- Email: [email protected]
Post traumatic stress disorder and coping in a sample of adult survivors of the Italian earthquake
Psychiatry Research 229 (2015) 353–358
Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Post traumatic stress disorder and coping in a sample of adult survivors of the Italian earthquake V. Cofini a,n, A. Carbonelli a, M.R. Cecilia a, N. Binkin b, F. di Orio a a b
Department of Life, Health and Environmental Sciences, University of L’Aquila, Italy School of Public Health, San Diego State University, USA
art ic l e i nf o
a b s t r a c t
Article history: Received 30 December 2014 Received in revised form 8 May 2015 Accepted 27 June 2015 Available online 2 July 2015
The aim was to investigate the prevalence of post traumatic stress disorder (PTSD) in people who had left their damaged homes and were still living in temporary housing more than a year after the April 2009 L’Aquila (Italy) earthquake. In addition, we evaluated the differences in coping strategies implemented by persons who had and who did not have PTSD. A cross-sectional prevalence study was carried out on a sample of 281 people aged 418 years and living in temporary housing after the earthquake. The questionnaires used include the Davidson Trauma Scale and the Brief Cope. The prevalence of PTSD was 43%. Women and the non-employed were more vulnerable to PTSD, while, age and level of education were not associated with PTSD. Those with PTSD symptoms often employed maladaptive coping strategies for dealing with earthquake and had the highest scores in the domains of denial, venting, behavioral disengagement, self-blame. By contrast, those without PTSD generally had more adaptive coping mechanisms. Adults who were living in temporary housing after the earthquake experienced high rates of PTSD. The difference in coping mechanisms between those who have PTSD and those who do not also suggests that they influence the likeliness of developing PTSD. & 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Natural disasters Psychological distress Post-traumatic syndrome Prevalence
1. Introduction Numerous studies have investigated the prevalence and risk factors for post-traumatic stress disorder (PTSD) following an earthquake. In these studies, prevalence has ranged from 14.5% to 48.2% and appears to be greater in cities that have been heavily damaged than in those with lesser damage (Xu and Song, 2011). On an individual level, studies have shown that damage to victims’ homes increases the risk of PTSD (Cerdá et al., 2013; Kilic and Ulusoy, 2003), and that the quality of life is lower in those who live in temporary housing (Zhang et al., 2011). On April 6th 2009, the city of L’Aquila and surrounding villages in central Italy experienced an earthquake with a magnitude of 5.9 on the Richter (6.3 moment magnitude Mw) scale (Istituto Nazionale Geofisica e Vulcanologia (INGV), 2009). It resulted in 309 fatalities and 1600 n
Corresponding author. E-mail addresses: vincenza.cofi[email protected] (V. Cofini), [email protected] (A. Carbonelli), [email protected] (M.R. Cecilia), [email protected] (N. Binkin), [email protected] (F. di Orio). http://dx.doi.org/10.1016/j.psychres.2015.06.041 0165-1781/& 2015 Elsevier Ireland Ltd. All rights reserved.
persons who were injured, including 200 with severe injuries requiring hospitalization. More than 65,000 people were displaced (Dell’Osso et al., 2011a). In the city of L’Aquila, damages were most severe in the old town, one of the largest of Europe and the center of local life with its many squares, churches, monuments, theaters, schools, and historical buildings. A year after the earthquake, about 45% of families in L’Aquila had houses that were considered “uninhabitable” because of structural damage (Cofini and Colonna, 2011). For these families, the Government built blocks of temporary housing in rural areas that lacked many basic services and transport and were far from the center of the city. A number of studies of high school and college students that were conducted at varying intervals after the earthquake demonstrated high levels of PTSD. A study conducted in L’Aquila ten months after the earthquake demonstrated a prevalence of PSTD of 38% among students with a mean age of 17.65 7 0.74years (Dell’Osso et al., 2011a). A second study conducted in L’Aquila after 21 months demonstrated a prevalence of 31% in a sample of 475 adolescents (Dell’Osso et al., 2011b), and a third study showed that 36% of 512 students from L’Aquila, who were in their senior year of high school had PTSD according to DSM-5 criteria (Carmassi,
354
V. Cofini et al. / Psychiatry Research 229 (2015) 353–358
2015). Between April 2009 and January 2010 a study of college students estimated the prevalence of PTSD at 14% (Pollice et al., 2012). The one study that focused on older individuals and was done on a probabilistic sample of the adult population 18–69 years of age conducted from 14 to 19 months after the earthquake, estimated the prevalence of PTSD equal to 4.1%, considerably lower than the values seen in the teenage and young adult population (Gigantesco et al., 2013). While most studies of affected population have focused on the general population, less is known about PTSD in individuals who had to leave their homes and rearrange their lives in an entirely new context, away from their work, their schools, their church, and their familiar environment. The uncertainty about the future of their homes, lack of social life and gathering places, in addition to the shock of the earthquake, have been highly traumatic to many. In this study, we examined the prevalence of PTSD in people who had left their damaged homes and were still living in temporary housing more than a year after the earthquake. In addition, we evaluated the differences in coping strategies implemented by persons who had and who did not have PTSD. Such information can help guide psychosocial interventions aimed at preventing or alleviating the post-traumatic symptoms in survivors who have been abruptly uprooted from their previous lives. 2. Methods
Frequency and severity scores were summed for each symptom, resulting in a total of 17 variables used in the analyses (Elhai et al., 2006). The DTS total score was computed by adding all item responses together, with a possible range of 0–136. Persons with a score of over 40 points were considered to have PTSD for purposes of the analysis. The Brief COPE (BC) is the abridged version of the COPE inventory and includes fourteen scales, each assessing different coping skill dimensions: self-distraction, denial, active coping, substance use, use of emotional support, use of instrumental support, behavioral disengagement, venting, positive framing, planning, humor, acceptance, religion, and self-blame. The BC has only 2 items in each scale. It is used to assess trait coping (the usual way people cope with stress in everyday life) and state coping (the particular way people cope with a specific stressful situation) (Muller and Spitz, 2003). In the BC, each scale has a maximum of 8 points, and the higher the score for a scale, the more is the impact of the specific coping skill dimension assessed. In addition to the DTS and BC, the survey gathered information on employment status, level of education, and other socioeconomic variables. 2.6. Statistical analysis We calculated the percent prevalence of PTSD symptoms overall and by age (treated as categorical), gender, educational level (low: senior high school or less, high: university degree), and employment status (yes, no). Two-tailed Chi-square tests were used to identify associations between covariates and PTSD, and odds ratios and 95% confidence intervals (OR and 95% CI) were calculated with logistic model. To analyze the BC data, Shapiro – Wilk test was used for normality and Bartlett's test was used for equal variances. One-way Anova model was used for normal continuous variables with Bonferroni test for post hoc comparison. Wilcoxon rank sum test, or one-way analysis of variance by ranks (Kruskal-Wallis Test) with post hoc estimation were used when appropriate. All analyses were done by using STATA/MP 12.01 software.
2.1. Study design We conducted a cross-sectional prevalence study. 2.2. Study population The eligible study population consisted of all those living in temporary housing after the earthquake (Seismic C.A.S.E.-Sustainable and Ecological Complexes Project or M.A.P-Temporary Housing Modules). 2.3. Sampling A cluster sample design was used, with the household as the sampling unit (Bennett et al., 1991). The sample size calculation of 96 clusters was based on a presumed design effect of 2.2, a prevalence of post traumatic stress disorder equal to 15% (Priebe et al., 2009), and an alpha of 0.05, a desired level of precision of 7 3%, and that in each household, there would be an average of 3 adult members who could be interviewed. The list of the temporary lodgings assigned in June 2010, published by the city of L’Aquila, was used to randomly select 96 households. 2.4. Data collection The interviews were conducted by staff of the research group, who underwent 2 days training conducted by expert from University of L’Aquila. Interviews took place between July 2010 and October 2010 (15 to 18 months after the earthquake, after 7–10 months living in new housing). Prior to initiating the survey, an awareness campaign and meetings with citizens committees were held to explain the purpose of the study. All persons gave their informed consent prior to their inclusion in the study. For each household, up to two visits were made to schedule an appointment for an interview. If no one was home during the two attempts, the household was excluded from the survey. The inclusion criteria were age Z 18 years, able to read Italian, and willing to consent to participate in the study. 2.5. Measures Subjects enrolled were investigated using the Davidson Trauma Scale (DTS) (Davidson et al., 1997) to measure the frequency and severity of PTSD-related symptoms and the Brief Cope (Carver, 1997), which explores the coping style of individuals and how they respond to stressful situations (situational or dispositional past). The DTS is a 17-item scale measuring each DSM-IV symptom of PTSD: criteria B (re-experiencing intrusive memories), criteria C (avoidance and numbness); and criteria D (hyperarousal). For each item, the subject rated both frequency and severity of symptoms during the previous week on a 5-point (0–4) Likert-type scales.
