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research-article2014
JAPXXX10.1177/1078390314536615Journal of the American Psychiatric Nurses AssociationNiitsu et al.
Original Article
A Pilot Study of the Psychological Impact of the Great East Japan Earthquake and Tsunami
Journal of the American Psychiatric Nurses Association 2014, Vol. 20(3) 194–202 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078390314536615 jap.sagepub.com
Kosuke Niitsu1, Shinobu Watanabe-Galloway2, Harlan Sayles3, Julia Houfek4, and Michael Rice5
Abstract BACKGROUND: There is evidence that a large-scale disaster may have indirect psychological impact on the individuals who were not involved with the disaster first hand. The 2011 earthquake and tsunami disasters in Japan provide an opportunity to investigate the potential global effect of indirect exposure associated with intense media coverage. OBJECTIVES: To compare the disaster’s psychological impact between Japanese and non-Japanese students; to determine what factors are associated with higher psychological impact. DESIGN: A cross-sectional, anonymous online survey of university students in the Midwest. RESULTS: Japanese students scored significantly higher on the Impact of Event Scale–Revised (IES-R) hyperarousal subscale compared with non-Japanese students. Those who were in Japan when the disaster occurred exhibited significantly higher psychological impact levels. There were significant correlations between media exposure and two IES-R subscales: avoidance and hyperarousal. CONCLUSIONS: The results support the finding from 9/11 studies that indirect exposure is associated with stress-related psychological responses. Keywords posttraumatic stress disorder, natural disaster, indirect exposure A 9.0 magnitude earthquake occurred in the Tohoku area of Japan on March 11, 2011, at 2:36 p.m. (local time). The earthquake generated a large tsunami and caused a tremendous amount of damage to buildings, lifeline infrastructure (gas, water, and electricity), communication systems, transportation systems, and human health (World Health Organization Western Pacific Region [WHO], 2011). The tsunami hit the coast line from the Tohoku region to the Kanto region covering a continuous stretch of land more than 500 km (315 miles) in length with waves measuring up to approximately 38 meters (125 feet) high. The worst affected area was in the Tohoku region, but the tsunami had a devastating effect extending damage well beyond this region. The tsunami completely altered the landscape by destroying the infrastructure and also causing a nuclear meltdown at the Daiichi plant in Fukushima Prefecture. In October 2011, 6 months following the disasters, the number of deaths stood at 15,821 and the number of persons still missing was 3,962 (Japanese National Police Agency, 2011a). In a July 2011 report, the WHO (2011) identified mental health as a constant and ongoing concern associated with the tsunami, as certain conditions, such as posttraumatic stress disorder (PTSD), may appear long after the
catastrophic event. In Japan, mental illness is associated with a great stigma (Ando, Yamaguchi, Aoki, & Thornicroft, 2013). Japanese people “are socially programmed to feel a sense of shame if they lack will power,” and it is reported that almost two thirds of Japanese people with mental illness never seek professional help (Desapriya & Nobutada, 2002, p. 1866). Most Japanese people think that people cannot recover from mental disorders and consider psychosocial factors such as weakness of personality 1
Kosuke Niitsu, BSN, RN, University of Nebraska Medical Center College of Nursing, Omaha, NE, USA 2 Shinobu Watanabe-Galloway, PhD, University of Nebraska Medical Center College of Public Health, Omaha, NE, USA 3 Harlan Sayles, MS, University of Nebraska Medical Center College of Public Health, Omaha, NE, USA 4 Julia Houfek, PhD, APRN-CNS, University of Nebraska Medical Center College of Nursing, Omaha, NE, USA 5 Michael Rice, PhD, APRN-NP, University of Colorado College of Nursing, Aurora, CO, USA Corresponding Author: Kosuke Niitsu, University of Nebraska Medical Center, College of Nursing, 985330 Nebraska Medical Center, Omaha, NE 98198-5330, USA. Email: [email protected]
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Niitsu et al. as the cause of mental illness rather than biological factors (Ando et al., 2013). Japanese people are socially programmed to suppress their emotions and “pretend to be fine” even when experiencing great distress (Kayama, 2011). The stigma associated with mental illness and the tendency to suppress emotions may be reflected by the suicide rate. In 2010, the Japanese suicide rate was 36 per 100,000 among men and 14 per 100,000 among women (Japanese National Police Agency, 2011b) compared with the U.S. rate of 11.8 suicide deaths per 100,000 people (Centers for Disease Control and Prevention [CDC], 2012). Kayama (2011) reported that the number of Japanese people who committed suicide each year is increasing, possibly due to the Great East Japan Earthquake and Tsunami. Kayama (2011) also added that the number of suicides committed by young people is also increasing, even in cities far from the affected regions.
