effects of not knowing one’s original name and identity, family members, or family history. Most mental health professionals agree that when the child’s basic sense of security is disrupted, the impact may be long-term. A stable relationship with a parental figure capable of fulfilling the child’s emotional and physical needs is critical to the child’s psychological development and ability to maintain psychological equilibrium throughout life (Klein, 1974; Krell, 1985, 1993; Winnicot, 1965). This type of stable parent-child relationship was unattainable for the majority of Jewish children in Nazi occupied Europe between the years 1939 and 1945.

There is no exact information regarding the number of children who survived the Holocaust. However, it is known that approximately 50,000 children settled in Israel at the end of the Second World War. Most of the Jewish children who managed to survive the Holocaust were hidden in Christian families, convents, monasteries, orphanages, or among partisans. Typically, these children were given new identities. Those handed to foster families or Catholic institutions at a very early age often lost all trace of their original identity.

Regardless of the fact that the majority of child survivors now live nor- mal and creative lives as adults (Krell, 1993), a number of qualitative studies examining PTSD symptoms and adaptation strategies, suggest that most of the participants in these studies still suffer from the survivor syndrome and FTSD symptoms (Breiner, 1996; Krell, 1993; Mazor & Mendelsohn, 1998; Moskovitz & Krell, 1990; Robinson, Rapaport-Bar-Sever, & Rapaport, 1994; Tauber, 1996). Kestenberg (1992, 1993) maintains that child survivors often suffer from depres- sion, phobias, and distorted self-images. Other researchers have suggested that the most outstanding psychological effects of their former persecution are the loss of psychological identity and feelings of self-worth (Bunk & Eggers, 1993), as well as a lifelong sense of bereavement (Mazor & Mendelsohn, 1998).

The concept of personal identity refers to an inner sense of wholeness and security which is achieved when there is continuity between the individual’s per- ception of self and others’ perceptions of himher (Erikson, 1968). Personal iden- tity is the outcome of identifications with significant others and developmental processes experienced throughout life. The formation of one’s identity begins in infancy and continues through adulthood. Identification plays a central role in the individual’s ability to form object relationships (Klein, 1976). If the process of identification is arrested or sabotaged, there may be long-term detrimental effects on the individual. Such effects may include poor quality of life and a weakened personality structure (Jensen, Huber, Cundick, & Carlson, 199 1).

This report addresses a group of child Holocaust survivors who, in addition to being exposed to the atrocities of the Holocaust, do not know their true identity as a result of being separated from their parents during early childhood. To the best

Psychological Distress, Quality of Life, and Lost Identity 86 1

of our knowledge, there is no quantitative research regarding the consequences of losing one’s original identity on the psychological well being of child Holocaust survivors. We compared two groups of child Holocaust survivors: those who man- aged to retain their original family identity (knowledge of name and identity of biological parents), and those who had lost this identity. The two groups were assessed on the following variables: Prevalence of full and partial PTSD, inten- sity of PTSD symptomatology, quality of life (QoL), psychological distress, and potency. It was hypothesized that the survivors with lost identity would exhibit higher frequency of PTSD, higher levels of PTSD symptoms, lower QoL, more psychological distress, and lower potency scores than survivors who knew their original identity.

Method

Participants

Participants (N = 46; 23 men and 23 women) were recruited from among the members of two “hidden children” organizations in Israel. All participants were Holocaust survivors who were born after 1931 in areas occupied by the Nazis (Poland, Belgium, and France) during the Second World War. Participants con- sisted of two groups: Group I (n = 23) included survivors who had lost their orig- inal family identity (i.e., did not know their original name or who their biological parents were). Group I1 (n = 23) included Holocaust survivors who had retained knowledge of their original identity. The groups were matched as to where the person had been during the Holocaust (i.e., whether the person had been hiding in the woods, in a Catholic orphanage, with a Christian family, or in a concentration camp). Both groups were approached by telephone by undergraduate students in Psychology and Social Work. If they agreed to participate they were met individu- ally in their home. Table 1 shows the demographic variables for the two groups. No significant differences were found between the group means with regard to gen- der, marital status, education, and age. Two persons with lost identity who were approached refused to participate and five persons with known identity refused. Data collection was conducted in the spring of 1999.

Instruments

Demographic data questionnaire. In this questionnaire, information was obtained regarding identity, sex, age, education, marital status, and where the person had been during the Holocaust. If the survivor had been in more than one place, he/she was asked to indicate which had been the main, or most important, experience.

862 Amir and Lev-Wiesel

Table 1. Demographic Characteristics of the Two Study Groups

Lost identity Known identity (n = 23) (n = 23)

% Males 52 48 x 2 (1, N = 46) = 0.09 96 Married 73 71 x 2 (1. N = 46) = 0.09 % Educationa 55 49 x 2 ( l , N =46)=0.12 Age M = 62.83 M = 64.65 t(44) = 1.47

Holocaust experience (SD = 3.95) (SD = 3.21)

Hiding in woods 4 4 Catholic orphanage 5 5 Christian family 12 12 Concentration camp 2 2

USome education beyond high school.

