Posttraumatic stress disorder 1 month after 2008 earthquake in China: Wenchuan earthquake survey

Psychiatry Research 187 (2011) 392–396

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Psychiatry Research j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s

Posttraumatic stress disorder 1 month after 2008 earthquake in China: Wenchuan earthquake survey Bo Wang a,1, Chunping Ni a,b,1, Jingyuan Chen c, Xuedong Liu d, Anhui Wang a, Zhongjun Shao a, Dan Xiao a, Hai Cheng a, Jianhui Jiang a, Yongping Yan a,⁎ a

Department of Epidemiology, School of Military Preventive Medicine, Fourth Military Medical University, 17 Changlexi Street, Xi, an, Shaanxi 710032, PR China Department of Nursing, Fourth Military Medical University, 17 Changlexi Street, Xi, an, Shaanxi 710032, PR China Department of Occupational and Environmental Hygiene, School of Military Preventive Medicine, Fourth Military Medical University, 17 Changlexi Street, Xi, an, Shaanxi 710032, PR China d Department of Neurology, Xijing Hospital, Fourth Military Medical University, 17 Changlexi Street, Xi, an, Shaanxi 710032, PR China b c

a r t i c l e

i n f o

Article history: Received 3 December 2008 Received in revised form 24 June 2009 Accepted 5 July 2009 Keywords: Chinese Earthquake Posttraumatic stress disorder Prevalence

a b s t r a c t The objective of the study was to understand the rate of posttraumatic stress disorder (PTSD) and to explore the effects of sociodemographic characteristics and the disaster losses on the development of PTSD 1 month after the 2008 earthquake in China. A random sample of 430 survivors were investigated for PTSD with a self-report questionnaire including the Posttraumatic Stress Disorder Self-rating Scale and Survivor Information Questionnaire between June 15 and June 20, 2008. Chi-square analysis and multivariate logistic regression analysis, were used to evaluate PTSD morbidity and risk factors of survivors. A total of 257 (62.8%) subjects met the criteria for PTSD 1 month after the earthquake. Married status (odds ratio (OR) = 2.22, 95%confidence interval (CI): 1.06–4.65), female gender (OR = 2.36, 95%CI: 1.51–3.70), having deaths or injury of family members (OR = 1.67, 95%CI: 1.07–2.57), low education level (OR = 1.39, 95%CI: 1.07–1.80), and losses of possessions (OR = 1.82, 95%CI: 1.05–3.16) all had a significant effect on survivors' PTSD. PTSD was as prevalent in disaster victims in China as in those elsewhere. In the early stage of disasters, those victims who were female, not well educated, and suffered considerable losses in their possessions or family members should be closely attended to during the early psychological intervention. Crown Copyright © 2009 Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction Posttraumatic stress disorder (PTSD) is a psychiatric disorder that can occur after experiencing or witnessing a life-threatening traumatic event, such as rape, military combat, violent crimes and assault, and natural disaster (American Psychiatric Association [APA], 2000). Primary symptoms of PTSD include a host of symptoms that are categorized under the following three criteria after exposure to an overwhelming traumatic experience: persistent re-experiencing of the traumatic event, active and passive avoidance of reminders, and persistent hyperarousal. Symptoms from each of these clusters are required for a diagnosis of PTSD, and they must persist for at least 1 month after the trauma and be accompanied by clinically significant distress and impairment (APA, 2000). Exposure to earthquakes is associated with increased risk of psychiatric problems, especially PTSD, major depressive disorder, and psychiatric disorders (Carr et al., 1995; Karancı and Rüstemli, 1995; McMillen et al.,

⁎ Corresponding author. Department of Epidemiology, School of Military Preventive Medicine, Fourth Military Medical University, 17 Changlexi Street, Xi, an, Shaanxi, PR China, 710032. Tel./fax: +86 29 84774868. E-mail address: [email protected] (Y. Yan). 1 These two authors contributed equally to this work.