Literature Review: Disaster Subpopulations Disasters such as the Great East Japan Earthquake and Tsunami expose entire populations to trauma (Nemeroff et al., 2006). North (2004) proposed a conceptual model for Disaster Exposure Subpopulations. Within the model there are several subpopulations who respond differently to the same traumatic event. The first group affected by disaster consists of those individuals who directly experience the disaster in different forms: injury to themselves, death of a family member or friend, or serious property damage. The second group consists of those individuals who indirectly experience the disaster. Their electricity and water may have been cut off and/or they may sustain minor property damage. If the event is massive and widespread, many individuals outside an affected community may be remotely affected, as has happened with the 9/11 terrorist attack and the Great East Japan Earthquake and Tsunami Disaster. Within each of the three groups, there are some people who develop PTSD and other negative psychological responses. Direct traumatic exposure is exposure to “actual or threatened death, serious injury, or sexual violence” (American Psychiatric Association [APA], 2013, p. 271). In contrast, indirect traumatic exposure is defined as knowledge of an event through a first person account of actual or threatened death or serious injury, irrespective of the relationship to the survivor (Zimering, Gulliver, Knight, Munroe, & Keane, 2006). Individuals may experience indirect exposure through others with whom they have significant relationships, such as family and friends, who were directly involved in or witnessed a traumatic event (Gil & Caspi, 2006; Zimering et al., 2006). Indirect exposure can also occur through sensory impressions of traumatic events, such as watching events on television (Dougall, Hayward, & Baum, 2005; Nixon & Nishith,
2005; Pollack et al., 2006), and through learning about traumatic experiences from people other than family and friends such as therapists, professional helpers, and disaster workers who come into contact with victims (Zimering et al., 2006). The assumption of the original Biological DoseResponse Model is that an individual’s risk of illness varies with the magnitude of a stressor (Dohrenwend & Dohrenwend, 1974; Wyler, Masuda, & Holmes, 1971). This assumption was supported by the findings of studies which reported higher rates of PTSD for those who directly experienced events as compared with those who witnessed events (Hoge et al., 2004). The relationship is also supported by evidence that higher rates of PTSD occur for events at close proximity as compared with those at a distance (Goenjian et al., 2005). Other studies also found prevalence of posttraumatic stress symptoms are lower among individuals with indirect exposure than those with direct exposure (Gil & Caspi, 2006; Pollack et al., 2006). These studies also confirmed the development of PTSD and posttraumatic stress symptoms among those indirectly exposed to disasters.
Purpose The new DSM-5 PTSD criteria limit indirect exposure of trauma and learning about the events through close family members or friends. Indirect exposure through the mass media does not apply when diagnosing PTSD. However, research on the impact of indirect exposure to disaster through mass media is relatively new and there are many unanswered questions. Mass media including television, radio, and the Internet play an important role in informing the public, providing disaster communication among professionals, and connecting family members and friends to disaster victims. At the same time, the media can be a major source of indirect exposure to disasters among members of the general public. Although the numbers of hours of television watched was not associated with PTSD symptoms in adults seeking mental health services following the Oklahoma City bombing (Tucker, Pfefferbaum, Nixon, & Dickson, 2000), two national studies reported an association between extensive viewing of television coverage and significant stress reactions after 9/11 (Schlenger et al., 2002; Schuster et al., 2001). Although it was a very unfortunate event, the Great East Japan Earthquake and Tsunami Disaster provides an opportunity for us to investigate the potential international effect of indirect exposure due to the intense media coverage following disasters. This study investigated potential long-term (1-year postdisaster) psychological impact of the Great East Japan Earthquake and Tsunami among Japanese and non-Japanese university students
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Figure 1. Proposed bivariate relationships between risk factors and trauma-related psychological impact.
living in the United States. The purposes of this study were to (a) compare psychological impact levels between Japanese and non-Japanese students and (b) determine what risk factors are associated with higher psychological impact levels.
Conceptual Framework and Hypotheses The Disaster Exposure Subpopulations Model (North, 2004) and the Biological Dose-Response Model informed the conceptual framework for this study (Figure 1). Risk factors for psychological impact were chosen from the published literature about human response to disasters (Mitani, 2008; Neria & Sullivan, 2011; Suvak, Maguen, Litz, Silver, & Holman, 2008; Zimering et al., 2006). In this study, past trauma was included based on the psychoanalytic model of the PTSD, which proposes that unresolved psychological conflict due to past trauma may be reactivated by the disaster (Sadock & Sadock, 2008). In addition, sociocultural factors and media exposure were identified as risk factors. These factors were combined with the chosen disaster subpopulations (Japanese and non-Japanese) and variables indicating the dose of exposure (e.g., in Japan when the disaster occurred, amount of media viewing, psychological reactions to media presentations, and the types of environmental stimuli captured in media). A hypothesis regarding the first purpose of this
study is that Japanese students should exhibit higher psychological impact levels compared with non-Japanese students. Hypotheses regarding the second purpose of this study are that there will be positive relationships between trauma-related psychological impact and all risk factors except cumulative years in the United States and media information perceived as helpful, which will have negative relationships (Figure 1).
Method Design The pilot study was a cross-sectional, anonymous online survey of students at a major university in the Great Plains region. The questions were posted on online using the software program Zoomerang (n.d.). An invitation to participate that included the web link to the survey was emailed to each student. Study participants were Japanese and non-Japanese students attending the university during the spring 2012 semester. All these students were identified by the administrative office at each of the four university campuses across the state. The survey was conducted during April to May 2012, around the first anniversary of the Great East Japan Disasters, and the survey was available both in English and Japanese. The Japanese version was translated by one of the investigators (KN) whose
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Niitsu et al. primary language is Japanese. The Japanese translation was reviewed for accuracy by three visiting Japanese faculty members at the university. The study was approved by the university institutional review board where the study was conducted.