3. Results As shown in Fig. 1, 92 out of 96 sampled households were successfully contacted for the study; these households had a total of 332 persons. Two individuals were excluded because of speech difficulties, twenty-nine were excluded because they were o18 years of age, five refused to participate, and 15 were absent at moment of interview, resulting in a final sample size of 281. The average age was 43 years ( 7 16), and 54% were women. Socio-demographic characteristics, analyzed by gender, are presented in Table 1. In general, men were significantly likely to have a lower level of education, but there were no gender differences in age and employment status. The estimated prevalence of PTSD among the 271 respondents who completed the DTS was 43% (95%CI: 36.2–49.7%). The average score for intrusive memories was 17 on a scale of 0–20 (95% CI: 15–18), 13 (95% CI: 12–15) for the avoidance and numbing on a 0– 28 scale, an average of 14 (95% CI: 12–16) on a 0–20 scale for an increase in anxiety and hyperarousal. The prevalence of PTSD and its association with specific sociodemographic characteristics are shown in Table 2. Women and the unemployed were significantly more likely to meet the case definition of PTSD. The analysis of the Brief Cope data demonstrated that overall, the sample had the highest mean scores in active coping (6.0; 95% CI: 5.8–6.2), acceptance (5.9; 95%CI: 5.7–6.1) and planning (5.7; 95%CI: 5.5-5.9) and the lowest mean scores in substance use (2.5; 95%CI: 2.4–2.6), behavioral disengagement (3.4; 95%CI: 3.2–3.6) and humor (3.8; 95%CI: 3.6–3.9). The mean score at dimensions of Brief Cope by selected socio demographic characteristics of the participants and the bivariate associations between BC scales and these characteristics, are shown in Table 3. Age was a strong predictor of coping strategies, although there was not always a linear relationship between increasing age and coping scores. Age had an important influence on coping strategies in the domains of religious coping, emotional support, self-blame, behavioral disengagement, humor and
V. Cofini et al. / Psychiatry Research 229 (2015) 353–358
355
Sampling Clusters (Households) N. 5016
Sampled Clusters: N. 96
Contacted N 92
Not contacted N=4
Eligible
Not Eligible N=2 because of language N=29 because of age <18 years
YES
N.332
YES NO Agreed to participate N.301
Refused: N=5 Absent: N=15
YES
Respondents n. 281
Fig. 1. : Recruitment of study population.
Table 1 Socio demographic characteristics of survey participants by gender. Female
P-valuenn
Total sample
Male
n
%
n
%
n
%
Age, yearsn 18–34 35–55 455 total
91 91 69 251
36.3 36.3 27.4 100.0
43 36 35 114
37.7 31.6 30.7 100.0
48 55 34 137
35.0 40.2 24.8 100.0
0.34
Educational leveln Low High total
193 78 271
71.2 28.8 100.0
102 24 126
81.0 19.1 100.0
91 54 145
62.7 37.2 100.0
0.00
Employment statusn Yes No total
172 103 275
62.5 37.5 100.0
83 46 129
64.3 35.7 100.0
89 57 146
61.0 39.0 100.0
0.58
use of self-blame Except for higher scores for humor among men and for denial and venting among women, no significant differences were observed by gender. With respect to employment status, persons who were employed had significantly higher scores than nonworkers in acceptance and lower scores in religion and denial. As shown in Table 4, those with and without PTSD showed significant differences with respect to the several coping strategies. Individuals with PTSD had higher mean coping scores for religion, self-distraction, self-blame, denial, venting, and behavioral disengagement and lower values for acceptance compared with those who did not have PTSD.
4. Discussion
n The numbers within the categories do not have the total of 281 due to missing data nn Chi square test
substance use. Recourse to religious coping and behavioral disengagement increased with age and were significantly higher among those over 55 years, while humor was a significantly higher in the youngest age group, as was substance use. The young also showed an increased reliance on emotional support and greater
In our study, which examined the prevalence of PTSD and coping strategies more than year after a major earthquake in a population that was forced to move to temporary housing because of severe damage from their homes, the prevalence of PTSD was 43%. The prevalence appears to be higher than reported in two other studies conducted in the city on different populations and different age groups, although each study used different methods and they were conducted at different intervals following the earthquake. Gigantesco et al. (2013) estimated a prevalence of 4.1% in a representative sample of persons 18–69 years of age 14–19 months after the earthquake. The study was conducted by telephone and included the general population of the city, most of
356
V. Cofini et al. / Psychiatry Research 229 (2015) 353–358
Table 2 Risk factors for PTSD. No. of respondents 271
PTSD n (%: 95%CI) 116 (43%: 36.17-49.71)
Odds ratio (95%CI)
p-value
Total Gendern Male Female
123 147
40 (32.5%: 24.7–41.4) 76 (51.7%: 43.1–60.2)
1 2.2 (1.4–3.5)
0.00
Age range, yearsn 18–34 35–55 455
88 89 65
40 (45.5%: 34.4–57.0) 35 (39.3%: 28.2–51.7) 30 (46.2%: 34.0–58.8)
1 0.8 (0.5–2.0) 1.0 (0.5–1.3)
0.67
Education attainmentn Low High
186 76
80 (43.0%: 35.7–50.6) 33 (43.4%: 32.1–55.5)
1 1.0 (0.6–1.7)
0.95
Employment statusn Yes No
166 99
61 (36.8%: 28.6–45.7) 54 (54.6%: 44.9–63.8)
1 2.1 (1.2–3.5)
0.01
n
The numbers within the categories do not have the total of 271 due to missing data
whom had not experienced the prolonged displacement of our study population (2013). The levels were, however, within the range reported in other studies. A review of 2005, reported that the prevalence of PTSD in the first 1–2 years after a disaster has ranged between 5% (1985, Puerto Rico floods) and 60% (1987, Tornado in eastern North Carolina), although most of the reported values were in the lower half of this range (1988, Yun Nan earthquake, 9%; 1989, Newcastle
earthquake, 18%; 1993, Hurricane Hugo in South Carolina, 5%) (Galea et al., 2005). The highest prevalences were found in specific groups, including populations seen in clinical settings (Livanou et al., 2002) and people who were in areas heavily affected by disaster (Jin et al., 2014; Zhang et al., 2012; Wang et al., 2011); these levels were more similar to those seen in our study population. In our study, we also found higher scores for the different
Table 3 Brief Cope scores by socio demographic characteristics of respondents. Gendera
Age, yearsa
Employment Statusa
M (n 127)
F (n 148)
p
18–34 (n 90)
35–55 (n 90)
455 (n 68)
p
Yes (n 169)
No (n 102)
p
5.7 7 1.74
5.8 71.84
0.75
5.7 7 1.71
5.9 71.80
5.6 7 1.76
0.56
5.8 7 1.77
5.5 7 1.83
0.17
5.17 1.68
5.3 71.77
0.61
5.2 7 1.77
5.2 71.61
5.17 1.71
0.90
5.3 7 1.74
5.0 7 1.70
0.08
Religionb
4.3 7 2.10
4.8 72.11
0.06
4.0 7 1.99
4.5 72.04
5.2 7 2.20
0.00**
4.4 7 2.00
4.9 7 2.24
0.03**
Using emotional supportb
4.4 7 1.68
4.6 71.77
0.45
4.9 7 1.76
4.2 71.54
4.5 7 1.73
0.02**
4.4 7 1.66
4.7 7 1.84
0.14
Using instrumental supportb
4.7 7 1.81
4.8 71.88
0.64
4.9 7 1.93
4.6 71.66
4.9 7 1.86
0.64
4.6 7 1.82
5.0 7 1.90
0.11
5.17 1.81
5.2 71.73
0.49
5.4 7 1.73
4.9 71.74
5.17 1.82
0.17
5.17 1.83
5.2 7 1.67
0.51
Self-blameb
4.3 7 1.54
4.6 71.50
0.20
4.8 7 1.57
4.17 1.51
4.5 7 1.51
0.02**
4.4 7 1.52
4.6 7 1.50
0.37
Active copingc
6.0 7 1.55
6.0 71.73
0.90
6.17 1.53
6.17 1.77
5.8 7 1.71
0.48
Brief cope scores Planningb Positive reframing
Self-distraction
b
b
5.9 7 1.66
6.0 7 1.64
0.60
**
5.8 7 1.76
6.17 1.69
0.22
5.8 7 1.59
6.3 71.71
5.6 7 1.78
0.03
6.2 7 1.67
5.5 7 1.75
0.00**
Humorc
4.17 1.75
3.5 71.57
0.01**
4.3 7 1.74
3.5 71.49
3.5 7 1.74
0.00**
3.9 7 1.67
3.6 7 1.67
0.21
Denialc
3.7 7 1.77
4.0 71.80
0.05**
3.8 7 1.75
3.6 71.61
4.3 7 2.00
0.09
3.6 7 1.56
4.3 7 2.04
0.04**
Ventingc
4.2 7 1.60
4.9 71.72
0.00**
4.6 7 1.73
4.6 71.72
4.5 7 1.75
0.94
Acceptance
c
Substance use
c
2.7 7 1.46 c
Behavioral disengagement a
3.4 7 1.39
2.3 70.84 3.5 71.51
0.06 0.71
2.8 7 1.41 3.17 1.35
2.4 71.11 3.3 71.38
The numbers within the categories do not have the total of 281 due to missing data One way Anova, c Wilcoxon rank sum test ** Significant b
2.2 7 0.62 3.8 7 1.58
4.4 7 1.63
4.8 7 1.82
0.08
**
2.4 7 1.08
2.6 7 1.34
0.36
**
3.3 7 1.38
3.6 7 1.57
0.14
0.00 0.01
V. Cofini et al. / Psychiatry Research 229 (2015) 353–358
Table 4 Mean Brief Cope scores by PTSD status. No PTSDa (n 152)
PTSDa (n 116)
Brief cope scores
Mean points
Ds
Mean points
Ds
p-value
Planningb Positive reframingb Religionb Using emotionalsupportb Using instrumentalsupportb Self-distractionb Self-blameb Active copingc Acceptancec Humorc Denialc Ventingc Substance usec Behavioral disengagementc
5.8 5.2 4.3 4.4 4.7 4.9 4.2 5.9 6.2 4.0 3.5 4.3 2.4 3.1