2000). The prevalence of PTSD reported from different countries among victims of earthquake trauma has varied over a wide range. For example, after the 1988 Armenian Earthquake, the Manual of Mental Disorders, 3rd Edition, Revised (DSM-III-R) rate of PTSD was found to be 87% and 73% post-earthquake at 1.5 and 4.5 years, respectively (Goenjian et al., 1994, 2000). In China, the rate of earthquake-related PTSD within 5 months and 9 months was 23% and 24%, respectively (Wang et al., 2000; Cao et al., 2003). Among the Indian earthquake survivors, the prevalence of PTSD was reported as 23% (Sharan et al., 1996a,b). Studies from Turkey showed that the estimated prevalence for PTSD was 25–43% (Başoglu et al., 2002; Tural et al., 2004) for an average of 1 year after the earthquake. Many risk factors for PTSD have been reported in previous studies. Risk or etiologic factors, which were related to the development of PTSD, may be divided into pre-, peri-, and post-exposure factors. Important risk factors included female gender, marital and family status, occupation, education (Berton and Stabb, 1996; Breslau et al., 1997), having experienced multiple traumatic events in the past (Robin et al., 1997; Dahl et al., 1998), specific personality traits (McFarlane, 1990), and the degree of fear of dying or being seriously injured in the accident (McFarlane, 1988; Ehlers et al., 1998; Mollica et al., 1998). Additional factors that may mediate vulnerability to PTSD include past psychiatric history, positive family history of psychiatric illness, severity of trauma, reaction at time of trauma, and factors related to the traumatic event

0165-1781/$ – see front matter. Crown Copyright © 2009 Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2009.07.001

B. Wang et al. / Psychiatry Research 187 (2011) 392–396

(e.g., intensity, duration, degree of exposure, extent of damage, and losses sustained) (Brewin et al., 2000; Frans et al., 2005). At 2:28 p.m. Beijing time, on May 12, 2008, an earthquake measuring 7.9 magnitude on the Richter scale, with its epicenter in Wenchuan county, hit a number of cities and counties in the southwest of China. It was the most devastating disaster that had occurred in China in the last 30 years. The quake belt involves a population of 7,000,000 in an area of 30,000 km2 covering 254 towns of 21 counties (cities), such as Beichuan, Wenchuan, Mianzhu, Qingchuan, Shifang, Dujiangyan, Pingwu, Anxian, Jiangyou, Pengzhou, Maoxian, Lixian, Chongzhou, Baoxing, Xiaojin, Heishui, Songpan, Dayi, Pixian, Wenjiang, and Lushan (Earthquake Bureau of Sichuan Province, 2008). Qingchuan county, as one of the earthquake areas in the quake belt, is located 100 km away from Wenchuan county. Disaster relief authorities assessed Qingchuan county as having experienced a severe level of destruction. Even though the numbers varied, the estimated death toll in Qingchuan county was 4821 people and 15,489 people were injured. Over 1,350,000 buildings, including houses, working places, schools, hospitals, and other public places, were destroyed by the massive earthquakes. The financial loss to the economy in Qingchuan county was estimated to be 50 billion (Ying, 2008). Although many epidemiological PTSD studies have been conducted, those studies related to earthquakes mainly dealt with the medium- and long-term psychosocial impact of these traumatic events (Goenjian et al., 2000; Carr et al., 1995; Wang et al., 2000; Başoglu et al., 2002; Cao et al., 2003; Chou et al., 2004; Groome and Soureti, 2004), while the early development of PTSD in earthquake victims has been investigated in only a few studies (Kato et al., 1996; Chen et al., 2001; Soldatos et al., 2006). Wenchuan earthquake was the strongest disaster in the last 30 years in China. Resulting in different destruction from other disasters, it is necessary to study the early impact of the vast disaster and identify those at risk of mental disorders in order to take effective countermeasures against PTSD shortly after the disaster. The main objective of this study is to determine the prevalence of PTSD 1 month after the 2008 earthquake in China and to explore its risk factors in survivors living in the quake belt when the aftershocks continued. 2. Methods 2.1. Subjects Sampling was conducted in Qingchuan county. Residents experienced extreme threats to their lives and witnessed mutilating injuries and grotesque deaths. These traumatogenic experiences persisted for days after the earthquake. The survey covered all the settlement areas of Qiaozhuang town in Qingchuan county. First, some tents for displaced earthquake survivors were randomly selected on the basis of the number of the tents. Second, one respondent within each selected tent was randomly selected according to birth date. Of all persons within the tents, those who experienced the violent earthquake and aged from 18 to 65 years were available to interview. Exclusion criteria were psychotic illness and positive family history of psychiatric illness before the earthquake, history of conversional fainting, and use of benzodiazepines for less than 1 month at assessment. 2.2. Questionnaire instrument 2.2.1. Posttraumatic Stress Disorder Self-rating Scale (PTSD-SS) This is a brief screening instrument for PTSD, designed by Liu et al. in 1998 (Liu et al., 1998). Based on the definition and diagnostic criteria in the Manual of Mental Disorders, 4th Edition (DSM-IV) and Chinese classification and diagnostic Criteria of Mental Disorders, 2nd Edition, Revised (CCMD-II-R), the PTSD-SS was constructed with psychological testing and statistical techniques. The reliability and validity of the PTSDSS has been examined (Liu et al., 1998). The reliability coefficients were 0.9207 for internal consistency (Cronbach α), 0.9539 for split-half reliability, and 0.8677 for test -retest reliability. Principal component analysis with Varimax rotation identified the following three factors: re-experience/avoidance symptoms, psychological disorders/functional impairment, and emotional numbing/hypervigilance. The correlations between PTSD-SS and SAS, SDS, and YSR were 0.2064, 0.3536, and 0.2062, respectively. The PTSD-SS consisted of 24 items. Each item was rated on a five-point Likert scale: 1 (no symptom), 2 (mild), 3 (moderate), 4 (severe), or 5 (extremely severe). A total PTSD score was calculated by summing the values of each item to estimate the prevalence and severity of PTSD. A cutoff of 50 points on the PTSD-SS was a good predictor of PTSD diagnosis based on the previous studies (Liu et al., 1998). Persons