Instrumentation The Impact of Event Scale–Revised (IES-R). The IES-R (Weiss & Marmar, 1997) was used to measure psychological impact. The IES-R consists of 22 items: 8 reexperience/intrusion items, 8 avoidance items, and 6 hyperarousal items. It is rated on a scale of 0 (not at all) to 4 (extremely) by asking the subject to report how distressing each item has been during the past week. Past studies have reported that the scale items exhibit a high degree of intercorrelation (r = .52-.87) and high levels of internal consistency (Intrusion: r = .87-.94; Avoidance: r = .84-.87; Hyperarousal: r = .79-.91; Creamer, Bell, & Failla, 2003; Weiss & Marmar, 1997). Six-month test– retest reliability ranged from .89 to .94 (Weiss & Marmar, 1997). Asukai et al. (2002) translated the IES-R into Japanese (IES-R-J) and reported similar internal consistency (Intrusion: r = .88-.91; Avoidance: r = .88-.90; Hyperarousal: r = .80-.86) and test–retest values (r = .86, p = .0001). Asukai et al. (2002) suggested a total score above 25 is a discriminate cutoff value for the diagnosis of PTSD. In this study, the Cronbach’s alphas for the IES-R subscales were the following: Intrusion, .83; Avoidance, .82; and Hyperarousal, .66. The Hyperarousal subscale reliability score approximates .70, which is acceptable. The lower value may reflect variation in cultural expression, which needs further exploration. The Life Events Checklist (LEC). The LEC (Blake et al., 1995) was used to measure past trauma. The LEC is a brief self-administered inventory assessing potentially traumatic events. The LEC was used to obtain an assessment of PTSD symptoms related to both direct and indirect Japanese earthquake and tsunami exposure. Participants rate 17 potentially traumatic events on a 5-item checklist (happened to me, witnessed it, heard/ learned about it, not sure, or doesn’t apply). This measure was used in other PTSD studies including one by Zimering et al. (2006) on 9/11. The Japanese version of the instrument has been previously used in a study of PTSD among young Japanese women (Mizuta et al., 2005). For this investigation, we used the Japanese translation of this instrument by Asukai (2008). In this study, the LEC had a Cronbach’s alpha of .82. The Sociocultural Factors. These variables included place of citizenship and cumulative years living in the United States. In addition, several dose response variables were
measured dichotomously (yes/no): whether participants were in Japan during the disaster or immediately after, whether they have gone back to Japan since the occurrence of the disaster, and whether they have a friend or family member living in one of the prefectures affected by the disaster. Place of citizenship was recorded as Japan, the United States, or other county. Cumulative years in the United States were treated as continuous data. A score of 1 was given for yes and 0 for no. The questions were adapted from survey questions of the 9/11 event (Schlenger et al., 2002). Media Exposure. See Table 1 for questions used to assess media exposure, which were also adapted from Schlenger et al. (2002). The questions addressed time spent watching video images of the disaster, emotional responses to the images, and the temporal witnessing of types of disaster events (e.g., tsunami waves washing ashore). Dichotomous responses (0 = No; 1 = Yes) to assess temporal witnessing were summed for these questions, with possible scores ranging from 0 to 3. Internal consistency for the summed scale scores ranged from .560 (“Family members looking for somebody”) to .764 (“Someone got killed or who had died”). All questions were used as separate variables in the analysis.
Analysis Comparisons of the various IES-R scores between Japanese and non-Japanese students were made using Mann–Whitney tests. Associations of the various IES-R scores with Life Event Checklist scores, sociocultural variables, and media exposure measures were examined using bivariate correlations. All analyses were conducted using IBM® SPSS Grad Pack Version 20. Statistical significance was set at .05.
Results The online survey invitation was emailed to a total of 1,023 (137 Japanese and 886 non-Japanese) students within the University of Nebraska system. A total of 30 (13 non-Japanese and 17 Japanese) students responded to the survey (Table 2). Only two (15.4%) of non-Japanese participants were males compared with 58.8% of the Japanese students. Results of the Mann–Whitney U test, which were used to compare median IES-R total, intrusion, avoidance, and hyperarousal scores between Japanese and non-Japanese respondents, are presented in Table 3. Japanese students scored significantly higher on the IES-R hyperarousal subscale compared with non-Japanese students. Table 4 shows Pearson and Spearman correlation coefficients that were used to analyze associations between
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Table 1. Media Exposure Questions and Scores. Variables Amount Hours viewed
Reaction Upset
Helpful
Environmental stimuli Wave Killed Escape Family
Questions Thinking about March 11 and the first few days afterwards, on average, how many hours per day did you watch the TV or Internet coverage of the disaster? How upset or distressed were you by the images and descriptions of the disaster that you heard or saw on the TV, radio, or through other news coverage?
How helpful or reassuring did you find the information about the disaster that you heard or was on the TV, radio, or through other news coverage?
“A wave sweeping out the town and destroying the buildings.” Select all answers that apply. “Someone got killed or who had died.” Select all answers that apply. “People running and trying to escape from the tsunami wave.” Select all answers that apply. “Family members looking for somebody.” Select all answers that apply.