1.78 1.73 2.01 1.62 1.79 1.83 1.34 1.70 1.67 1.65 1.67 1.66 1.15 1.31
5.7 5.2 5.0 4.7 4.9 5.4 4.8 6.1 5.6 3.6 4.3 5.0 2.6 3.8
1.77 1.75 2.16 1.79 1.91 1.64 1.69 1.54 1.80 1.71 1.85 1.70 1.24 1.59
0.53 0.87 0.01** 0.09 0.42 0.04** 0.00** 0.30 0.02** 0.07 0.00** 0.00** 0.14 0.00**
a
The numbers within the categories do not have the total of 271 due to missing
data b
One way Anova, Wilcoxon rank sum test ** Significant c
dimensions of PTSD than reported elsewhere, including in some major earthquakes in Pakistan and Taiwan where the PTSD prevalences were high (41% thirty months after the disaster in Pakistan (Ali et al., 2012) and among professional and non-professional rescuers were 19.8% and 31.8%, respectively, one months after the disaster in Taiwan (Guo et al., 2004). In our study, the average score was 17 for intrusive memories, 13 for avoidance and numbing, and 14 for anxiety and hyperarousal. In the Pakistan study, values for the three dimensions were 13, 12, and 9 (Ali et al., 2012), respectively, while in Taiwan, the values were 9, 7, and 8, respectively (Guo et al., 2004). However, such studies have estimated the prevalence of the disorder and the average of the three scores on individuals in different ages and with different methods, making it difficult to assess the significance of the higher values in L’Aquila. The findings on socio-demographic characteristics associated with an increased risk of PTSD are generally compatible with the findings of others (Chen et al., 2007; Armenian et al., 2000; .Basoglu et al., 2002; Kılıç and Ulusoy , 2003; Yang et al. ,2003). As in our study, others have demonstrated that women appear more vulnerable to PTSD (Priebe et al. 2009; Wang et al. 2009, 2011; Dell’Osso et al. 2011a). However, our study and that of Gigantesco et al. (2013) showed that age and level of education were not associated with PTSD. By contrast, several studies done elsewhere (Karanci and Rustemli, 1995; Armenian et al., 2000; Basoglu et al. ,2002; Kılıç and Ulusoy, 2003; Priebe et al., 2009; Ali et al., 2012) have demonstrated that older age and lower education are associated with increased risks for PTSD. Few studies have examined the role of overall social and economic context after a disaster on the risk of PTSD (Galea et al., 2005). Our study demonstrated that those who were unemployed suffered more PTSD, and Gigantesco et al. (2013), also showed in L’Aquila that individuals with economic difficulties are more exposed to the risk of developing PTSD. Understanding the coping mechanisms following an earthquake is important in developing appropriate interventions. After an earthquake, the affected population must adapt quickly to changes in their living situations and face constant fear of aftershocks. This sequence of events may affect significantly the ability of an individual to cope with a disaster. With respect to coping strategies, we observed different patterns
357
of coping strategies by gender, age, employment status, and presence of PTSD. Gender differences occurred in the use of humor, denial and the venting. Men were more likely to deal with the event by deemphasizing it. Women, by contrast, were more likely to deny what had happened and more likely to outwardly demonstrate their feelings or denying that it had affected them. Evidence in the literature also confirms the existence of gender differences in coping strategies adopted: women are more likely to vent their emotions and to seek emotional and instrumental support; men, on the other hand, are more prone to use drugs and alcohol to cope to stressful life events (Carver et al., 1989). The gender differences that Carver et al., observed, also suggest that men rely on themselves to cope with stress, while women seek greater help others. We observed that age also influenced acceptance and coping mechanisms. The acceptance was lower in subjects with age4 55 years. Recourse to religious coping and behavioral disengagement was higher with increasing age, while resorting to emotional support, self-blame, humor and the use of substances tended to be greater in the group of younger subjects. An interesting finding of our study was the major differences in coping strategies for those with and without PTSD. In general, those with PTSD symptoms often employed maladaptive coping strategies for dealing with earthquake, and had the highest scores in the domains of denial, venting, behavioral disengagement, selfblame. By contrast, those without PTSD generally had more adaptive coping mechanisms, including greater acceptance, a coping strategy that is antithetical to denial (Carver et al., 1989). They also were more likely to exhibit planning although the difference was not statistically significant (p 40.05). People suffering from PTSD had higher average scores for less active but nonetheless adaptive coping strategies (Carver et al., 1989) including religion, use of emotional support and use of instrumental support, although only the religious coping was statistically different between the two groups. The presence of adaptive coping strategies in subjects that do not develop PTSD following the earthquake and maladaptive coping strategies in who manifests the disorder suggests the existence of a relationship between the two variables. The scale of the Brief Cope used in this study is “dispositional” and thus permits investigation of habitual tendencies of persons to cope with a stressful life event. It can be assumed, therefore, that following the earthquake, the habitual use of adaptive strategies may have protected against the development of PTSD, while using maladaptive strategies have increased the risk of psychopathology. Evidence in the literature supports this hypothesis. In the context of traumatic events, the use of active coping strategies or instrumental strategies, such as positive restructuring, active coping and seeking emotional support, allow a good adaptation to stress. By contrast, the passive coping strategies such as avoidance, are often maladaptive (Resnick, 1988; Sharkansky et al., 2000; North et al., 2001; Silver et al., 2002; Ozer et al., 2003; Linley and Joseph, 2004). People with avoidant coping style are also more likely to show symptoms of acute stress disorder after traumatic events (Bartone et al. 1989. Bryant and Harvey 1995, Johnsen et al., 1998, 2002). A limitation is that the study did not investigate whether participants had PTSD, linked to a different traumatic experience since the DTS scale does not provide temporal references. Therefore, it is important to be cautious in interpreting the results obtained. Finally an issue in this paper is that it is difficult to make meaningful comparisons with other studies since they differ in the degree to which the population has been exposed, the magnitude of the event, the time elapsed since the disaster, and local circumstances such as availability of local housing and the speed of rebuilding homes and infrastructure. Similar issues have been noted in the review of Galea et al. (2005). Despite the limits presented, our study demonstrates that
358
V. Cofini et al. / Psychiatry Research 229 (2015) 353–358
adults who have been displaced and who remain in limbo about the study the fate of their homes (renovation or demolition), without knowing how long they lived in temporary housing experience high rates of PTSD more than a year after the disaster. It also suggests that coping mechanisms differ between those who have PTSD and those who do not. Although it cannot be entirely ruled out that the coping mechanisms are a function of having PTSD, our findings suggest that instead existing dispositional coping methods influence the likeliness of developing PTSD. The study supports the need for decision makers to be aware of mental health needs of populations affected by disasters such as earthquakes, particularly those who have been displaced, whose social lives had been disrupted, and who and are faced with chronic uncertainty about their future.
Conflict of interest The authors declare that they have no conflict of interest.
Ethical standards The authors assert that all procedures contributing to this work comply with the ethical standards on human observational study.
Acknowledgments The authors gratefully acknowledge the support of the European Commission FP6 funded project MICRODIS, administered by the Centre for Research on the Epidemiology of Disasters at the Catholic University of Louvain, Belgium. The support of MICRODISL’Aquila team members is acknowledged with further gratitude: David Alexander, Caterina Antinori, Diego Guidotti, Christian Iasio, Michele Magni , Fausto Marincioni, Roberto Miniati and Francesco Barbano.