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with scores of 50–60 on the PTSD-SS were considered to have mild PTSD; however, those with higher scores than 60 were considered to have moderate-to-severe PTSD. Since respondents were not directly evaluated by a clinician, the diagnosis of PTSD should be considered to represent PTSD-like mental disorder. The PTSD-SS was a valid screening instrument, which meshed well with Chinese culture and had been used to explore the impact of disasters in previous studies (Hui et al., 2001; Li et al., 2004). 2.2.2. Survivor information questionnaire This is a self-administered questionnaire, designed to elicit information on sociodemographic characteristics (e.g., age, gender, ethnicity, marital status, education background, and registered permanent residence), trauma experience, psychiatric history, family history of psychiatric illness, and the disaster losses (e.g., the type and amount of losses they experienced, losses from injury to oneself, deaths of family members, damage to one's house, and other losses of possessions). Most of the information was assessed on a dummy coded scale (response was coded 0 for a no response and 1 for a yes response). The questions related to losses of family members, physical injury, and damage to one's house were assessed on a ‘‘yes'’ or ‘‘no’’ scale. The level of possessions loss was assessed on a three-level scale. 2.3. Data collection methods The study was approved by the ethics committee of the Fourth Military Medical University. Before the survey, consent was also obtained from the subjects. No one refused to participate in the investigation. The survey was conducted between June 15 and 20, 2008 in the selected tents in Qingchuan county. Trained investigators, who worked in Qingchuan county as medical rescuers, carried out the survey. Subjects were given a self-report questionnaire. For some subjects, the self-report questionnaire was completed with the assistance of investigators because of the subjects' relatively low education level. 2.4. Statistical analysis The SPSS statistical software package (version 16.0) was used for all data analyses. PTSD rates per 100 study subjects were calculated to describe the incidence of PTSD by gender, age group, ethnicity, and damage characteristics. The difference in the rate of PTSD 1 month after the earthquake by age, gender, ethnicity, and the disaster experiences was tested by chi-square analysis. Results were considered statistically significant if P ≤ 0.05. To assess the contributions of sociodemographic characteristics and the disaster experiences to PTSD, multivariate logistic regression analysis was performed, with or without PTSD as the dependent variable, and eight items including age, gender, registered residence, marital status, education level, damage to one's house, deaths or injury of family members, and losses of possessions as independent variables. Variables were selected for inclusion in the multivariable models if they were at least marginally significant (P ≤ 0.05). For each odds ratio (OR), the 95% confidence interval (CI) was calculated.