Scores Continuous, up to 24 hours
0 = Not at all upset 1 = A little upset 2 = Moderately upset 3 = Very upset 4 = Extremely upset NA = I did not watch, listen to, or read any news coverage 0 = Not at all helpful 1 = A little helpful 2 = Moderately helpful 3 = Very helpful 4 = Extremely helpful NA = I did not watch, listen to, or read any news coverage 0 = I didn’t see it on TV/Internet 0/1 = I saw it on TV/Internet live, as it happened on March 11 0/1 = I saw it replayed on TV/Internet on March 11 after it had happened 0/1 = I saw it replayed on TV/Internet in the days following March 11 Score ranges from 0 to 3
Table 2. Demographic Characteristics of Survey Respondents. Non-Japanese Citizenship Japan USA Others Total Sex Male (% within group) Female (% within group) Total (% within group) Race Asian White Latino American Indian/Alaska Native Total Mean age (SD)
Japanese
0 11 2 13 (43.3%)
17 0 0 17 (56.7%)
2 (15.4%) 11 (84.6%) 13 (100%)
10 (58.8%) 7 (41.2%) 17 (100%)
3 8 1 1 13 31 (10.42)
17 0 0 0 17 23.47 (5.21)
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Overall 17 11 2 30 (100%) 12 (40%) 18 (60%) 30 (100%) 20 8 1 1 30 26.73 (8.62)
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Niitsu et al. Table 3. IES-R Median Score Comparisons Between Japanese and Non-Japanese Students. Median (Min, Max) IES-R Total IES-R Intrusion IES-R Avoidance IES-R Hyperarousal
Non-Japanese
Japanese
Mann–Whitney U test
8.00 (0.00, 26.00) 0.38 (0.00, 1.38) 0.25 (0.00, 2.50) 0.00 (0.00, 0.33)
7.00 (1.00, 40.00) 0.25 (0.13, 2.38) 0.50 (0.00, 1.75) 0.33 (0.00, 1.50)
94 (p = .488) 105 (p = .816) 89 (p = .363) 52.5 (p = .010)*
*p ≤ .05.
Table 4. Correlations of PTSD-Like Symptoms with Past Trauma, Sociocultural Factors, and Media Exposure.
Past trauma (Pearson) Life Event Checklist Sociocultural Factors (Pearson) Japanese Were in Japan Gone to Japan Friends Years in USA Media Exposure (Spearman) Hours Upset Helpful Wave Killed Escape Family
IES-R Total
IES-R Intrusion
IES-R Avoidance
.063
.111
.003
.202 .479* .114 .221 −.223
.115 .401* .118 .213 −.182
.078 .351* −.013 .044 −.069
.288 .207 .104 −.105 .082 −.024 .355
.173 .220 .101 −.172 .107 −.102 .182
.354* .175 .019 −.161 −.069 −.054 .364*
IES-R Hyperarousal .042 .444* .506* .260 .406* −.421* .300 .359* .413* .413* .363* .415* .441*
*p ≤ .05.
the risk factors (past experience, social factors, and media exposure) and the psychological impact outcome (IESR). No significant correlations between past trauma and IES-R scores were observed. Having Japanese citizenship was significantly associated with the IES hyperarousal, but not with total, intrusion, or avoidance scores. Those who were in Japan when the disaster occurred exhibited significantly higher psychological impact levels in all total, intrusion, avoidance, and hyperarousal subscales. More years spent in the United States was negatively associated with hyperarousal. There were significant positive correlations between media exposure and two IES-R subscales: avoidance and hyperarousal.
Discussion This pilot study provides additional evidence that a largescale disaster may have indirect psychological impact on the individuals who were not involved with the disaster first hand. The results are consistent with the Biological DoseResponse Model (Dohrenwend & Dohrenwend, 1974;
Wyler et al., 1971). Being in Japan when the disaster occurred was related to higher IES-R scores, which is congruent with findings from 9/11 studies (Gil & Caspi, 2006; Pollack et al., 2006) that the prevalence of PTSD is higher among those who were in close proximity to the disaster area compared with those who were in distant areas (Goenjian et al., 2005; Hoge et al., 2004). Japanese students scored significantly higher on the IES-R hyperarousal subscale (Table 4), suggesting that they may have had greater identification with the disaster. In other words, Japanese students may have related the event more personally to themselves compared with non-Japanese students. In this study, there was a significant positive relationship between having a friend or family member living in one of the prefectures affected by the disaster and IES-R hyperarousal (Table 3). This result supports the previous findings that individuals experience indirect exposure through significant others who were directly involved in or witnessed a traumatic event (Gil & Caspi, 2006; Zimering et al., 2006). This study also supports the findings from previous studies that indirect exposure through sensory impressions
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of traumatic events, such as watching events on television has psychological effects (Dougall et al., 2005; Nixon & Nishith, 2005; Pollack et al., 2006). The results showed the significant positive relationship between hours of media exposure as well as environmental stimuli (family members seeking for others) and IES-R avoidance scores (Table 4). This finding is congruent with Horowitz’s (2011) conceptualization of avoidance as a protective mechanism that limits the mental review of distressing, intrusive thoughts, and emotion in the early stages of stress responses. In addition, multiple media exposure variables are significantly positively related to the IES-R hyperarousal score (Table 4). This may imply that media exposure may affect viewers who are more susceptible to startle reactions (Schlenger et al., 2002; Schuster et al., 2001). Contrary to prediction, helpful media exposure was positively related to increased physiological arousal. Although most items on the IES-R hyperarousal subscale indicate emotional distress, participants may have responded to some items (e.g., I had trouble falling asleep) based on both negative and positive emotions. The findings suggest the clinical importance of using the symptom cluster triad of intrusion, avoidance, and hyperarousal when assessing stress responses of persons exposed to traumatic events. A suggested nursing intervention is to limit media exposure when a large-scale disaster occurs even if it is perceived as helpful as positive emotions (reassurance) may contribute to hyperarousal. Limiting media exposure such as limiting access to the TV or Internet coverage of disasters in schools may have public policy implications. Avoidance was related to dose response of media coverage and also possible type of visual images (i.e., seeing family members search). This may be related to