Rachel Yehuda: Cause and Effect

To discover why some survivors of trauma experience PTSD and some don't, scientist Rachel Yehuda must convince a community of Holocaust survivors to let her study them.

Rachel Yehuda is a professor of psychiatry and neuroscience at the Icahn School of Medicine at Mount Sinai and Director of the Mental Health Patient Care Center at the James J. Peters Bronx Veterans Affairs hospital. Her research on PTSD has included both human populations and animal models, neuroendocrinology, and genomic and molecular biological studies of trauma. 


Episode Transcript

During my fifth year of graduate school, I made a decision that would change my life.  I decided to stop killing rodents.  I had been studying the effects of stress hormones on brain function on rats, and I loved the topic.  I loved doing brain surgeries on the animals but I hated stressing them, and I really hated chopping their heads off with the rat guillotine to get their brains.  We called this sacrificing.  I was doing so much sacrificing that I started to have nightmares about it and that’s why I decided to stop. 

Now, my graduate school advisor was concerned.  Well, he was about to lose his most experienced assassin, but he also worried about my career.  Without having animal brains, how would I succeed as a neuroscientist?  So he strongly advised me to reconsider. 

But instead, I got pregnant and I decided it was time to start living with my husband, Mitch.  We had been married for almost four years already but I hadn’t found the time to move in with him because I was so busy in graduate school. 

So I moved out of state.  I had a baby, a boy, Daniel.  I somehow managed to write my dissertation.  I did some retraining in psychology and I landed a postdoctoral fellowship at Yale Medical School in the Psychiatry Department.  And the best part of that was no rats. 

So it’s 1988 and I’m at the West Haven VA.  There's a new diagnosis and it’s called posttraumatic stress disorder, PTSD, and it’s controversial.  That’s because stress effects go away when you remove the stressor.  But the Vietnam veterans at the VA behaved like they were still in combat even though the war had been over for nearly two decades.  They had depression and anxiety and nightmares and that’s why they established the diagnosis.  But a lot of people thought that’s just regular mental illness and it has nothing to do with combat trauma. 

As for me, I just couldn’t understand why there needed to be a controversy when we just measure stress hormones.  And who best to do that better than me?  No one. 

So I really thought I was at the right place at the right time but, certainly, if stress hormones were elevated, this would be proof that the Vietnam veterans were still under stress.  But when I measured the hormone cortisol, our levels were low in those with PTSD.  It didn’t make any sense to me and I couldn’t explain it unless of course I had done something wrong.  So we decided to repeat the experiment. 

Of course I was praying for a different outcome.  High levels of cortisol that would have legitimized the diagnosis and, of course, it would have legitimized me too.  But the results came out the same.  Cortisol levels were lower in combat veterans with PTSD. 

So I started to get really excited.  Here was a juicy mystery to solve and I published the findings thinking that everybody would be excited too.  I could not have been prepared for what happened next. 

Advocates for the diagnosis were really upset.  The data had apparently undermined a political cause and people started saying such derogatory things about my research, questioning my data and my methods and my conclusions and even my motives.  It’s all still there in the scientific literature for anyone to read.  But the point is my brand new career was taking a nosedive and I had to do something fast. 

But I was pregnant again.  So I had my baby, a girl, Erica.  And during my two-week maternity leave, unpaid, I had plenty of time to think.  I knew that I had done the cortisol measures correctly and also my gut told me that the Vietnam veterans were not exaggerating the effects of combat.  So what are we looking at here?  Could it be that something had gone wrong with the normal stress response that was preventing recovery?  Or maybe it wasn’t normal stress at all but traumatic stress.  Maybe somehow the effects of trauma are different in a way that explains why symptoms persist. 

I knew that what I needed to do to understand this was try to come up with some examples of long-lasting effects of trauma from my professional clinical experience.  But I didn’t have any.  So I had to think about this based on my personal experience. 

I grew up in the Jewish community of Cleveland Ohio, which was also home to hundreds of holocaust survivors who emigrated from DP Camps following the war.  I figured the holocaust is at least as bad as Vietnam.  Many of the children of holocaust survivors were my classmates and my friends.  Had we ever talked about the holocaust?  Were their parents suffering? 

I remember the first time in the ‘60s when someone tried to tell me what a concentration camp was and all I could do was conjure up images of summer camp.  And in the ‘70s, we used to have all of these discussions about whether the holocaust could happen again in the United States.  I really thought those were rhetorical questions.  I guess I felt safe.  But I could see that my friends who had holocaust-survivor parents were actually, in some way, preparing for this possibility. 

Now, my father being a rabbi in the community and also my mother, I guess they had many occasions to interact with survivors.  So in retrospect, now that I thought of it, there were hushed whispers that so-and-so was orphaned at an early age, parents brutally murdered.  And there was one family that cooked, ate, and slept in their basement leaving two floors above unoccupied.  I guess they still felt like they were in hiding. 

So I grew increasingly focused on holocaust survivors.  I’m breastfeeding my little Erica thinking, “I wonder what cortisol levels are like in holocaust survivors?” 

So when I came back, I couldn’t wait to tell my postdoctoral mentor my idea.  I said, “We have to measure cortisol levels in holocaust survivors.” 

And he said, “You know, it’s a good idea, but where would we find money for this project?  And how are you going to find holocaust survivors at Yale?” 

But I already knew.  “We should go to Cleveland.  It’s only 500 miles away.  We could drive there in ten hours.  And we could all stay at my parents’ house.  They have four bedrooms.  And my mother would cook for us.”  I didn’t really think we needed money.  What we needed was to get holocaust survivors to agree to talk to a stranger, a psychiatrist, and relieve their most traumatic experiences and catalog 50 years of mental health symptoms and then give me their blood and urine so I can measure stress hormones.  And that’s not something money can buy, let me tell you. 