3. Results 3.1. Survey response and sociodemographic characteristics The original sample contained 430 study subjects, representing a response rate of 100.0%. After removing 21 subjects whose questionnaire was not completed fully or not completed according to the actual facts, data of 409 subjects remained with an effective rate of 95.1%. Of the 409 study subjects, there were 205 males and 204 females. Their mean age was 38.1 years (range 18–65); there was no significant difference in age between males and females. The majority of subjects was married (84.1%) and had children (76.5%). Although 97.3% of the subjects reported being indoors during the earthquake, only five had been slightly injured. 3.2. Incidence rate and symptoms of PTSD Among the study subjects, 257 subjects met the criteria for PTSD 1 month post-earthquake, and the rate of PTSD was 62.8%. Eighty-two and 175 subjects were assessed to have mild and moderate-to-severe PTSD (with the rate of 20.0% and 42.8%), respectively. More specifically, the most common individual PTSD symptoms were as follows: being afraid that the event would occur again (97.7%), having unwanted memories (96.9%), getting really upset when reminded of the event (95.7%), repeatedly thinking back to the event (94.9%), being dysphoric (91.1%), and having trouble concentrating (90.3%) (Table 1).

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Table 1 Frequency of PTSD symptoms in PTSD cases 1 month after earthquake(n = 257). Symptoms Subjective assessment of the traumatic event Having influence on one's mental health Re-experiencing of the traumatic memories Getting really upset when reminded of the event Having unwanted memories Repeatedly thinking back about the event Having unpleasant dreams Being dysphoric Having flashbacks Having physical problems Active and passive avoidance of reminders Losing interest in things one used to enjoy Feeling distant from family members Trying not to think about the event Being unconcerned with other people Staying away from reminders of the event Being pessimistic and disappointed Being unable to remember part(s) of the event Persistent hyperarousal Being afraid of taking place of the event once more Being more uptight or frightened Having sleep problems Having trouble concentrating Being more aggressive or impulsive Being more irritable or losing one's temper Society functional impairment Having influence on one's study or work Having poor remembrance Being guilty

N

%

Table 2 Sociodemographic characteristics and the disaster experiences of subjects assessed for PTSD 1 month after the earthquake. Characteristics

255

99.2

246 249 244 203 234 216 192

95.7 96.9 94.9 79.0 91.1 84.0 74.7

237 97 212 86 208 200 190

92.2 37.7 82.5 33.5 80.9 77.8 73.9

251 219 212 232 161 222

97.7 85.2 82.5 90.3 62.6 86.4

228 221 111

88.7 86.0 43.2

The rates of PTSD 1 month after the earthquake by gender, age, ethnicity, and damage characteristics are summarized in Table 2. Female survivors had significantly higher PTSD rates than male survivors (71.1% vs. 54.6%, P = 0.001). The PTSD rate among married survivors was significantly different from the PTSD rate among the unmarried survivors (66.9% vs. 41.5%, P = 0.000). The PTSD rate (70.4%) of the survivors with deaths or injury of family members was significantly higher than that of those survivors without deaths or injury of family members (P = 0.047). There was a statistically significant difference of the PTSD rates 1 month after the earthquake among those survivors with different ages (P = 0.000), and the rate of survivors (78.8%) at age 41-50 was highest. The rate of PTSD increased from 33.3% to 66.0% as the the survivors' losses of possessions increased. 3.3. Risk factors for the occurrence of PTSD From the analysis of multivariate logistic regression, five risk factors were entered in the logistic regression model, including married status (OR = 2.22, 95%CI = 1.06–4.65), female gender (OR = 2.36, 95%CI = 1.51–3.70), having deaths or injury of family members (OR = 1.67, 95%CI = 1.07–2.57), low education level (OR = 1.39, 95%CI = 1.07–1.80), and losses of possessions (OR = 1.82, 95%CI = 1.05–3.16) (Table 3).

Total numbers of victims

Gender Male 205 Female 204 Age (years) 18–30 83 31–40 156 41–50 104 51–65 66 Registered residence City or town 329 Countryside 79 Marital status Unmarried 65 Married 344 Education (years) ≤6 29 7–9 134 10–12 118 ≥ 13 127 Damage to one's house No 310 Yes 99 Deaths or injury of family members No 294 Yes 115 Losses of possessions High 344 Moderate 58 Low 6

PTSD N (%)

non-PTSD N (%)

χ2

P

112(54.6) 145(71.1)

93(45.4) 59(28.9)

11.84

0.001

37(44.6) 98(62.8) 82(78.8) 40(60.6)

46(55.4) 58(37.2) 22(21.2) 26(39.4)

23.40

0.000

207(62.9) 50(63.3)

122(37.1) 29(36.7)

27(41.5) 230(66.9)