identification with family members or emotional responses to interpersonal relationships. Because avoidance functions as a protective mechanism in the early stages adapting to traumatic events, clinicians can view it as a coping mechanism that contributes to the person’s safety, which is a basic need and the first stage of recovery (Herman, 1997; Wheeler, 2008). By assessing the person’s symptom presentation of intrusion, avoidance, and hyperarousal, clinicians can assess and facilitate the person’s movement to the later stages of recovery, which involves reconstructing the traumatic story and necessitates experiencing more intense emotions, and finally restoring the connection between the survivor and his/her community and a sense of equilibrium (Herman, 1997; Horowitz, 2011). For future research continued study about the mental health effects of indirect exposure through the media to a large-scale disaster and other variables on stress response is needed. The contribution of culture/ethnicity to mental health responses to indirect exposure to large-scale
disasters would be an important variable to consider. Interestingly, in this study, Japanese students who lived longer in the United States also reported less hyperarousal in response to the earthquake and tsunami. Possibly, this response reflects not only distance from the disaster in terms of time and space, but the influence of cultural environment on perceptions. Japanese culture is group-oriented whereas American culture emphasizes individuality. Possibly, in addition to a national identification with Japan, Japanese students reporting less time in the United States may have had a greater distress response because of their group-orientation. Because of the limited number of Japanese students in the United States and the length of time since the disaster, a followup qualitative study to describe Japanese students’ retrospective perceptions of how culture influenced their responses to the earthquake and tsunami may provide additional knowledge about cultural influences on stress responses to disasters. The domains presented in the Cultural Formulation Interview (CFI) in DSM-5 (APA, 2013) can inform the development of the qualitative questions. Finally, the unexpected finding that helpful media exposure was related to hyperarousal is noteworthy. Additional study about how the types of media and the dose and time of exposure affect psychological and physiologic stress responses may provide a better understanding about the effects of indirect media exposure on health.
Limitations This pilot study has several limitations. First, due to difficulties in obtaining approval from the three campuses in the university system to invite student participation, the survey was conducted later than expected (during the final weeks of the spring semester) and produced a poor response rate (3%). Second, due to the small sample size, we could not assess the prevalence rate of PTSD symptoms among Japanese and non-Japanese respondents as originally planned. Last, due to the small sample size and the imbalanced male-to-female ratio, the non-Japanese students may not have been a representative control group. Therefore, considerable caution is needed when interpreting the results.
Conclusion This pilot study investigated long-term psychological impact of the 2011 earthquake among Japanese and nonJapanese college students living in the United States. Japanese students scored significantly higher on the IES-R hyperarousal subscale compared with non-Japanese students. No significant correlations between past trauma and IES-R scores were observed. Those who were in
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Niitsu et al. Japan when the disaster occurred exhibited significantly higher psychological distress levels. There were significant correlations between media exposure and two IES-R subscales: avoidance and hyperarousal. The results support the finding from 9/11 studies that indirect exposure is associated with negative psychological responses. Author Roles Mr. Niitsu and Dr. Watanabe-Galloway conceptualized the project. Mr. Niitsu developed the research proposal and collected the data under the supervision of Dr. Watanabe-Galloway and Dr. Rice. Mr. Sayles assisted with data analysis and interpretation. Drs. Rice, Watanabe-Galloway, and Houfek participated in data interpretation and overall manuscript construction and review.
Acknowledgments We express our gratitude to supportive students, staff, and faculty of the University of Nebraska Medical Center who devoted their time and effort to the Nebraska Standing with Japan Project, and the research participants for their contributions to this work.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Nixon, R. D. V., & Nishith, P. (2005). September 11 attacks: Prior interpersonal trauma, dysfunctional cognitions, and trauma response in a Midwestern university sample. Violence and Victims, 20(4), 471-480. North, C. S. (2004). Approaching disaster mental health research after the 9/11 World Trade Center terrorist attacks. Psychiatric Clinics of North America, 27(3), 589-602. doi:10.1016/j.psc.2004.03.001 Pollack, M. H., Simon, N. M., Fagiolini, A., Pitman, R., McNally, R. J., Nierenberg, A. A., . . .Ghaemi, S. N. (2006). Persistent posttraumatic stress disorder following September 11 in patients with bipolar disorder. Journal of Clinical Psychiatry, 67(3), 394-399. Sadock, B. J., & Sadock, V. A. (2008). Kaplan & Sadock’s concise textbook of clinical psychiatry. Philadelphia, PA: Lippincott Williams & Wilkins. Schlenger, W. E., Caddell, J. M., Ebert, L., Jordan, B. K., Rourke, K. M., Wilson, D., . . . Kulka, R. A. (2002). Psychological reactions to terrorist attacks: Findings from the national study of Americans’ reactions to September 11. Journal of the American Medical Association, 288(5), 581-588. Schuster, M. A., Stein, B. D., Jaycox, L. H., Collins, R. L., Marshall, G. N., Elliott, M. N., . . .Berry, S. H. (2001). A national survey of stress reactions after the September 11, 2001, terrorist attacks. New England Journal of Medicine, 345(20), 1507-1512. Suvak, M., Maguen, S., Litz, B. T., Silver, R. C., & Holman, E. A. (2008). Indirect exposure to the September 11 terrorist
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research-article2014
JAPXXX10.1177/1078390314536615Journal of the American Psychiatric Nurses AssociationNiitsu et al.
