Research report Depression, anxiety and loss of resilience after multiple traumas: an illustration of a mediated moderation model of sensitization in a group of children who survived the Nazi Holocaust Pierre Fossion a , Christophe Leys b,n , Chantal Kempenaers c , Stephanie Braun c , Paul Verbanck a , Paul Linkowski c a Brugmann Hospital, Université Libre de Bruxelles, Brussels, Belgium b Faculty of Psychology, Université Libre de Bruxelles, Brussels, Belgium c Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium article info Article history: Received 14 March 2013 Received in revised form 19 July 2013 Accepted 12 August 2013 Keywords: Resilience Holocaust Trauma Older adults abstract Background: Depressive and anxiety disorders (DAD) have become a major public health problem. Multiple trauma is known to increase the risk of DAD through a sensitization mechanism. We investigate the hypothesis that resilience is a mediator of this mechanism. Methods: Former Hidden Children (FHC), the Jewish youths who spent World War II in various hideaway shelters across Nazi-occupied Europe, were compared with a control group. In each group, we measured the presence of multiple traumas, the resilience with the Resilience Scale for Adults, which has a six factors solution, and the DAD with the Hopkins Symptoms Checklist. We test a mediated modera- tion model with childhood trauma as the predictor; Later trauma as the moderator; Resilience as the mediator; and DAD as the outcome variable. Results: Results are consistent with a sensitization model of DAD mediated by resilience: confrontation with a primary trauma during childhood followed by secondary trauma(s) after childhood damages resilience, which, in turn, results in higher level of DAD. Limitations: We are unable to differentiate if the sensitization process is a consequence of the nature of the trauma endured by FHC (long-standing exposure to extreme external events) or a consequence of the fact that this first trauma occurred during childhood. Conclusions: Resilience construct is multi-factorial and a limited damaging of some of the factors is sufficient to lead to DAD even if other factors remain unaltered. Resilience can be altered by multiple traumas and, therefore, needs to be bolstered in therapy sessions. & 2013 Published by Elsevier B.V. 1. Introduction Depressive and anxiety disorders (DAD) have become a major public health problem in Western countries. In the USA, the life- time prevalences of depressive and anxiety disorders are 28.8% and 20.8%, respectively. In Europe, DAD result in 6% of the burden of all diseases with respect to disability-adjusted life years (DALYs) and are projected to be the disease with the second highest number of DALYs in 2020 (http://www.nimh.nih.gov/ index.shtml). Therefore, an accurate understanding of the risk factors leading to DAD is of crucial importance for both medical and economic reasons. Several authors have emphasized the genetic, biological, socie- tal and psychological components of DAD (Beck and Alford, 2009; Kroenke et al., 2007). This paper focuses on the societal and psychological factors. First, several authors (Mollica et al., 1993; Scholte et al., 2004; Veling et al., 2013) emphasized a link between the presence of a trauma during lifetime and DAD. But, more speci- fically, trauma endured during childhood is known to increase the risk of DAD in adulthood (Terr, 1991; Wingo et al., 2010). Moreover, given that 34% of men and 25% of women in the general population have experienced two or more traumatic events during their lifetime (Kessler et al., 1995), understanding how people cope with multiple trauma is of particular interest. Many studies converge to a sensitization model (Breslau et al., 1999; Green et al., 2000; Sullivan et al., 2009), which implies a reduction in resistance to additional stress following previous exposure to trauma. In the present paper, we further explore this sensitization mechanism by proposing a model based on the concept of Contents lists available at ScienceDirect journal homepage: www.elsevier.com/locate/jad Journal of Affective Disorders 0165-0327/$ - see front matter & 2013 Published by Elsevier B.V. http://dx.doi.org/10.1016/j.jad.2013.08.018 n Correspondence to: Centre de Recherche en Psychologie Sociale et Intercul- turelle, Université Libre de Bruxelles, Bureau DC10.130, Avenue Franklin Roosevelt 50, CP191 1050 Bruxelles, Belgium. Tel.: þ32 26 504 229. E-mail address: cleys@ulb.ac.be (C. Leys). Please cite this article as: Fossion, P., et al., Depression, anxiety and loss of resilience after multiple traumas: an illustration of a mediated moderation model of.... Journal of Affective Disorders (2013), http://dx.doi.org/10.1016/j.jad.2013.08.018i Journal of Affective Disorders ∎ (∎∎∎∎) ∎∎∎–∎∎∎