References Ali, M., Farooq, N., Bhatti, M.A., Kuroiwa, C., 2012. Assessment of prevalence and determinants of posttraumatic stress disorder in survivors of earthquake in Pakistan using Davidson Trauma Scale. J. Affect. Disord. 136 (3). http://dx.doi. org/10.1016/j.jad.2011.12.023 238-43. Armenian, H.K., Morikawa, M., Melkonian, A.K., Hovanesian, A.P., Haroutunian, N., Saigh, P.A., Akiskal, K., Akiskal, H.S., 2000. Loss as a determinant of PTSD in a cohort of adult survivors of the 1988 earthquake in Armenia: implications for policy. Acta Psychiatr. Scand. 102 (1), 58–64. Bartone, P.T., Ursano, R.J., Wright, K.M., Ingraham, L.H., 1989. The impact of a military air disaster on the health of assistance workers. A prospective study. J. Nerv. Ment. Dis. 177 (6), 317–328. Bennett, S., Woods, T., Liyanage, W.M., Smith, D.L., 1991. A simplified general method for cluster-sample surveys of health in developing countries. World Health Stat. Q. 44 (3), 98–106. Basoglu, M., Salcioglu, E., Livanou, M., 2002. Traumatic stress responses in earthquake survivors in Turkey. J. Trauma. Stress 15 (4), 269–276. Bryant, R.A., Harvey, A.G., 1995. Avoidant coping style and post-traumatic stress following motor vehicle accidents. Behav. Res. Therapy 33 (6), 631–635. Carmassi, C.B., 2015. Impact of DSM-5 PTSD and gender on impaired eating behaviors in 512 Italian earthquake survivors. Psychiatry Res. 225 (1), 64–69. Carver, C.S., Sheirer, M.F., Weintraub, J.K., 1989. Assessing coping strategies: a theoretically based approach. J. Personal. Soc. Psychol. 56, 267–283. Carver, C.S., 1997. You want to measure coping but your protocol’too long: consider the brief cope. Int. J. Behav. Med. 4 (1), 92–100. Cerdá, M., Paczkowski, M., Galea, S., Nemethy, K., Péan, C., Desvarieux, M., 2013. Psychopathology in the aftermath of the Haiti earthquake: a population-based study of posttraumatic stress disorder and major depression. Depress. Anxiety 30 (5). http://dx.doi.org/10.1002/da.22007 413-24. Chen, C.H., Tan, H.K., Liao, L.R., Chen, H.H., Chan, C.C., Cheng, J.J., Chen, C.Y., Wang, T. N., Lu, M.L., 2007. Long-term psychological outcome of 1999 Taiwan earthquake survivors: a survey of a high-risk sample with property damage. Compr. Psychiatry 48 (3), 269–275.
Cofini, V., Colonna, F., 2011. La sistemazione della popolazione aquilana. In Il terremoto dell’Aquila, analisi e riflessioni sull’emergenza. Edizioni L’Una, 75–96. Davidson, J.R., Book, S.W., Colket, J.T., Tupler, L.A., Roth, S., David, D., Hertzberg, M., Mellman, T., Beckham, J.C., Smith, R.D., Davison, R.M., Katz, R., Feldman, M.E., 1997. Assessment of a new self-rating scale for post-traumatic stress disorder. Psychol. Med. 27 (1), 153–160. Dell’Osso, L., Carmassi, C., Massimetti, G., Daneluzzo, E., Di Tommaso, S., Rossi, A., 2011a. Full and partial PTSD among young adult survivors 10 months after the L’Aquila 2009 earthquake: gender differences. J. Affect. Disord. 131 (1–3), 79–83. http://dx.doi.org/10.1016/j.jad.2010.11.023. Dell’Osso, L., Carmassi, C., Massimetti, G., Conversano, C., Daneluzzo, E., Riccardi, I., Stratta, P., Rossi, A., 2011b. Impact of traumatic loss on post-traumatic spectrum symptoms in high school students after the L’Aquila 2009 earthquake in Italy. J. Affect. Disord. 134 (1–3), 59–64. http://dx.doi.org/10.1016/j.jad.2011.06.025. Elhai, J.D., Lindsay, B.M., Gray, M.J., Grubaugh, A.L., North, T.C., Frueh, B.C., 2006. Examining the uniqueness of frequency and intensity symptom ratings in posttraumatic stress disorder assessment. J. Nervous Ment. Dis. 194, 940–944. Galea, S., Nandi, A., Vlahov, D., 2005. The Epidemiology of Post-Traumatic Stress Disorder after Disasters. Epidemiol. Rev. 27 (1), 78–91. Gigantesco, A., Mirante, N., Granchelli, C., Diodati, G., Cofini, V., Mancini, C., Carbonelli, A., Tarolla, E., Minardi, V., Salmaso, S., D’Argenio, P., 2013. Psychopathological chronic sequelae of the 2009 earthquake in L’Aquila, Italy. J. Affect. Disord. 148 (2–3). http://dx.doi.org/10.1016/j.jad.2012.12.006. E 265-71. Guo, Y.J., Chen, C.H., Lu, M.L., Tan, H.K., Lee, H.W., Wang, T.N., 2004. Posttraumatic stress disorder among professional and non-professional rescuers involved in an earthquake in Taiwan. Psychiatry Res. 127 (1–2), 35–41. Istituto Nazionale Geofisica e Vulcanologia (INGV), 2009. The L’Aquila seismic sequence-April. (accessed 24.08.09). Archived 7 September 2009. Jin, Y., Xu, J., Liu, H., Liu, D., 2014. Posttraumatic stress disorder and posttraumatic growth among adult survivors of wenchuan earthquake after 1 year: prevalence and correlates. Arch. Psychiatric Nurs. 28 (1), 67–73. http://dx.doi.org/ 10.1016/j.apnu.2013.10.010. Johnsen, B.H., Eid, J., Laberg, J.C., Thayer, J.F., 2002. The effect of sensitization and coping style on post‐traumatic stress symptoms and quality of life: two longitudinal studies. Scand. J. Psychol. 43 (2), 181–188. Johnsen, B.H., Laberg, J.C., Eid, J., 1998. Coping strategies and mental health problems in a military unit. Mil. Med. 163 (9), 599–602. Karanci, A.N., Rustemli, A., 1995. Psychological consequences of the 1992 Erzincan (Turkey) earthquake. Disasters 19 (1), 8–18. Kılıç, C., Ulusoy, M., 2003. Psychological effects of the November 1999 earthquake in Turkey: an epidemiological study. Acta Psychiatr. Scand. 108 (3), 232–238. Linley, P.A., Joseph, S., 2004. Positive change following trauma and adversity: a review. J. Trauma. Stress 17 (1), 11–21. Livanou, M., Bassoglu, M., Ssalcioglu, E., Kalendar, D., 2002. Traumatic stress responses in treatment-seeking earthquake survivors in Turkey. J. Nervous Ment. Dis. 190 (12), 816–823. Muller, L., Spitz, E., 2003. [Multidimensional assessment of coping: validation of the Brief COPE among French population]. L’encéphale 29 (6), 507–518. North, C.S., Spitznagel, E.L., Smith, E.M., 2001. A prospective study of coping after exposure to a mass murder episode. Ann. Clin. Psychiatry 13 (2), 81–87. Ozer, E.J., Best, S.R., Lipsey, T.L., Weiss, D.S., 2003. Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol. Bull. 129 (1), 52–73. Pollice, R., Bianchini, V., Roncone, R., Casacchia, M., 2012. Psychological distress and post-traumatic stress disorder (PTSD) in young survivors of L’Aquila earthquake. Riv. Psichiatria 47 (1), 59–64. http://dx.doi.org/10.1708/1034.11292. Priebe, S., Grappasonni, I., Mari, M., Dewey, M., Petrelli, F., Costa, A., 2009. Posttraumatic stress disorder six months after an earthquake. Soc. Psychiatry Psychiatric Epidemiol. 44 (5), 393–397. Resnick, P.A., 1988. Reactions of female and male victims of rape or robbery. National Institute of Mental Health, Washington, D.C. Sharkansky, E.J., King, D.W., King, L.A., Wolfe, J., Erickson, D.J., Stokes, L.R., 2000. Coping with Gulf War combat stress: Mediating and moderating effects. J. Abnorm. Psychol. 109 (2), 188. Silver, R.C., Holman, E.A., McIntosh, D.N., Poulin, M., Gil-Rivas, V., 2002. Nationwide longitudinal study of psychological responses to September 11. J.Am. Med. Assoc. 288 (10), 1235–1244. Wang, B., Ni, C., Chen, J., Liu, X., Wang, A., Shao, Z., Xiao, D., Cheng, H., Jiang, J., Yan, Y., 2011. Posttraumatic stress disorder 1 month after 2008 earthquake in China: Wenchuan earthquake survey. Psychiatry Res. 187 (3). http://dx.doi.org/ 10.1016/j.psychres.2009.07.001 392-6. Wang, L., Zhang, Y., Wang, W., Shi, Z., Shen, J., Li, M., Xin, Y., 2009. Symptoms of posttraumatic stress disorder among adult survivors three months after the Sichuan earthquake in China. J. Trauma. Stress 22 (5), 444–450. Xu, J., Song, X.,, 2011. A cross-sectional study among survivors of the 2008 Sichuan earthquake: prevalence and risk factors of posttraumatic stress disorder. Gen. Hosp. Psychiatry 33 (4), 386–392. http://dx.doi.org/10.1016/j. genhosppsych.2011.05.004. Yang, Y.K., Yeh, T.L., Chen, C.C., Lee, C.K., Lee, I.H., Lee, L.C., Jeffries, K.J., 2003. Psychiatric morbidity and posttraumatic symptoms among earthquake victims in primary care clinics. General Hospital Psychiatry 25 (4), 253–261. Zhang, Z., Shi, Z., Wang, L., Liu, M., 2011. One year later: Mental health problems among survivors in hard-hit areas of the Wenchuan earthquake. Pub. Health 125 (5), 293–300. http://dx.doi.org/10.1016/j.puhe.2010.12.008. Zhang, Z., Wang, W., Shi, Z., Wang, L., Zhang, J., 2012. Mental health problems among the survivors in the hard-hit areas of the Yushu earthquake. PLoS One 7 (10), e46449. http://dx.doi.org/10.1371/journal.pone.0046449, www.DSM5.org.
Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Post traumatic stress disorder and coping in a sample of adult survivors of the Italian earthquake V. Cofini a,n, A. Carbonelli a, M.R. Cecilia a, N. Binkin b, F. di Orio a a b
Department of Life, Health and Environmental Sciences, University of L’Aquila, Italy School of Public Health, San Diego State University, USA
art ic l e i nf o
a b s t r a c t
Article history: Received 30 December 2014 Received in revised form 8 May 2015 Accepted 27 June 2015 Available online 2 July 2015
The aim was to investigate the prevalence of post traumatic stress disorder (PTSD) in people who had left their damaged homes and were still living in temporary housing more than a year after the April 2009 L’Aquila (Italy) earthquake. In addition, we evaluated the differences in coping strategies implemented by persons who had and who did not have PTSD. A cross-sectional prevalence study was carried out on a sample of 281 people aged 418 years and living in temporary housing after the earthquake. The questionnaires used include the Davidson Trauma Scale and the Brief Cope. The prevalence of PTSD was 43%. Women and the non-employed were more vulnerable to PTSD, while, age and level of education were not associated with PTSD. Those with PTSD symptoms often employed maladaptive coping strategies for dealing with earthquake and had the highest scores in the domains of denial, venting, behavioral disengagement, self-blame. By contrast, those without PTSD generally had more adaptive coping mechanisms. Adults who were living in temporary housing after the earthquake experienced high rates of PTSD. The difference in coping mechanisms between those who have PTSD and those who do not also suggests that they influence the likeliness of developing PTSD. & 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Natural disasters Psychological distress Post-traumatic syndrome Prevalence
1. Introduction Numerous studies have investigated the prevalence and risk factors for post-traumatic stress disorder (PTSD) following an earthquake. In these studies, prevalence has ranged from 14.5% to 48.2% and appears to be greater in cities that have been heavily damaged than in those with lesser damage (Xu and Song, 2011). On an individual level, studies have shown that damage to victims’ homes increases the risk of PTSD (Cerdá et al., 2013; Kilic and Ulusoy, 2003), and that the quality of life is lower in those who live in temporary housing (Zhang et al., 2011). On April 6th 2009, the city of L’Aquila and surrounding villages in central Italy experienced an earthquake with a magnitude of 5.9 on the Richter (6.3 moment magnitude Mw) scale (Istituto Nazionale Geofisica e Vulcanologia (INGV), 2009). It resulted in 309 fatalities and 1600 n
Corresponding author. E-mail addresses: vincenza.cofi[email protected] (V. Cofini), [email protected] (A. Carbonelli), [email protected] (M.R. Cecilia), [email protected] (N. Binkin), [email protected] (F. di Orio). http://dx.doi.org/10.1016/j.psychres.2015.06.041 0165-1781/& 2015 Elsevier Ireland Ltd. All rights reserved.
persons who were injured, including 200 with severe injuries requiring hospitalization. More than 65,000 people were displaced (Dell’Osso et al., 2011a). In the city of L’Aquila, damages were most severe in the old town, one of the largest of Europe and the center of local life with its many squares, churches, monuments, theaters, schools, and historical buildings. A year after the earthquake, about 45% of families in L’Aquila had houses that were considered “uninhabitable” because of structural damage (Cofini and Colonna, 2011). For these families, the Government built blocks of temporary housing in rural areas that lacked many basic services and transport and were far from the center of the city. A number of studies of high school and college students that were conducted at varying intervals after the earthquake demonstrated high levels of PTSD. A study conducted in L’Aquila ten months after the earthquake demonstrated a prevalence of PSTD of 38% among students with a mean age of 17.65 7 0.74years (Dell’Osso et al., 2011a). A second study conducted in L’Aquila after 21 months demonstrated a prevalence of 31% in a sample of 475 adolescents (Dell’Osso et al., 2011b), and a third study showed that 36% of 512 students from L’Aquila, who were in their senior year of high school had PTSD according to DSM-5 criteria (Carmassi,
354
V. Cofini et al. / Psychiatry Research 229 (2015) 353–358
2015). Between April 2009 and January 2010 a study of college students estimated the prevalence of PTSD at 14% (Pollice et al., 2012). The one study that focused on older individuals and was done on a probabilistic sample of the adult population 18–69 years of age conducted from 14 to 19 months after the earthquake, estimated the prevalence of PTSD equal to 4.1%, considerably lower than the values seen in the teenage and young adult population (Gigantesco et al., 2013). While most studies of affected population have focused on the general population, less is known about PTSD in individuals who had to leave their homes and rearrange their lives in an entirely new context, away from their work, their schools, their church, and their familiar environment. The uncertainty about the future of their homes, lack of social life and gathering places, in addition to the shock of the earthquake, have been highly traumatic to many. In this study, we examined the prevalence of PTSD in people who had left their damaged homes and were still living in temporary housing more than a year after the earthquake. In addition, we evaluated the differences in coping strategies implemented by persons who had and who did not have PTSD. Such information can help guide psychosocial interventions aimed at preventing or alleviating the post-traumatic symptoms in survivors who have been abruptly uprooted from their previous lives. 2. Methods
Frequency and severity scores were summed for each symptom, resulting in a total of 17 variables used in the analyses (Elhai et al., 2006). The DTS total score was computed by adding all item responses together, with a possible range of 0–136. Persons with a score of over 40 points were considered to have PTSD for purposes of the analysis. The Brief COPE (BC) is the abridged version of the COPE inventory and includes fourteen scales, each assessing different coping skill dimensions: self-distraction, denial, active coping, substance use, use of emotional support, use of instrumental support, behavioral disengagement, venting, positive framing, planning, humor, acceptance, religion, and self-blame. The BC has only 2 items in each scale. It is used to assess trait coping (the usual way people cope with stress in everyday life) and state coping (the particular way people cope with a specific stressful situation) (Muller and Spitz, 2003). In the BC, each scale has a maximum of 8 points, and the higher the score for a scale, the more is the impact of the specific coping skill dimension assessed. In addition to the DTS and BC, the survey gathered information on employment status, level of education, and other socioeconomic variables. 2.6. Statistical analysis We calculated the percent prevalence of PTSD symptoms overall and by age (treated as categorical), gender, educational level (low: senior high school or less, high: university degree), and employment status (yes, no). Two-tailed Chi-square tests were used to identify associations between covariates and PTSD, and odds ratios and 95% confidence intervals (OR and 95% CI) were calculated with logistic model. To analyze the BC data, Shapiro – Wilk test was used for normality and Bartlett's test was used for equal variances. One-way Anova model was used for normal continuous variables with Bonferroni test for post hoc comparison. Wilcoxon rank sum test, or one-way analysis of variance by ranks (Kruskal-Wallis Test) with post hoc estimation were used when appropriate. All analyses were done by using STATA/MP 12.01 software.
2.1. Study design We conducted a cross-sectional prevalence study. 2.2. Study population The eligible study population consisted of all those living in temporary housing after the earthquake (Seismic C.A.S.E.-Sustainable and Ecological Complexes Project or M.A.P-Temporary Housing Modules). 2.3. Sampling A cluster sample design was used, with the household as the sampling unit (Bennett et al., 1991). The sample size calculation of 96 clusters was based on a presumed design effect of 2.2, a prevalence of post traumatic stress disorder equal to 15% (Priebe et al., 2009), and an alpha of 0.05, a desired level of precision of 7 3%, and that in each household, there would be an average of 3 adult members who could be interviewed. The list of the temporary lodgings assigned in June 2010, published by the city of L’Aquila, was used to randomly select 96 households. 2.4. Data collection The interviews were conducted by staff of the research group, who underwent 2 days training conducted by expert from University of L’Aquila. Interviews took place between July 2010 and October 2010 (15 to 18 months after the earthquake, after 7–10 months living in new housing). Prior to initiating the survey, an awareness campaign and meetings with citizens committees were held to explain the purpose of the study. All persons gave their informed consent prior to their inclusion in the study. For each household, up to two visits were made to schedule an appointment for an interview. If no one was home during the two attempts, the household was excluded from the survey. The inclusion criteria were age Z 18 years, able to read Italian, and willing to consent to participate in the study. 2.5. Measures Subjects enrolled were investigated using the Davidson Trauma Scale (DTS) (Davidson et al., 1997) to measure the frequency and severity of PTSD-related symptoms and the Brief Cope (Carver, 1997), which explores the coping style of individuals and how they respond to stressful situations (situational or dispositional past). The DTS is a 17-item scale measuring each DSM-IV symptom of PTSD: criteria B (re-experiencing intrusive memories), criteria C (avoidance and numbness); and criteria D (hyperarousal). For each item, the subject rated both frequency and severity of symptoms during the previous week on a 5-point (0–4) Likert-type scales.