Original Article
A Pilot Study of the Psychological Impact of the Great East Japan Earthquake and Tsunami
Journal of the American Psychiatric Nurses Association 2014, Vol. 20(3) 194–202 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078390314536615 jap.sagepub.com
Kosuke Niitsu1, Shinobu Watanabe-Galloway2, Harlan Sayles3, Julia Houfek4, and Michael Rice5
Abstract BACKGROUND: There is evidence that a large-scale disaster may have indirect psychological impact on the individuals who were not involved with the disaster first hand. The 2011 earthquake and tsunami disasters in Japan provide an opportunity to investigate the potential global effect of indirect exposure associated with intense media coverage. OBJECTIVES: To compare the disaster’s psychological impact between Japanese and non-Japanese students; to determine what factors are associated with higher psychological impact. DESIGN: A cross-sectional, anonymous online survey of university students in the Midwest. RESULTS: Japanese students scored significantly higher on the Impact of Event Scale–Revised (IES-R) hyperarousal subscale compared with non-Japanese students. Those who were in Japan when the disaster occurred exhibited significantly higher psychological impact levels. There were significant correlations between media exposure and two IES-R subscales: avoidance and hyperarousal. CONCLUSIONS: The results support the finding from 9/11 studies that indirect exposure is associated with stress-related psychological responses. Keywords posttraumatic stress disorder, natural disaster, indirect exposure A 9.0 magnitude earthquake occurred in the Tohoku area of Japan on March 11, 2011, at 2:36 p.m. (local time). The earthquake generated a large tsunami and caused a tremendous amount of damage to buildings, lifeline infrastructure (gas, water, and electricity), communication systems, transportation systems, and human health (World Health Organization Western Pacific Region [WHO], 2011). The tsunami hit the coast line from the Tohoku region to the Kanto region covering a continuous stretch of land more than 500 km (315 miles) in length with waves measuring up to approximately 38 meters (125 feet) high. The worst affected area was in the Tohoku region, but the tsunami had a devastating effect extending damage well beyond this region. The tsunami completely altered the landscape by destroying the infrastructure and also causing a nuclear meltdown at the Daiichi plant in Fukushima Prefecture. In October 2011, 6 months following the disasters, the number of deaths stood at 15,821 and the number of persons still missing was 3,962 (Japanese National Police Agency, 2011a). In a July 2011 report, the WHO (2011) identified mental health as a constant and ongoing concern associated with the tsunami, as certain conditions, such as posttraumatic stress disorder (PTSD), may appear long after the
catastrophic event. In Japan, mental illness is associated with a great stigma (Ando, Yamaguchi, Aoki, & Thornicroft, 2013). Japanese people “are socially programmed to feel a sense of shame if they lack will power,” and it is reported that almost two thirds of Japanese people with mental illness never seek professional help (Desapriya & Nobutada, 2002, p. 1866). Most Japanese people think that people cannot recover from mental disorders and consider psychosocial factors such as weakness of personality 1
Kosuke Niitsu, BSN, RN, University of Nebraska Medical Center College of Nursing, Omaha, NE, USA 2 Shinobu Watanabe-Galloway, PhD, University of Nebraska Medical Center College of Public Health, Omaha, NE, USA 3 Harlan Sayles, MS, University of Nebraska Medical Center College of Public Health, Omaha, NE, USA 4 Julia Houfek, PhD, APRN-CNS, University of Nebraska Medical Center College of Nursing, Omaha, NE, USA 5 Michael Rice, PhD, APRN-NP, University of Colorado College of Nursing, Aurora, CO, USA Corresponding Author: Kosuke Niitsu, University of Nebraska Medical Center, College of Nursing, 985330 Nebraska Medical Center, Omaha, NE 98198-5330, USA. Email: [email protected]
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Niitsu et al. as the cause of mental illness rather than biological factors (Ando et al., 2013). Japanese people are socially programmed to suppress their emotions and “pretend to be fine” even when experiencing great distress (Kayama, 2011). The stigma associated with mental illness and the tendency to suppress emotions may be reflected by the suicide rate. In 2010, the Japanese suicide rate was 36 per 100,000 among men and 14 per 100,000 among women (Japanese National Police Agency, 2011b) compared with the U.S. rate of 11.8 suicide deaths per 100,000 people (Centers for Disease Control and Prevention [CDC], 2012). Kayama (2011) reported that the number of Japanese people who committed suicide each year is increasing, possibly due to the Great East Japan Earthquake and Tsunami. Kayama (2011) also added that the number of suicides committed by young people is also increasing, even in cities far from the affected regions.