38(58.5) 114(33.1)

15.01

0.000

21(72.4) 92(68.7) 75(63.6) 69(54.3)

8(27.6) 42(31.3) 43(36.4) 58(45.7)

7.05

0.070

195(62.9) 60(60.6)

115(37.1) 39(39.4)

0.23

0.620

176(59.9) 81(70.4)

118(40.1) 34(29.6)

3.96

0.047

227(66.0) 27(46.6) 2(33.3)

117(34.0) 31(53.4) 4(66.7)

10.27

0.006

0.004

0.951

aspects of the trauma, having a sense of disconnectedness, or feeling that the world seems unreal) in addition to the symptoms experienced in PTSD. The 2008 earthquake in China was a large-scale catastrophe, with the quake above 7.9 magnitude on the Richter scale and hundreds of aftershocks with horrible negative consequences on the physiological, psychological, and social well-being of individuals, families, and the economic infrastructures. In our previous studies, the prevalence of ASD after the earthquake was found to be 76.8% (Yan et al., 2008). In this study, we determined the prevalence of PTSD 1 month after the earthquake. Previous epidemiologic studies estimated the prevalence of PTSD between 7.8% and 80.0% (Peterson et al., 2002; Kates et al., 2002; Tso et al., 2004). The analysis on PTSD prevalence in this sample, based on the PTSD-SS, revealed that almost 62.8% of trauma survivors suffered from mild-to-moderate or severe levels of PTSD 1 month after the earthquake. Compared with the prevalence of PTSD after other earthquakes (Wang et al., 2000; Başoglu et al., 2002; Cao et al., 2003; Tural et al., 2004), the rate of PTSD 1 month after the Wenchuan earthquake was found to be higher. This may be ascribed to different methodologies, the time elapsed between the onset of the disaster and data collection, the methods of sampling and case detection, and the severity of negative consequence. In the present study, the questionnaires were completed by survivors themselves in the earthquake

4. Discussion Acute stress disorder (ASD) and PTSD are both disorders that may develop after exposure to a traumatic event. Examples of traumatic events include military combat, natural disasters, terrorist incidents, spousal abuse, child abuse, automobile accidents, and violent assaults. The two principal differences between ASD and PTSD are the timing and nature of the symptoms. First, in ASD, the symptoms and functional impairment last 2 days to 4 weeks after exposure, whereas in PTSD, the symptoms and dysfunction persist longer than 1 month (APA, 2000). Second, to be diagnosed with ASD, a person must have dissociative symptoms (e.g., difficulty remembering important

Table 3 Logistic odds ratios (OR) and 95% confidence interval (95%CI) for PTSD of selected risk factors. Variables

B

SE

Wald c2

P

OR

95% CI

Constant Marital status Gender Deaths or injury of family members Education background Losses of possessions