PTSD Scale. The PTSD inventory used in the study was a self-repon scale adapted from Horowitz, Wilner, Kaltreider, and Alvarez (1980). This instrument has been used extensively in Israel (e.g., Amir & Sol, 1999). The PTSD Scale is based on DSM-Ill-R criteria (American Psychiatric Association, 1987) for the diagnosis of PTSD. The scale consists of 17 items corresponding to the 17 main symptoms of PTSD. Respondents indicate for each statement whether or not they have experienced the specified symptom “during the last month.” The PTSD Scale assesses whether or not a person is suffering from PTSD, and measures the in- tensity of the three primary symptom groups: Intrusion, avoidance, and arousal. Following the change of the criteria in DSM-IV (American Psychiatric Associa- tion, 1994), an additional item was added to the questionnaire in the present study which assesses whether the respondent’s response to threat involved feelings of intense fear, helplessness, or a sense of horror. Respondents rate the occurrence of each symptom on a 4-point scale: 1: does not occur at all, 3: sometimes occurs, 5: occurs often, and 7: occurs very often. A score of 5 or 7 is considered full endorsement and a score of 3 partial endorsement of that symptom. Cronbach’s a! in this study was .74, .83, and .83 for intrusion, avoidance, and arousal, respec- tively. In completing the PTSD scale, the survivor was asked to specifically relate to Holocaust experiences (even if he/she had experienced additional traumatic life events). Leshem (1999) found for 69 Yom Kippur War veterans the following means and standard deviations: M = 2.42, SD = 1.15; M = 2.19, SD = 1.07 and M = 1.8 1. SD = 1.03, for intrusiveness, arousal, and avoidance, respectively.

Quality of life. In order to assess QoL we used a generic instrument, the WHOQOL-Bref (The WHOQOL Group, 1998). This instrument was developed simultaneously by 15 academic centers world-wide under the auspices of the World Health Organization. It consists of 26 items divided into four broad domains: Physical health (I), psychological health (II), social relations (111), and environ- ment (IV). Cronbach’s a! in the present study was .81, .76, .79, and .82 for domains I, 11,111, and IV, respectively. In the above mentioned study with Yom Kippur War

Psychological Distress, Quality of Life, and Lost Identity 863

veterans (Leshem, 1999) the following means and standard deviations were ob- tained: M = 14.22, SD = 2.33; M = 15.36, SD = 2.23; M = 15.12, SD = 3.08 and M = 14.38, SD = 2.4 for the physical, psychological, social, and environ- mental domains, respectively.

Psychological distress. The SCL-90 is a self-report measure that assesses the occurrence of psychiatric symptoms during the preceding 2 weeks. This scale pro- vides a measure of the seventy of general psychiatric symptomatology (Derogatis, 1977). In this study, we related to four subscales most relevant to the research question: Depression, anxiety, obsessive-compulsive problems, and somatization. The Hebrew version has been used extensively in PTSD research in Israel (e.g., Amir & Sol, 1999). Cronbach’s (Y in this study for the scales of depression, anxi- ety, obsessive-compulsive problems, and somatization were .92, .90, .80, and .87 respectively. The American norms for the SCL-90 (Degogatis, 1977) in a non- clinical sample are as follows: M = 0.36, SD = 0.44; M = 0.30, SD = 0.37; M = 0.37,SD = 0.45; and M = 0.36,SD = 0.42 for depression, anxiety, obsessive-compulsive problems, and somatisation, respectively.

The Potency Scale (Ben-Sira, 1985). “Potency” is defined by Ben-Sira (1985) as the individual’s level of self-esteem, sense of control over hisher life, commit- ment to society (as opposed to alienation), and perception of society as being a just and orderly entity (as opposed to anomie). It is an experience-based confidence both in one’s capacity to cope with stressors and the belief that things, conse- quently, usually work out reasonably well. Potency has the capacity to arrest the delitionous impact of stress over and above other personal resources, meaning it is activated when other personal resources prove inadequate (Ben-Sira, 1983, 1985).

The Potency Scale consists of 19 items that assess the respondent on these variables. The distribution of items is as follows: Self-confidence (3 items), control (6 items), social commitment (5 items), and social significance and order (5 items). The items appear in statement form and the respondent is requested to rate the degree to which he/she agrees with each statement on a 5-point scale. One total score is given which reflects the mean across all 19 items. The Potency Scale has been found to be a reliable and valid measure in a number of studies conducted on different populations in Israel (Ben-Sira, 1985, 1991; Lev-Wiesel & Shamai, 1997). Cronbach’s a in this study was .89. In a study of a nonclinical sample awaiting relocation in the Golan Heights the potency mean and standard deviation were found to be M = 3.67 and SD = .58 (Lev-Wiesel, 1998).