3. Results As shown in Fig. 1, 92 out of 96 sampled households were successfully contacted for the study; these households had a total of 332 persons. Two individuals were excluded because of speech difficulties, twenty-nine were excluded because they were o18 years of age, five refused to participate, and 15 were absent at moment of interview, resulting in a final sample size of 281. The average age was 43 years ( 7 16), and 54% were women. Socio-demographic characteristics, analyzed by gender, are presented in Table 1. In general, men were significantly likely to have a lower level of education, but there were no gender differences in age and employment status. The estimated prevalence of PTSD among the 271 respondents who completed the DTS was 43% (95%CI: 36.2–49.7%). The average score for intrusive memories was 17 on a scale of 0–20 (95% CI: 15–18), 13 (95% CI: 12–15) for the avoidance and numbing on a 0– 28 scale, an average of 14 (95% CI: 12–16) on a 0–20 scale for an increase in anxiety and hyperarousal. The prevalence of PTSD and its association with specific sociodemographic characteristics are shown in Table 2. Women and the unemployed were significantly more likely to meet the case definition of PTSD. The analysis of the Brief Cope data demonstrated that overall, the sample had the highest mean scores in active coping (6.0; 95% CI: 5.8–6.2), acceptance (5.9; 95%CI: 5.7–6.1) and planning (5.7; 95%CI: 5.5-5.9) and the lowest mean scores in substance use (2.5; 95%CI: 2.4–2.6), behavioral disengagement (3.4; 95%CI: 3.2–3.6) and humor (3.8; 95%CI: 3.6–3.9). The mean score at dimensions of Brief Cope by selected socio demographic characteristics of the participants and the bivariate associations between BC scales and these characteristics, are shown in Table 3. Age was a strong predictor of coping strategies, although there was not always a linear relationship between increasing age and coping scores. Age had an important influence on coping strategies in the domains of religious coping, emotional support, self-blame, behavioral disengagement, humor and
V. Cofini et al. / Psychiatry Research 229 (2015) 353–358
355
Sampling Clusters (Households) N. 5016
Sampled Clusters: N. 96
Contacted N 92
Not contacted N=4
Eligible
Not Eligible N=2 because of language N=29 because of age <18 years
YES
N.332
YES NO Agreed to participate N.301
Refused: N=5 Absent: N=15
YES
Respondents n. 281
Fig. 1. : Recruitment of study population.
Table 1 Socio demographic characteristics of survey participants by gender. Female
P-valuenn
Total sample
Male
n
%
n
%
n
%
Age, yearsn 18–34 35–55 455 total
91 91 69 251
36.3 36.3 27.4 100.0
43 36 35 114
37.7 31.6 30.7 100.0
48 55 34 137
35.0 40.2 24.8 100.0
0.34
Educational leveln Low High total
193 78 271
71.2 28.8 100.0
102 24 126
81.0 19.1 100.0
91 54 145
62.7 37.2 100.0
0.00
Employment statusn Yes No total
172 103 275
62.5 37.5 100.0
83 46 129
64.3 35.7 100.0
89 57 146
61.0 39.0 100.0
0.58
use of self-blame Except for higher scores for humor among men and for denial and venting among women, no significant differences were observed by gender. With respect to employment status, persons who were employed had significantly higher scores than nonworkers in acceptance and lower scores in religion and denial. As shown in Table 4, those with and without PTSD showed significant differences with respect to the several coping strategies. Individuals with PTSD had higher mean coping scores for religion, self-distraction, self-blame, denial, venting, and behavioral disengagement and lower values for acceptance compared with those who did not have PTSD.
4. Discussion
n The numbers within the categories do not have the total of 281 due to missing data nn Chi square test
substance use. Recourse to religious coping and behavioral disengagement increased with age and were significantly higher among those over 55 years, while humor was a significantly higher in the youngest age group, as was substance use. The young also showed an increased reliance on emotional support and greater
In our study, which examined the prevalence of PTSD and coping strategies more than year after a major earthquake in a population that was forced to move to temporary housing because of severe damage from their homes, the prevalence of PTSD was 43%. The prevalence appears to be higher than reported in two other studies conducted in the city on different populations and different age groups, although each study used different methods and they were conducted at different intervals following the earthquake. Gigantesco et al. (2013) estimated a prevalence of 4.1% in a representative sample of persons 18–69 years of age 14–19 months after the earthquake. The study was conducted by telephone and included the general population of the city, most of
356
V. Cofini et al. / Psychiatry Research 229 (2015) 353–358
Table 2 Risk factors for PTSD. No. of respondents 271
PTSD n (%: 95%CI) 116 (43%: 36.17-49.71)
Odds ratio (95%CI)
p-value
Total Gendern Male Female
123 147
40 (32.5%: 24.7–41.4) 76 (51.7%: 43.1–60.2)
1 2.2 (1.4–3.5)
0.00
Age range, yearsn 18–34 35–55 455
88 89 65
40 (45.5%: 34.4–57.0) 35 (39.3%: 28.2–51.7) 30 (46.2%: 34.0–58.8)
1 0.8 (0.5–2.0) 1.0 (0.5–1.3)
0.67
Education attainmentn Low High
186 76
80 (43.0%: 35.7–50.6) 33 (43.4%: 32.1–55.5)
1 1.0 (0.6–1.7)
0.95
Employment statusn Yes No
166 99
61 (36.8%: 28.6–45.7) 54 (54.6%: 44.9–63.8)
1 2.1 (1.2–3.5)
0.01
n
The numbers within the categories do not have the total of 271 due to missing data
whom had not experienced the prolonged displacement of our study population (2013). The levels were, however, within the range reported in other studies. A review of 2005, reported that the prevalence of PTSD in the first 1–2 years after a disaster has ranged between 5% (1985, Puerto Rico floods) and 60% (1987, Tornado in eastern North Carolina), although most of the reported values were in the lower half of this range (1988, Yun Nan earthquake, 9%; 1989, Newcastle
earthquake, 18%; 1993, Hurricane Hugo in South Carolina, 5%) (Galea et al., 2005). The highest prevalences were found in specific groups, including populations seen in clinical settings (Livanou et al., 2002) and people who were in areas heavily affected by disaster (Jin et al., 2014; Zhang et al., 2012; Wang et al., 2011); these levels were more similar to those seen in our study population. In our study, we also found higher scores for the different
Table 3 Brief Cope scores by socio demographic characteristics of respondents. Gendera
Age, yearsa
Employment Statusa
M (n 127)
F (n 148)
p
18–34 (n 90)
35–55 (n 90)
455 (n 68)
p
Yes (n 169)
No (n 102)
p
5.7 7 1.74
5.8 71.84
0.75
5.7 7 1.71
5.9 71.80
5.6 7 1.76
0.56
5.8 7 1.77
5.5 7 1.83
0.17
5.17 1.68
5.3 71.77
0.61
5.2 7 1.77
5.2 71.61
5.17 1.71
0.90
5.3 7 1.74
5.0 7 1.70
0.08
Religionb
4.3 7 2.10
4.8 72.11
0.06
4.0 7 1.99
4.5 72.04
5.2 7 2.20
0.00**
4.4 7 2.00
4.9 7 2.24
0.03**
Using emotional supportb
4.4 7 1.68
4.6 71.77
0.45
4.9 7 1.76
4.2 71.54
4.5 7 1.73
0.02**
4.4 7 1.66
4.7 7 1.84
0.14
Using instrumental supportb
4.7 7 1.81
4.8 71.88
0.64
4.9 7 1.93
4.6 71.66
4.9 7 1.86
0.64
4.6 7 1.82
5.0 7 1.90
0.11
5.17 1.81
5.2 71.73
0.49
5.4 7 1.73
4.9 71.74
5.17 1.82
0.17
5.17 1.83
5.2 7 1.67
0.51
Self-blameb
4.3 7 1.54
4.6 71.50
0.20
4.8 7 1.57
4.17 1.51
4.5 7 1.51
0.02**
4.4 7 1.52
4.6 7 1.50
0.37
Active copingc
6.0 7 1.55
6.0 71.73
0.90
6.17 1.53
6.17 1.77
5.8 7 1.71
0.48
Brief cope scores Planningb Positive reframing
Self-distraction
b
b
5.9 7 1.66
6.0 7 1.64
0.60
**
5.8 7 1.76
6.17 1.69
0.22
5.8 7 1.59
6.3 71.71
5.6 7 1.78
0.03
6.2 7 1.67
5.5 7 1.75
0.00**
Humorc
4.17 1.75
3.5 71.57
0.01**
4.3 7 1.74
3.5 71.49
3.5 7 1.74
0.00**
3.9 7 1.67
3.6 7 1.67
0.21
Denialc
3.7 7 1.77
4.0 71.80
0.05**
3.8 7 1.75
3.6 71.61
4.3 7 2.00
0.09
3.6 7 1.56
4.3 7 2.04
0.04**
Ventingc
4.2 7 1.60
4.9 71.72
0.00**
4.6 7 1.73
4.6 71.72
4.5 7 1.75
0.94
Acceptance
c
Substance use
c
2.7 7 1.46 c
Behavioral disengagement a
3.4 7 1.39
2.3 70.84 3.5 71.51
0.06 0.71
2.8 7 1.41 3.17 1.35
2.4 71.11 3.3 71.38
The numbers within the categories do not have the total of 281 due to missing data One way Anova, c Wilcoxon rank sum test ** Significant b
2.2 7 0.62 3.8 7 1.58
4.4 7 1.63
4.8 7 1.82
0.08
**
2.4 7 1.08
2.6 7 1.34
0.36
**
3.3 7 1.38
3.6 7 1.57
0.14
0.00 0.01
V. Cofini et al. / Psychiatry Research 229 (2015) 353–358
Table 4 Mean Brief Cope scores by PTSD status. No PTSDa (n 152)
PTSDa (n 116)
Brief cope scores
Mean points
Ds
Mean points
Ds
p-value
Planningb Positive reframingb Religionb Using emotionalsupportb Using instrumentalsupportb Self-distractionb Self-blameb Active copingc Acceptancec Humorc Denialc Ventingc Substance usec Behavioral disengagementc
5.8 5.2 4.3 4.4 4.7 4.9 4.2 5.9 6.2 4.0 3.5 4.3 2.4 3.1
