JERUSALEM — Daughters of Holocaust survivors who functioned adequately in their daily activities have been found particularly vulnerable to psychological distress when they contracted breast cancer.

Israeli researchers who studied middle-aged women with breast cancer who were born to Holocaust survivors found they reacted with "extreme psychological distress" to their illness compared with other patients.

The 113 second-generation women were matched medically and sociodemographically with a comparison group of 114.

The long-term study, published in the American Journal of Psychiatry, tested Jewish women who had been treated for their tumors at Hadassah-University Hospital in Jerusalem's Ein Kerem, the Rabin Medical Center-Beilinson Campus in Petach Tikva, and Sheba Hospital in Tel Hashomer eight months to eight years before they were interviewed.

The researchers were amazed to find extreme differences on two self-reporting questionnaires that assessed the women's psychological conditions. The daughters of Shoah survivors had extremely high scores when asked about intruding, obsessive thoughts and about forcing themselves to avoid frightening or unpleasant thoughts.

While regular patients had "mild psychological distress" — a normal reaction to having cancer — the second-generation survivors scored high on depression, anxiety, hostility, and psychosomatic symptoms.

Many had scores considered to be in the range of psychopathology, said Professor Lea Baider, a Hadassah psycho-oncologist who headed the study, along with Professor Tamar Peretz, director of the Sharett Institute for Oncology, and the late Dr. Atara Kaplan De-Nour.

Second-generation women whose mothers were still alive showed even more severe symptoms, and some refused to tell their mothers of their illness so as not to burden them.

"Children born to survivors were raised when talking about the Holocaust was taboo, as cancer is still a taboo subject among many people," Baider said. "We believe this contributes to their extreme distress.

"In addition, survivors regarded their children as their hope for the future and invested everything in their survival. The children also witnessed psychological difficulties of the parents. All this can help explain our findings."

Peretz, who worked with Baider on a previous long-term study (published in 1994 in General Hospital Psychiatry) on the psychological stresses of Holocaust survivors who developed breast cancer, said she can easily pick out second-generation women among her breast-cancer patients.

"They take it very badly, and you have to take much time to discuss the illness with them," Peretz said. "Group therapy providing emotional support after treatment of their cancer doesn't work for them; they need individual therapy, which is much more expensive and not covered by the health funds."

She thinks that in another decade or so, oncologists will begin to see similar psychological reactions among the third generation of Holocaust survivors.

The research — which Peretz called "the most focused and comprehensive ever to be conducted in the field" — has been expanded following publication last year. The team is now summing up comparisons between the original groups and other women who did not have breast cancer but are daughters of Holocaust survivors, and healthy women without a connection to the Holocaust.

"Our study clearly shows that vulnerability of one traumatized generation is passed down to the offspring. This is a population at risk, and they need suitable emotional support," said Baider, who is seeking a grant that would allow her to study male cancer patients who are sons of Shoah survivors.

Danny Brom, a clinical psychologist and director of the Israel Center for the Treatment of Psychotrauma at Herzog Memorial Hospital in Jerusalem, said he had not read the paper, but he was persuaded that children of Holocaust survivors can be far more psychologically vulnerable when faced with a traumatic life event.

Brom, who edited the latest issue of the Israel Journal of Psychiatry, which is devoted to the psychological effects of the Holocaust on child survivors and on the second generation, said he does not think men from the second generation would react differently from women who contracted cancer.