Results

In order to examine the impact of retaining, versus not retaining, one’s original identity on PTSD symptomatology, QoL, psychological distress, and potency, two analyses were performed: First, we calculated the frequency of survivors suffering from full and partial PTSD in the two research groups. Following this, we compared

864 Amir and L e v - W i d

the two groups (lost identity versus known identity) in terms of the four groups of psychological variables, PTSD symptoms, QoL, psychological distress, and potency.

Because of the small sample size, we combined survivors with full PTSD and partial PTSD in each group. Ten participants (50% of those with no missing values) with lost identity had full and partial PTSD. In the group with known identity 10 participants (46% of those with no missing values) had this diagnosis. There was no significant difference between the two survivor groups in terms of the frequency of full and partial PTSD symptoms ( x 2 c 1).

Three MANOVAs with the two study groups (lost identity and known Identity) as the independent variable were performed: (1) With the three PTSD scales as the dependent variables; no significant effect for group was obtained, Wilks' lambda (3,42) = .99,m. (2) With the four SCL-90 scales as the dependent variables; a significant effect for group was obtained, Wilks' lambda (4.41) = .79. p < .05. (3) With the four WHOQOL-Bref scales as the dependent variables; a significant effect for group was obtained, Wilks' lambda (4,41) = .75, p < .05. An ANOVA for potency did not reveal any significant difference between the two groups. It should be noted that, as the hypothesis was that the survivors with lost identity would have higher distress scores, lower QoL, and potency scores than would the survivors with known identity, the appropriate p level is according to a one-tailed test. Means, SDs, and unvariate one-tailed t-tests scores are presented in Table 2.

As can be seen from Table 2 the t-tests for the PTSD Scale did not reveal any significant group effects on any of the subscales. In three of the four measures of the WHOQOL-Bref, the physiological domain, the psychological domain, and

Table 2. Means and Standard Deviations (in Parentheses) for the Psychological Variables Among Survivors With Lost and Known Identity (N = 46)

Lost identity Known identity (n = 23) (n = 23) t(44)

PTSD Intrusion 3.95 (I .36) 3.96 ( I .60) .oo Arousal 3.45 ( I .89) 3.28 (1.34) -.34

Domain I-Physical 12.14 (4.10) 15.76 (2.74) 3.54..

Avoidance 2.71 (1.11) 2.74 (I .37) .08

Quality of life

Domain II-Psychological 12.75 (2.98) 14.37 (2.29) 2.08' Domain 111-Social 13.27 (2.36) 14.78 (3.28) 1.78' Domain IV-Environmental 14.22 ( I .72) 14.71 (2.44) 0.80

SCL90 Depression 1.18 (9) 0.12 (254) - 1.87' Anxiety 0.93 (.74) 0.61 (.SO) -1.61' Obssessive<ornpulsive 0.94 (.73) 0.69 (.49) - 1.29 Somatization 1.13 (.93) 0.58 (.43) -2.44-

Potency 3.56 (.91) 3.64 (.69) .I0

* p < .05. ' * p < .01. All tests were one-tailed.

Psychological Distress, Quality of Life, and Lost Identity 865

the social domain, the survivors with known identity scored significantly higher than did the survivors with lost identity. The univariate r-tests for the SCL-90 subscales revealed that of the four measures, the two groups differed significantly on the measures of somatization, depression, and anxiety in that the survivors with lost identity had higher distress scores than did the survivors with known identity. When looking at the norms and data from other studies, it can be seen that both samples are somewhat higher on distress than nonclinical samples, with the exception of the scores for the QoL domains for the group of known identity and for the potency score.

Discussion

This study attempted to examine the impact of lost identity on Holocaust child survivors’ psychological well-being in adulthood. The results indicated that not knowing one’s original identity does not lead to greater levels of PTSD. Both survivors who knew their original identity and survivors who lost their identity evidenced similar levels of full or partial PTSD as well as intensity of PTSD-symp- toms. However, survivors with lost identity had significantly lower physiological, psychological, and social QoL and had significantly higher levels of depression, anxiety, and somatization compared to those who had retained their identity. The groups did not differ with regard to their potency score.

It should be emphasized that both groups of child Holocaust survivors in the present study were somewhat more symptomatic on most measures than were other groups of respondents; therefore, the difference between them should be seen in the context of Holocaust survivors and not as survivors versus nonsurvivors.

It is interesting to note, contrary to our expectations, the potency measure did not show any difference between the groups. This shows, as Ben-Sira (1991) suggested, that potency may be an inborn trait consisting of one’s capacity to bear pain and one’s ability to respond correctly with no hesitation in threatening, unexpected situations. This line of thinking may also be strengthened by the fact that there was no significant difference between the potency scores of the two study groups and the nonclinical Golan Heights’ sample mentioned in the method section.

