Full and partial PTSD among earthquake survivors in rural Taiwan

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Abstract

In 1999, a major earthquake struck central Taiwan. Ten months after the earthquake, survivors were surveyed to examine the background factors of demographics and exposure that are associated with posttraumatic stress disorder (PTSD) and subthreshold posttraumatic stress disorder (PTSS) and to investigate the relationships between other psychiatric problems and PTSD and PTSS following the earthquake. Subjects (n=252) randomly selected from two rural communities near the epicenter of the earthquake were interviewed to obtain the following information: demographic characteristics; extent of earthquake exposure; severity of posttraumatic stress symptoms; other psychiatric morbidity; and other morbidity-related factors, including general mental health, disability, stress vulnerability, social support, and wellbeing. Three diagnostic groups were identified with regard to trauma-related symptoms: full PTSD, partial PTSD (PTSS), and non-PTSD. Prevalence rates were calculated and bivariate and multivariate comparisons adjusted for age, sex and education were performed. The prevalence rates for PTSD (n=26) and PTSS (n=48) were 10.3% and 19.0%, respectively. The PTSD and PTSS groups differed significantly from non-PTSD on most variables, with greater likelihood of the following: female gender; total trauma exposure; generalized anxiety disorder; suicidality; any other axis I disorder; general psychopathology, disability; and impaired wellbeing. Few differences were observed between the PTSD and PTSS groups, although greater likelihood for major depression, trauma-related loss of life, and impaired stress vulnerability were noted in the PTSD group. In conclusion, PTSD and PTSS are commonly observed following earthquake exposure and are associated with similarly high levels of psychosocial impairment.

Introduction

Earthquakes and their consequences present a major global public health problem. As with other natural disasters, they strike quickly, often without warning, and are uncontrollable, affecting large populations and leaving injury, death, and destruction in their wake. In the aftermath of trauma, with the loss of loved ones and livelihoods, survivors are at increased risk for experiencing psychological distress, including posttraumatic stress disorder (PTSD) (Sharan et al., 1996, Goenjian et al., 2000, Wang et al., 2000), dissociative reactions (Cardena et al., 1993), (Nolen-Hoeksema et al., 1991) and nightmares (Wood et al., 1992).

The prevalence of PTSD reported in victims of earthquake trauma ranges from 13 to 95% (McMillen et al., 2000, Armenian et al., 2000). This places a substantial proportion of affected populations at risk for developing consequences of PTSD, including impairment in relationships, work, and leisure activities (Kessler et al., 1995, Amaya-Jackson et al., 1999). Age may impact the course of the disorder, with elderly subjects having been found to show a significant decrease in posttraumatic symptoms between the third and eighth week post earthquake in one study (Kato et al., 1996). This finding may have been due to lower psychological stress, extensive social networks, and successful coping in previous disaster experiences.

In many instances, a person's symptoms may fall short of meeting full diagnostic criteria for PTSD. While the clinical importance of subthreshold or partial PTSD (PTSS) remains unresolved, PTSS is not uncommon, with a point prevalence of 3–4% in US and Canadian communities (Davidosn et al., 2002, Stein et al., 1997, Ballenger et al., 2000) and is associated with levels of impairment similar to those seen with full PTSD (Weiss et al., 1992, Carlier and Gersons, 1995, Blanchard et al., 1996, Schnurr et al., 1993, Stein et al., 1997). The issue of subsyndromal PTSD in earthquake survivors has been discussed previously by McMillen (McMillen et al., 2000), who reported intrusive symptoms and hyperarousal, but not avoidance/numbing, in 48% of survivors of the Northridge, California earthquake. Of note, McMillen's definition of a traumatic stress reaction did not require symptoms to be present in each of the PTSD symptom clusters. While acknowledging that subsyndromal PTSD may be defined in more than one way, we adhere to the criteria given below (Section 2.2) which is in line with the definition proposed by the International Consensus Group on Depression and Anxiety (Ballenger et al., 2000) and which requires significant impairment.

On September 21, 1999, an earthquake registering 7.3 on the Richter scale struck the island of Taiwan at 1:47 a.m. (Eastern Pacific Time), while much of the population was asleep. With its epicenter near the town of Ji Ji in Nantou County, the Ji Ji earthquake was the most severe earthquake in central Taiwan in the 20th century. Over 2000 deaths and 11,000 injuries were reported, largely related to the collapse of over 107,000 residential structures and other buildings. The economic loss from this disaster has been estimated at $11.5 billion (US) (Chiu et al., 2001).

We conducted the present cross-sectional study to assess the posttraumatic impact of the earthquake on two severely affected rural communities in Taiwan. The aims of this study were to (1) examine background demographic and exposure characteristics associated with PTSD and PTSS and (2) investigate the relationships between other psychiatric problems and PTSD and PTSS following the earthquake. Through the administration of a survey interview, a wide range of psychiatric morbidity was assessed, comparing subjects with PTSD, PTSS, and non-PTSD. These three groups were also compared with respect to impact of earthquake exposure, occurrence of past trauma, and other morbidity-related factors, such as disability, stress vulnerability, social support, and general wellbeing.

Section snippets

Sample

One of the areas most devastated by the earthquake was Chung-Liao Shiang, a region comprised of 18 villages and with a total population of 18,884 inhabitants and 4781 houses, as of 21 September 1999. Following the earthquake, 179 deaths (1% of this region's population) and extensive housing damage were reported, with total collapse of 2369 houses and partial collapse of 1136, representing significant damage to 83% of dwellings in the county.

From within this region, two severely damaged

Survey response

Due to extensive destruction from the earthquake, many families were unable to remain in their homes and subsequently relocated. At the time of the survey 10 months after the earthquake, 152 of the sampled households were not interviewed, due to inability to locate the family (n=121; 79.6%), refusal to participate in the survey (n=19; 12.5%), or ineligibility of household inhabitants (n=12; 7.9%). Two hundred and fifty-seven subjects subsequently consented to participate and completed the first

Prevalence of PTSD

Ten months following the 1999 earthquake in central Taiwan, PTSD was observed in 10.3%, and partial PTSD at 19.0%, of the population. This PTSD prevalence is lower than rates reported in other earthquake survivors (Sharan et al., 1996, Wang et al., 2000, Goenjian et al., 1994). Two previously published reports of survivors of the 1999 Taiwan earthquake found lower PTSD prevalence rates of 6.5% and 2.96% (Liao et al., 2000, Tang et al., 2000). These studies differed from the present study in

Acknowledgements

This study was supported by grants from the National Science Council, Taiwan, ROC to Dr. Lai and from Pfizer Pharmaceuticals, Inc. to Dr. Davidson.

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