To even give you a better perspective, one of my friends said that I would be the first person to do biologic research on holocaust survivors since Mengele. 

But I was undeterred.  I figured I would do some public speaking, town halls, focus groups, get buy-in.  I just needed the right pitch. 

So at the first venue, I decided that truth is my right pitch.  And I said I'd been working with Vietnam veterans and now I want to see whether holocaust survivors are similar.  And a man got up and said, “They had guns.  We were defenseless, hunted like pray.  You can’t compare us.  It’s totally different.”  I was not expecting that response. 

But I learned something important from it.  Trauma survivors are really focused on how their experiences make them different from other people.  So the next time, I said holocaust survivors are unique.  They can’t be compared to anyone and that’s because they endured the unimaginable and are amazing examples of coping and resilience. 

And a woman got up and said, “I’m not an example of that.  I have a lot of symptoms.  I have a lot of nightmares.  And my survival was pure chance.  Sounds like you're interested in studying luck.”  So I wasn’t expecting that either. 

But the good news about that was that here I had been tiptoeing around this whole idea of mental health symptoms because, let’s face it, I grew up with these people.  But maybe it was okay to talk about symptoms.  So the third time, I knew exactly what to do. 

I went in and I said, “I’m sure many of you in this room still have nightmares and suffer as a result of the holocaust.  If we can just locate the biologic source of these symptoms, we could develop treatments and end the suffering.” 

I really thought I had broken through, but a man got up and he said, “Biologic?  Science?  You mean like the ones the Nazis used to justify exterminating the Jews in the first place?  Are you trying to give Hitler a posthumous victory?  It’s not enough that he has our victims and now you want to give him the ammunition to be able to claim our survivors as his casualties?”  He was so angry, and all I could think of at that moment was that I missed my rats. 

With rats, I never had to walk this tightrope between stigmatizing the effects of what I had done to them and validating their symptoms.  But the truth was I was really deflated and I really didn’t know what to say.  I was completely out of pitches. 

In frustration, I turned to a woman that I had known for a long time as we were walking out and I said, “I just don’t understand.  I’m just asking for urine, something you're gonna throw out anyway.  If I can learn something from it, why won’t you help me?” 

She looked at me and she said, “If Rabbi Yehuda wants my urine, he can have it.” 

What?  What a strange thing to say.  And what does my father have to do with anything?  But then I understood.  It was my father’s goodness and dedication to the truth qualities so strong that if he asked for urine, his students trusted him enough to just give it to him. 

So it wasn’t about the pitch, it was about the trust.  You can’t do human research if people don’t trust you to be dedicated to the truth.  I knew that I would have to earn that trust.  Eventually, I must have because people started agreeing to be in the study.  And when they did, I got to take a whole group of my Yale colleagues to Cleveland. 

We borrowed a centrifuge and pipettes and lab supplies and we set up a laboratory in my parents’ basement and we used my mother’s cleaned-out freezer to store specimens.  And we made arrangements to interview holocaust survivors in the comfort of their own home. 

On the way down, I gave my crew some really critical instructions.  I said, “You know, they're gonna offer you coffee and cake.  Take it.  Ask for seconds, and then you can stay and get all the stories you need.” 

And when we measured cortisol levels in holocaust survivors we found that they were low, but only if the survivors had PTSD.  That turned out to be an important breakthrough. 

But why did so many of them have PTSD fifty years later?  More than half of them that we interviewed did.  And why hadn’t they spoken up about their symptoms in the past?  One woman explained it really well to me.  She said, “The veterans, they have VAs.  Where would we go?  We don’t have anywhere to go to be treated for what happened to us.” 

And those words resonated deeply.  I felt in them an obligation.  Holocaust survivors had just given something to me and now I would have to give something back. 

A few months later, I’m interviewing for a job at the Mount Sinai School of Medicine in the Department of Psychiatry and I told the chairman that one of the things I want to do is develop a Holocaust Clinic in New York.  He said it was a great idea.  In fact, a moral imperative, and he would help maybe even financially. 

We did set up the clinic.  We saw hundreds of holocaust survivors and their offspring who also came complaining about their symptoms.  A few years later, I finally got invited to give my first plenary talk at an international meeting.  I was so excited, but I was also so pregnant with my third child, Rebecca.  But I had to go.  I knew that the cortisol findings were still considered dubious and I had to take this opportunity to explain them. 

So I flew halfway around the world.  I got to the meeting.  I waddled up to the podium.  I said, “Hi, I’m Rachel Yehuda.  I’m pregnant.  Does anyone know how I got this way?  Of course, you all do.  Sex.  Pregnancy results from sex.” 

Oh, I should tell you that at that time that was actually a requirement. 

“But I’m sure a lot of you have had that too and yet not everyone in this room is pregnant.  For pregnancy to occur following sex, it can only happen to some people and only under the conditions where the hormonal environment is just right.  What I'd like to tell you today is that I think the same thing is true about trauma and PTSD.”

“PTSD doesn’t happen to everyone who’s exposed to trauma.  It may just be in some people and only when the hormonal environment is just right.  And having low cortisol levels at the time of the trauma may make it really difficult to suppress the body’s adrenaline levels which creates the perfect environment for PTSD to develop.”

I've just told you the story of my first few years as a scientist.  I had to be productive or my career wouldn’t launch.  But I also had to be reproductive or my family wouldn’t launch.  To my surprise, I found that the synergy of these two threads helped me find my scientific voice.  Thank you.