The finding that there was no difference between the two groups as to the rates of PTSD and intensity of PTSD symptoms was also counter to our expectations. It is possible that not knowing one’s identity is not a trauma in the sense of being exposed to physical danger (i.e., Criterion A, American Psychiatric Association, 1994), i.e., a trauma where the consequences may be less immediately disturbing, but have more pervasive long-term consequences, not necessarily PTSD or PTSD symptoms. The outcome may be the development of a different, perhaps more subtle and possibly more serious, pattern of symptoms that later expresses itself as lowered psychological well-being and QoL as was found in this study. In addition,

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it is possible that the time in the life of a person at which the trauma occurs may affect how PTSD is evidenced. When survivors are younger, trauma may have more pervasive effects on the personality and psychological functioning and not express itself as traditional PTSD symptoms of intrusive thoughts, avoidance, and hyperarousal.

Not knowing one’s identity appears to be associated with an exaggerated focus on physical well-being among child Holocaust survivors. This is expressed both in an increased level of somatization symptoms and a lower physical QoL. The finding that Holocaust survivors in general exhibit heightened levels of somatic complaints has been noted earlier (e.g., Bower, 1994, Stermer, Bar, & Levy, 1991) as well as higher levels of chronic pain (Yaari, Eisenberg, Adler, & Birkhan, 1999). Other research has shown that high degrees of somatization are often associated with very early psychological injury, such as sexual abuse (Bell, 1994). This suggests that somatizing behavior among adults may derive, in part, from childhood. This idea is supported by the findings of Stuart and Noves (1999) on somatizing patients, indicating that anxious attachment behavior derives from childhood experiences with caregivers. According to them, when under stress as adults, somatizers use physical complaints to elicit care. Concieveably, not knowing their identity may create a basic; underlying imbalance in Holocaust child survivors’ psychological state, anxious attachment behavior, and consequent somatization in adulthood. In addition, it is possible that they perceive their body as the only continuous, existing identity, and the only clear evidence of their original identity they have, and so feel it must be guarded with great caution. This is in line with van der Kolk’s research on the biology of PTSD suggesting that there are persistent and profound alternations in stress hormone secretion and memory processing in patients with PTSD (van der Kolk, 1999). According to van der Kolk (1999) the body seems to remember the trauma even if the mind seems to forget. Yehuda, McFarlene, and Shalev (1998) also suggested that the development of PTSD may be facilitated by an atypical biological response in the immediate aftermath of a traumatic event (in this case may be the separation from the parents) which in turn leads to a maladaptive psychological state.

It should be noted that heightened somatization scores have been found in a variety of trauma populations, most recently in studies with a community sample exposed to an airline crash (Chung, Easthope. Eaton, & McHugh, 1999). a health maintainance organization population in the USA (Andreski, Chilcoat, & Breslau, 1998) and Vietnam veterans (Beckham et al., 1998). This indicates the possibility that somatization is related to trauma exposure in general and not to Holocaust survivors in particular. Possibly the predisposition is formed at an early age and later exposure to trauma may activate this. Further studies should address this issue.

Some understanding of this specific population can be gathered from the study of adoption. Most studies on children’s adjustment have concluded that

Psychological Distress, Quality of Life, and Lost Identity 867

adopted children have increased problems, at least during middle childhood and early adolescence (Brodzinsky, 1993). When examining those studies focusing on the search process among adult adoptees (Schecter & Bertocci, 1990) it can be concluded that the need to know about one’s birth origin can be quite significant. The motivation for this search is complex, but essentially is grounded in feelings of loss and disconnectedness from one’s origin. In this sense, the psychology of adoptees and Holocaust surviviors who were separated from their families at an early age has some similarities, although the outcome for the latter group clearly is affected more by the trauma and atrocities they were exposed to. It should be noted that the present group of survivors were all members of a “hidden children” organization searching for clues and knowledge of their past (one of the stated purposes of this organization). In this sense they are similar to adoptees that are searching for their identity.

This study was limited in that there might be a potential third variable problem, in spite of the fact that we controlled the general type of experience (e.g., foster home, etc.). It may be that the group with lost identity differs from the comparison group in other ways, such as the quality of social support they received from their environment and personal resources prior to the Holocaust. Further studies should address this issue. In addition the sample was relatively small, which limits the . ability to generalize from the conclusions.

long lasting consequences with regard to one’s well-being. In conclusion, this study suggests that not knowing one’s identity can have

Acknowledgments

This research was supported by a grant from the Conference on Jewish Material Claims Against Germany, Inc. and by the Israel Science Foundation Grant number 777/99- 1. We thank Dr. Avi Besser for his invaluable help with all the drafts and data analyses of this paper.

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