Literature Review: Disaster Subpopulations Disasters such as the Great East Japan Earthquake and Tsunami expose entire populations to trauma (Nemeroff et al., 2006). North (2004) proposed a conceptual model for Disaster Exposure Subpopulations. Within the model there are several subpopulations who respond differently to the same traumatic event. The first group affected by disaster consists of those individuals who directly experience the disaster in different forms: injury to themselves, death of a family member or friend, or serious property damage. The second group consists of those individuals who indirectly experience the disaster. Their electricity and water may have been cut off and/or they may sustain minor property damage. If the event is massive and widespread, many individuals outside an affected community may be remotely affected, as has happened with the 9/11 terrorist attack and the Great East Japan Earthquake and Tsunami Disaster. Within each of the three groups, there are some people who develop PTSD and other negative psychological responses. Direct traumatic exposure is exposure to “actual or threatened death, serious injury, or sexual violence” (American Psychiatric Association [APA], 2013, p. 271). In contrast, indirect traumatic exposure is defined as knowledge of an event through a first person account of actual or threatened death or serious injury, irrespective of the relationship to the survivor (Zimering, Gulliver, Knight, Munroe, & Keane, 2006). Individuals may experience indirect exposure through others with whom they have significant relationships, such as family and friends, who were directly involved in or witnessed a traumatic event (Gil & Caspi, 2006; Zimering et al., 2006). Indirect exposure can also occur through sensory impressions of traumatic events, such as watching events on television (Dougall, Hayward, & Baum, 2005; Nixon & Nishith,
2005; Pollack et al., 2006), and through learning about traumatic experiences from people other than family and friends such as therapists, professional helpers, and disaster workers who come into contact with victims (Zimering et al., 2006). The assumption of the original Biological DoseResponse Model is that an individual’s risk of illness varies with the magnitude of a stressor (Dohrenwend & Dohrenwend, 1974; Wyler, Masuda, & Holmes, 1971). This assumption was supported by the findings of studies which reported higher rates of PTSD for those who directly experienced events as compared with those who witnessed events (Hoge et al., 2004). The relationship is also supported by evidence that higher rates of PTSD occur for events at close proximity as compared with those at a distance (Goenjian et al., 2005). Other studies also found prevalence of posttraumatic stress symptoms are lower among individuals with indirect exposure than those with direct exposure (Gil & Caspi, 2006; Pollack et al., 2006). These studies also confirmed the development of PTSD and posttraumatic stress symptoms among those indirectly exposed to disasters.
Purpose The new DSM-5 PTSD criteria limit indirect exposure of trauma and learning about the events through close family members or friends. Indirect exposure through the mass media does not apply when diagnosing PTSD. However, research on the impact of indirect exposure to disaster through mass media is relatively new and there are many unanswered questions. Mass media including television, radio, and the Internet play an important role in informing the public, providing disaster communication among professionals, and connecting family members and friends to disaster victims. At the same time, the media can be a major source of indirect exposure to disasters among members of the general public. Although the numbers of hours of television watched was not associated with PTSD symptoms in adults seeking mental health services following the Oklahoma City bombing (Tucker, Pfefferbaum, Nixon, & Dickson, 2000), two national studies reported an association between extensive viewing of television coverage and significant stress reactions after 9/11 (Schlenger et al., 2002; Schuster et al., 2001). Although it was a very unfortunate event, the Great East Japan Earthquake and Tsunami Disaster provides an opportunity for us to investigate the potential international effect of indirect exposure due to the intense media coverage following disasters. This study investigated potential long-term (1-year postdisaster) psychological impact of the Great East Japan Earthquake and Tsunami among Japanese and non-Japanese university students
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Figure 1. Proposed bivariate relationships between risk factors and trauma-related psychological impact.
living in the United States. The purposes of this study were to (a) compare psychological impact levels between Japanese and non-Japanese students and (b) determine what risk factors are associated with higher psychological impact levels.
Conceptual Framework and Hypotheses The Disaster Exposure Subpopulations Model (North, 2004) and the Biological Dose-Response Model informed the conceptual framework for this study (Figure 1). Risk factors for psychological impact were chosen from the published literature about human response to disasters (Mitani, 2008; Neria & Sullivan, 2011; Suvak, Maguen, Litz, Silver, & Holman, 2008; Zimering et al., 2006). In this study, past trauma was included based on the psychoanalytic model of the PTSD, which proposes that unresolved psychological conflict due to past trauma may be reactivated by the disaster (Sadock & Sadock, 2008). In addition, sociocultural factors and media exposure were identified as risk factors. These factors were combined with the chosen disaster subpopulations (Japanese and non-Japanese) and variables indicating the dose of exposure (e.g., in Japan when the disaster occurred, amount of media viewing, psychological reactions to media presentations, and the types of environmental stimuli captured in media). A hypothesis regarding the first purpose of this
study is that Japanese students should exhibit higher psychological impact levels compared with non-Japanese students. Hypotheses regarding the second purpose of this study are that there will be positive relationships between trauma-related psychological impact and all risk factors except cumulative years in the United States and media information perceived as helpful, which will have negative relationships (Figure 1).
Method Design The pilot study was a cross-sectional, anonymous online survey of students at a major university in the Great Plains region. The questions were posted on online using the software program Zoomerang (n.d.). An invitation to participate that included the web link to the survey was emailed to each student. Study participants were Japanese and non-Japanese students attending the university during the spring 2012 semester. All these students were identified by the administrative office at each of the four university campuses across the state. The survey was conducted during April to May 2012, around the first anniversary of the Great East Japan Disasters, and the survey was available both in English and Japanese. The Japanese version was translated by one of the investigators (KN) whose
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Niitsu et al. primary language is Japanese. The Japanese translation was reviewed for accuracy by three visiting Japanese faculty members at the university. The study was approved by the university institutional review board where the study was conducted.