1.78 1.73 2.01 1.62 1.79 1.83 1.34 1.70 1.67 1.65 1.67 1.66 1.15 1.31
5.7 5.2 5.0 4.7 4.9 5.4 4.8 6.1 5.6 3.6 4.3 5.0 2.6 3.8
1.77 1.75 2.16 1.79 1.91 1.64 1.69 1.54 1.80 1.71 1.85 1.70 1.24 1.59
0.53 0.87 0.01** 0.09 0.42 0.04** 0.00** 0.30 0.02** 0.07 0.00** 0.00** 0.14 0.00**
a
The numbers within the categories do not have the total of 271 due to missing
data b
One way Anova, Wilcoxon rank sum test ** Significant c
dimensions of PTSD than reported elsewhere, including in some major earthquakes in Pakistan and Taiwan where the PTSD prevalences were high (41% thirty months after the disaster in Pakistan (Ali et al., 2012) and among professional and non-professional rescuers were 19.8% and 31.8%, respectively, one months after the disaster in Taiwan (Guo et al., 2004). In our study, the average score was 17 for intrusive memories, 13 for avoidance and numbing, and 14 for anxiety and hyperarousal. In the Pakistan study, values for the three dimensions were 13, 12, and 9 (Ali et al., 2012), respectively, while in Taiwan, the values were 9, 7, and 8, respectively (Guo et al., 2004). However, such studies have estimated the prevalence of the disorder and the average of the three scores on individuals in different ages and with different methods, making it difficult to assess the significance of the higher values in L’Aquila. The findings on socio-demographic characteristics associated with an increased risk of PTSD are generally compatible with the findings of others (Chen et al., 2007; Armenian et al., 2000; .Basoglu et al., 2002; Kılıç and Ulusoy , 2003; Yang et al. ,2003). As in our study, others have demonstrated that women appear more vulnerable to PTSD (Priebe et al. 2009; Wang et al. 2009, 2011; Dell’Osso et al. 2011a). However, our study and that of Gigantesco et al. (2013) showed that age and level of education were not associated with PTSD. By contrast, several studies done elsewhere (Karanci and Rustemli, 1995; Armenian et al., 2000; Basoglu et al. ,2002; Kılıç and Ulusoy, 2003; Priebe et al., 2009; Ali et al., 2012) have demonstrated that older age and lower education are associated with increased risks for PTSD. Few studies have examined the role of overall social and economic context after a disaster on the risk of PTSD (Galea et al., 2005). Our study demonstrated that those who were unemployed suffered more PTSD, and Gigantesco et al. (2013), also showed in L’Aquila that individuals with economic difficulties are more exposed to the risk of developing PTSD. Understanding the coping mechanisms following an earthquake is important in developing appropriate interventions. After an earthquake, the affected population must adapt quickly to changes in their living situations and face constant fear of aftershocks. This sequence of events may affect significantly the ability of an individual to cope with a disaster. With respect to coping strategies, we observed different patterns
357
of coping strategies by gender, age, employment status, and presence of PTSD. Gender differences occurred in the use of humor, denial and the venting. Men were more likely to deal with the event by deemphasizing it. Women, by contrast, were more likely to deny what had happened and more likely to outwardly demonstrate their feelings or denying that it had affected them. Evidence in the literature also confirms the existence of gender differences in coping strategies adopted: women are more likely to vent their emotions and to seek emotional and instrumental support; men, on the other hand, are more prone to use drugs and alcohol to cope to stressful life events (Carver et al., 1989). The gender differences that Carver et al., observed, also suggest that men rely on themselves to cope with stress, while women seek greater help others. We observed that age also influenced acceptance and coping mechanisms. The acceptance was lower in subjects with age4 55 years. Recourse to religious coping and behavioral disengagement was higher with increasing age, while resorting to emotional support, self-blame, humor and the use of substances tended to be greater in the group of younger subjects. An interesting finding of our study was the major differences in coping strategies for those with and without PTSD. In general, those with PTSD symptoms often employed maladaptive coping strategies for dealing with earthquake, and had the highest scores in the domains of denial, venting, behavioral disengagement, selfblame. By contrast, those without PTSD generally had more adaptive coping mechanisms, including greater acceptance, a coping strategy that is antithetical to denial (Carver et al., 1989). They also were more likely to exhibit planning although the difference was not statistically significant (p 40.05). People suffering from PTSD had higher average scores for less active but nonetheless adaptive coping strategies (Carver et al., 1989) including religion, use of emotional support and use of instrumental support, although only the religious coping was statistically different between the two groups. The presence of adaptive coping strategies in subjects that do not develop PTSD following the earthquake and maladaptive coping strategies in who manifests the disorder suggests the existence of a relationship between the two variables. The scale of the Brief Cope used in this study is “dispositional” and thus permits investigation of habitual tendencies of persons to cope with a stressful life event. It can be assumed, therefore, that following the earthquake, the habitual use of adaptive strategies may have protected against the development of PTSD, while using maladaptive strategies have increased the risk of psychopathology. Evidence in the literature supports this hypothesis. In the context of traumatic events, the use of active coping strategies or instrumental strategies, such as positive restructuring, active coping and seeking emotional support, allow a good adaptation to stress. By contrast, the passive coping strategies such as avoidance, are often maladaptive (Resnick, 1988; Sharkansky et al., 2000; North et al., 2001; Silver et al., 2002; Ozer et al., 2003; Linley and Joseph, 2004). People with avoidant coping style are also more likely to show symptoms of acute stress disorder after traumatic events (Bartone et al. 1989. Bryant and Harvey 1995, Johnsen et al., 1998, 2002). A limitation is that the study did not investigate whether participants had PTSD, linked to a different traumatic experience since the DTS scale does not provide temporal references. Therefore, it is important to be cautious in interpreting the results obtained. Finally an issue in this paper is that it is difficult to make meaningful comparisons with other studies since they differ in the degree to which the population has been exposed, the magnitude of the event, the time elapsed since the disaster, and local circumstances such as availability of local housing and the speed of rebuilding homes and infrastructure. Similar issues have been noted in the review of Galea et al. (2005). Despite the limits presented, our study demonstrates that
358
V. Cofini et al. / Psychiatry Research 229 (2015) 353–358
adults who have been displaced and who remain in limbo about the study the fate of their homes (renovation or demolition), without knowing how long they lived in temporary housing experience high rates of PTSD more than a year after the disaster. It also suggests that coping mechanisms differ between those who have PTSD and those who do not. Although it cannot be entirely ruled out that the coping mechanisms are a function of having PTSD, our findings suggest that instead existing dispositional coping methods influence the likeliness of developing PTSD. The study supports the need for decision makers to be aware of mental health needs of populations affected by disasters such as earthquakes, particularly those who have been displaced, whose social lives had been disrupted, and who and are faced with chronic uncertainty about their future.
Conflict of interest The authors declare that they have no conflict of interest.
Ethical standards The authors assert that all procedures contributing to this work comply with the ethical standards on human observational study.
Acknowledgments The authors gratefully acknowledge the support of the European Commission FP6 funded project MICRODIS, administered by the Centre for Research on the Epidemiology of Disasters at the Catholic University of Louvain, Belgium. The support of MICRODISL’Aquila team members is acknowledged with further gratitude: David Alexander, Caterina Antinori, Diego Guidotti, Christian Iasio, Michele Magni , Fausto Marincioni, Roberto Miniati and Francesco Barbano.