− 5.07 0.80 0.86 0.45 0.33 0.60

1.18 0.38 0.23 0.25 0.13 0.28

18.57 4.41 14.02 3.23 6.26 4.54

0.000 0.036 0.000 0.045 0.012 0.033

2.22 2.36 1.67 1.39 1.82

1.06–4.65 1.51–3.70 1.07–2.57 1.07–1.80 1.05–3.16

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setting and the period of investigation lasted only 6 days. During the 6 days, all the study subjects were still threatened by the continuous aftershocks, which was different from other studies of the Wenchuan earthquake. For example, the prevalence of PTSD in survivors transferred to Guangzhou for treatment was reported to be 43.6% (Guo et al., 2008). Moreover, the study subjects came from a severely destroyed area. The stronger earthquake may have a larger impact on the mental health of the affected population (Sharan et al., 1996a,b). The higher prevalence in our study supports the idea that PTSD is a common response after exposure to a natural disaster. The findings reported here also suggest that more victims satisfy the criteria for PTSD in the early time after an earthquake. Regarding the preponderance of PTSD symptoms in the present study, symptoms of persistent hyperarousal and re-experience (i.e., being afraid that the event will occur again, having unwanted memories, as well as getting really upset when reminded of the event) were the most frequently encountered ones. Less common were the symptoms of active and passive avoidance. In a few previous studies on the impact of earthquakes, a more or less similar trend has been identified in terms of early posttraumatic symptoms (Kato et al., 1996; Sharan et al., 1996a,b; Chen et al., 2001; Groome and Soureti, 2004). Female gender has been established as a significant risk factor of PTSD (Carr et al., 1995; Berton and Stabb, 1996; Breslau et al., 1997). When compared with men, women's course of disease was more likely to be chronic and their prevalence ratio of PTSD was twice as high as that of men (Brewin et al., 2000; Foa and Street, 2001 ; Yehuda, 2004; Verger et al., 2004). The present study clearly confirms the results of those previous studies (Brewin et al., 2000; Foa and Street, 2001). Gender was found to have a significant effect on PTSD in this study, with females displaying significantly higher rate of PTSD than males. Previous studies relating age and PTSD have produced conflicting results, with some studies reporting severe PTSD in the younger age groups (Milne, 1977; Lonigan et al., 1991), whereas other studies have found different results (Cardozo et al., 2000; Liu et al., 2003; Wu et al., 2003). In this study, there were significantly different rates of PTSD in different age groups. Among the survivors, those aged 41–50 were found to have the highest rate of PTSD. The finding suggests that survivors in the 41–50 age group were more severely affected by direct exposure to the effects of the earthquake. The possible reason is that these people were looked upon as the family's economic resource and source of psychological support by their parents and children in China, which increased their stress level more than any other survivors. The present study showed marital status had a significant effect on PTSD. The married survivors were more likely to have severe PTSD, which was inconsistent with previous reports (Brewin et al., 2000; Riddle et al., 2007; Sophia et al., 2008). However, it is not clear why married survivors tend to report more severe PTSD than do unmarried survivors. One possibility is that the Chinese family pattern may play a role in the onset of PTSD after the earthquake. Chinese culture is notable for its emphasis on the whole family as opposed to the individual. In China, most married people still live together with their children and parents. When faced with a disaster, married survivors tend to be excessively worried about the damage to their family members and possessions. In the previous study (Riddle et al., 2007; Sophia et al., 2008; Priebe et al., 2008), high education was reported to be associated with a reduced prevalence of PTSD. The results of the present study are in agreement with the previous findings. For example, there was a significant difference of PTSD rates among those survivors with less than 6 years or more than 13 years of education (72.4% and 54.3%, respectively). One explanation for the lower PTSD rate among welleducated survivors is that those with higher school education may have more potential to cope with traumatic events (Priebe et al., 2008). Many studies have also documented the complex relationship between exposure, damage, and psychological sequelae in the after-

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math of disasters. Sharan et al. (1996a, b) reported that the destruction of house and possessions was significantly associated with subsequent psychiatric disorder. We also found that most individuals will develop posttraumatic stress reactions in earthquakes involving extremely severe destruction such as having deaths or injury of the family members and great losses of the possessions. Several studies reported that higher post-earthquake support may buffer the psychological impacts of extensive earthquake damage (Wang et al., 2000; Altindag et al., 2005). Therefore, measures such as social support and crisis intervention should be implemented as soon as possible after the earthquake to mitigate the impact of the disaster and reduce the probability of PTSD occurrence. There are notable limitations to this study that should be mentioned. First, although the study population was sampled randomly from a severely destroyed disaster area, those survivors who suffered serious injuries were not included entirely because some of them had been moved to other cities far from the quake belt for treatment. Second, we used a screening instrument rather than a diagnostic interview, so we defined cases as PTSD-like mental disorder. It is possible that there may be differences between the present result and the prevalence of PTSD estimated by clinicians. Despite the limitations, our study has a number of strengths. Unlike most previous reports dealing primarily with the long-term consequences of the traumatic events, this study first investigated the rates of PTSD and explored its risk factors 1 month after the earthquake in the disaster area in China. It provides timely pilot data on the impact of the Wenchuan earthquake, which can serve as a practical assessment for identifying those at risk of mental disorders and will be very important for not only Chinese but also Western literature on PTSD. In summary, the results of this study showed that (1) PTSD may be as prevalent in disaster victims in China as in those elsewhere; (2) married status, female gender, having deaths or injury of family members, low education level, and losses of possessions all had a significant effect on PTSD; and (3) in the early stage of disasters, counter-measures against PTSD should take into consideration the victims' sociodemographic characteristics and the degree of property destruction by the earthquake. Acknowledgments We thank the staff of the school of military preventive medicine of Fourth Military Medical University for their invaluable contribution in the data collection. This study was approved by the Fourth Military Medical University, People's Republic of China.

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