References Ali, M., Farooq, N., Bhatti, M.A., Kuroiwa, C., 2012. Assessment of prevalence and determinants of posttraumatic stress disorder in survivors of earthquake in Pakistan using Davidson Trauma Scale. J. Affect. Disord. 136 (3). http://dx.doi. org/10.1016/j.jad.2011.12.023 238-43. Armenian, H.K., Morikawa, M., Melkonian, A.K., Hovanesian, A.P., Haroutunian, N., Saigh, P.A., Akiskal, K., Akiskal, H.S., 2000. Loss as a determinant of PTSD in a cohort of adult survivors of the 1988 earthquake in Armenia: implications for policy. Acta Psychiatr. Scand. 102 (1), 58–64. Bartone, P.T., Ursano, R.J., Wright, K.M., Ingraham, L.H., 1989. The impact of a military air disaster on the health of assistance workers. A prospective study. J. Nerv. Ment. Dis. 177 (6), 317–328. Bennett, S., Woods, T., Liyanage, W.M., Smith, D.L., 1991. A simplified general method for cluster-sample surveys of health in developing countries. World Health Stat. Q. 44 (3), 98–106. Basoglu, M., Salcioglu, E., Livanou, M., 2002. Traumatic stress responses in earthquake survivors in Turkey. J. Trauma. Stress 15 (4), 269–276. Bryant, R.A., Harvey, A.G., 1995. Avoidant coping style and post-traumatic stress following motor vehicle accidents. Behav. Res. Therapy 33 (6), 631–635. Carmassi, C.B., 2015. Impact of DSM-5 PTSD and gender on impaired eating behaviors in 512 Italian earthquake survivors. Psychiatry Res. 225 (1), 64–69. Carver, C.S., Sheirer, M.F., Weintraub, J.K., 1989. Assessing coping strategies: a theoretically based approach. J. Personal. Soc. Psychol. 56, 267–283. Carver, C.S., 1997. You want to measure coping but your protocol’too long: consider the brief cope. Int. J. Behav. Med. 4 (1), 92–100. Cerdá, M., Paczkowski, M., Galea, S., Nemethy, K., Péan, C., Desvarieux, M., 2013. Psychopathology in the aftermath of the Haiti earthquake: a population-based study of posttraumatic stress disorder and major depression. Depress. Anxiety 30 (5). http://dx.doi.org/10.1002/da.22007 413-24. Chen, C.H., Tan, H.K., Liao, L.R., Chen, H.H., Chan, C.C., Cheng, J.J., Chen, C.Y., Wang, T. N., Lu, M.L., 2007. Long-term psychological outcome of 1999 Taiwan earthquake survivors: a survey of a high-risk sample with property damage. Compr. Psychiatry 48 (3), 269–275.
Cofini, V., Colonna, F., 2011. La sistemazione della popolazione aquilana. In Il terremoto dell’Aquila, analisi e riflessioni sull’emergenza. Edizioni L’Una, 75–96. Davidson, J.R., Book, S.W., Colket, J.T., Tupler, L.A., Roth, S., David, D., Hertzberg, M., Mellman, T., Beckham, J.C., Smith, R.D., Davison, R.M., Katz, R., Feldman, M.E., 1997. Assessment of a new self-rating scale for post-traumatic stress disorder. Psychol. Med. 27 (1), 153–160. Dell’Osso, L., Carmassi, C., Massimetti, G., Daneluzzo, E., Di Tommaso, S., Rossi, A., 2011a. Full and partial PTSD among young adult survivors 10 months after the L’Aquila 2009 earthquake: gender differences. J. Affect. Disord. 131 (1–3), 79–83. http://dx.doi.org/10.1016/j.jad.2010.11.023. Dell’Osso, L., Carmassi, C., Massimetti, G., Conversano, C., Daneluzzo, E., Riccardi, I., Stratta, P., Rossi, A., 2011b. Impact of traumatic loss on post-traumatic spectrum symptoms in high school students after the L’Aquila 2009 earthquake in Italy. J. Affect. Disord. 134 (1–3), 59–64. http://dx.doi.org/10.1016/j.jad.2011.06.025. Elhai, J.D., Lindsay, B.M., Gray, M.J., Grubaugh, A.L., North, T.C., Frueh, B.C., 2006. Examining the uniqueness of frequency and intensity symptom ratings in posttraumatic stress disorder assessment. J. Nervous Ment. Dis. 194, 940–944. Galea, S., Nandi, A., Vlahov, D., 2005. The Epidemiology of Post-Traumatic Stress Disorder after Disasters. Epidemiol. Rev. 27 (1), 78–91. Gigantesco, A., Mirante, N., Granchelli, C., Diodati, G., Cofini, V., Mancini, C., Carbonelli, A., Tarolla, E., Minardi, V., Salmaso, S., D’Argenio, P., 2013. Psychopathological chronic sequelae of the 2009 earthquake in L’Aquila, Italy. J. Affect. Disord. 148 (2–3). http://dx.doi.org/10.1016/j.jad.2012.12.006. E 265-71. Guo, Y.J., Chen, C.H., Lu, M.L., Tan, H.K., Lee, H.W., Wang, T.N., 2004. Posttraumatic stress disorder among professional and non-professional rescuers involved in an earthquake in Taiwan. Psychiatry Res. 127 (1–2), 35–41. Istituto Nazionale Geofisica e Vulcanologia (INGV), 2009. The L’Aquila seismic sequence-April. (accessed 24.08.09). Archived 7 September 2009. Jin, Y., Xu, J., Liu, H., Liu, D., 2014. Posttraumatic stress disorder and posttraumatic growth among adult survivors of wenchuan earthquake after 1 year: prevalence and correlates. Arch. Psychiatric Nurs. 28 (1), 67–73. http://dx.doi.org/ 10.1016/j.apnu.2013.10.010. Johnsen, B.H., Eid, J., Laberg, J.C., Thayer, J.F., 2002. The effect of sensitization and coping style on post‐traumatic stress symptoms and quality of life: two longitudinal studies. Scand. J. Psychol. 43 (2), 181–188. Johnsen, B.H., Laberg, J.C., Eid, J., 1998. Coping strategies and mental health problems in a military unit. Mil. Med. 163 (9), 599–602. Karanci, A.N., Rustemli, A., 1995. Psychological consequences of the 1992 Erzincan (Turkey) earthquake. Disasters 19 (1), 8–18. Kılıç, C., Ulusoy, M., 2003. Psychological effects of the November 1999 earthquake in Turkey: an epidemiological study. Acta Psychiatr. Scand. 108 (3), 232–238. Linley, P.A., Joseph, S., 2004. Positive change following trauma and adversity: a review. J. Trauma. Stress 17 (1), 11–21. Livanou, M., Bassoglu, M., Ssalcioglu, E., Kalendar, D., 2002. Traumatic stress responses in treatment-seeking earthquake survivors in Turkey. J. Nervous Ment. Dis. 190 (12), 816–823. Muller, L., Spitz, E., 2003. [Multidimensional assessment of coping: validation of the Brief COPE among French population]. L’encéphale 29 (6), 507–518. North, C.S., Spitznagel, E.L., Smith, E.M., 2001. A prospective study of coping after exposure to a mass murder episode. Ann. Clin. Psychiatry 13 (2), 81–87. Ozer, E.J., Best, S.R., Lipsey, T.L., Weiss, D.S., 2003. Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol. Bull. 129 (1), 52–73. Pollice, R., Bianchini, V., Roncone, R., Casacchia, M., 2012. Psychological distress and post-traumatic stress disorder (PTSD) in young survivors of L’Aquila earthquake. Riv. Psichiatria 47 (1), 59–64. http://dx.doi.org/10.1708/1034.11292. Priebe, S., Grappasonni, I., Mari, M., Dewey, M., Petrelli, F., Costa, A., 2009. Posttraumatic stress disorder six months after an earthquake. Soc. Psychiatry Psychiatric Epidemiol. 44 (5), 393–397. Resnick, P.A., 1988. Reactions of female and male victims of rape or robbery. National Institute of Mental Health, Washington, D.C. Sharkansky, E.J., King, D.W., King, L.A., Wolfe, J., Erickson, D.J., Stokes, L.R., 2000. Coping with Gulf War combat stress: Mediating and moderating effects. J. Abnorm. Psychol. 109 (2), 188. Silver, R.C., Holman, E.A., McIntosh, D.N., Poulin, M., Gil-Rivas, V., 2002. Nationwide longitudinal study of psychological responses to September 11. J.Am. Med. Assoc. 288 (10), 1235–1244. Wang, B., Ni, C., Chen, J., Liu, X., Wang, A., Shao, Z., Xiao, D., Cheng, H., Jiang, J., Yan, Y., 2011. Posttraumatic stress disorder 1 month after 2008 earthquake in China: Wenchuan earthquake survey. Psychiatry Res. 187 (3). http://dx.doi.org/ 10.1016/j.psychres.2009.07.001 392-6. Wang, L., Zhang, Y., Wang, W., Shi, Z., Shen, J., Li, M., Xin, Y., 2009. Symptoms of posttraumatic stress disorder among adult survivors three months after the Sichuan earthquake in China. J. Trauma. Stress 22 (5), 444–450. Xu, J., Song, X.,, 2011. A cross-sectional study among survivors of the 2008 Sichuan earthquake: prevalence and risk factors of posttraumatic stress disorder. Gen. Hosp. Psychiatry 33 (4), 386–392. http://dx.doi.org/10.1016/j. genhosppsych.2011.05.004. Yang, Y.K., Yeh, T.L., Chen, C.C., Lee, C.K., Lee, I.H., Lee, L.C., Jeffries, K.J., 2003. Psychiatric morbidity and posttraumatic symptoms among earthquake victims in primary care clinics. General Hospital Psychiatry 25 (4), 253–261. Zhang, Z., Shi, Z., Wang, L., Liu, M., 2011. One year later: Mental health problems among survivors in hard-hit areas of the Wenchuan earthquake. Pub. Health 125 (5), 293–300. http://dx.doi.org/10.1016/j.puhe.2010.12.008. Zhang, Z., Wang, W., Shi, Z., Wang, L., Zhang, J., 2012. Mental health problems among the survivors in the hard-hit areas of the Yushu earthquake. PLoS One 7 (10), e46449. http://dx.doi.org/10.1371/journal.pone.0046449, www.DSM5.org.