Instrumentation The Impact of Event Scale–Revised (IES-R). The IES-R (Weiss & Marmar, 1997) was used to measure psychological impact. The IES-R consists of 22 items: 8 reexperience/intrusion items, 8 avoidance items, and 6 hyperarousal items. It is rated on a scale of 0 (not at all) to 4 (extremely) by asking the subject to report how distressing each item has been during the past week. Past studies have reported that the scale items exhibit a high degree of intercorrelation (r = .52-.87) and high levels of internal consistency (Intrusion: r = .87-.94; Avoidance: r = .84-.87; Hyperarousal: r = .79-.91; Creamer, Bell, & Failla, 2003; Weiss & Marmar, 1997). Six-month test– retest reliability ranged from .89 to .94 (Weiss & Marmar, 1997). Asukai et al. (2002) translated the IES-R into Japanese (IES-R-J) and reported similar internal consistency (Intrusion: r = .88-.91; Avoidance: r = .88-.90; Hyperarousal: r = .80-.86) and test–retest values (r = .86, p = .0001). Asukai et al. (2002) suggested a total score above 25 is a discriminate cutoff value for the diagnosis of PTSD. In this study, the Cronbach’s alphas for the IES-R subscales were the following: Intrusion, .83; Avoidance, .82; and Hyperarousal, .66. The Hyperarousal subscale reliability score approximates .70, which is acceptable. The lower value may reflect variation in cultural expression, which needs further exploration. The Life Events Checklist (LEC). The LEC (Blake et al., 1995) was used to measure past trauma. The LEC is a brief self-administered inventory assessing potentially traumatic events. The LEC was used to obtain an assessment of PTSD symptoms related to both direct and indirect Japanese earthquake and tsunami exposure. Participants rate 17 potentially traumatic events on a 5-item checklist (happened to me, witnessed it, heard/ learned about it, not sure, or doesn’t apply). This measure was used in other PTSD studies including one by Zimering et al. (2006) on 9/11. The Japanese version of the instrument has been previously used in a study of PTSD among young Japanese women (Mizuta et al., 2005). For this investigation, we used the Japanese translation of this instrument by Asukai (2008). In this study, the LEC had a Cronbach’s alpha of .82. The Sociocultural Factors. These variables included place of citizenship and cumulative years living in the United States. In addition, several dose response variables were
measured dichotomously (yes/no): whether participants were in Japan during the disaster or immediately after, whether they have gone back to Japan since the occurrence of the disaster, and whether they have a friend or family member living in one of the prefectures affected by the disaster. Place of citizenship was recorded as Japan, the United States, or other county. Cumulative years in the United States were treated as continuous data. A score of 1 was given for yes and 0 for no. The questions were adapted from survey questions of the 9/11 event (Schlenger et al., 2002). Media Exposure. See Table 1 for questions used to assess media exposure, which were also adapted from Schlenger et al. (2002). The questions addressed time spent watching video images of the disaster, emotional responses to the images, and the temporal witnessing of types of disaster events (e.g., tsunami waves washing ashore). Dichotomous responses (0 = No; 1 = Yes) to assess temporal witnessing were summed for these questions, with possible scores ranging from 0 to 3. Internal consistency for the summed scale scores ranged from .560 (“Family members looking for somebody”) to .764 (“Someone got killed or who had died”). All questions were used as separate variables in the analysis.
Analysis Comparisons of the various IES-R scores between Japanese and non-Japanese students were made using Mann–Whitney tests. Associations of the various IES-R scores with Life Event Checklist scores, sociocultural variables, and media exposure measures were examined using bivariate correlations. All analyses were conducted using IBM® SPSS Grad Pack Version 20. Statistical significance was set at .05.
Results The online survey invitation was emailed to a total of 1,023 (137 Japanese and 886 non-Japanese) students within the University of Nebraska system. A total of 30 (13 non-Japanese and 17 Japanese) students responded to the survey (Table 2). Only two (15.4%) of non-Japanese participants were males compared with 58.8% of the Japanese students. Results of the Mann–Whitney U test, which were used to compare median IES-R total, intrusion, avoidance, and hyperarousal scores between Japanese and non-Japanese respondents, are presented in Table 3. Japanese students scored significantly higher on the IES-R hyperarousal subscale compared with non-Japanese students. Table 4 shows Pearson and Spearman correlation coefficients that were used to analyze associations between
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Table 1. Media Exposure Questions and Scores. Variables Amount Hours viewed
Reaction Upset
Helpful
Environmental stimuli Wave Killed Escape Family
Questions Thinking about March 11 and the first few days afterwards, on average, how many hours per day did you watch the TV or Internet coverage of the disaster? How upset or distressed were you by the images and descriptions of the disaster that you heard or saw on the TV, radio, or through other news coverage?
How helpful or reassuring did you find the information about the disaster that you heard or was on the TV, radio, or through other news coverage?
“A wave sweeping out the town and destroying the buildings.” Select all answers that apply. “Someone got killed or who had died.” Select all answers that apply. “People running and trying to escape from the tsunami wave.” Select all answers that apply. “Family members looking for somebody.” Select all answers that apply.
Scores Continuous, up to 24 hours
0 = Not at all upset 1 = A little upset 2 = Moderately upset 3 = Very upset 4 = Extremely upset NA = I did not watch, listen to, or read any news coverage 0 = Not at all helpful 1 = A little helpful 2 = Moderately helpful 3 = Very helpful 4 = Extremely helpful NA = I did not watch, listen to, or read any news coverage 0 = I didn’t see it on TV/Internet 0/1 = I saw it on TV/Internet live, as it happened on March 11 0/1 = I saw it replayed on TV/Internet on March 11 after it had happened 0/1 = I saw it replayed on TV/Internet in the days following March 11 Score ranges from 0 to 3
Table 2. Demographic Characteristics of Survey Respondents. Non-Japanese Citizenship Japan USA Others Total Sex Male (% within group) Female (% within group) Total (% within group) Race Asian White Latino American Indian/Alaska Native Total Mean age (SD)
Japanese
0 11 2 13 (43.3%)
17 0 0 17 (56.7%)
2 (15.4%) 11 (84.6%) 13 (100%)
10 (58.8%) 7 (41.2%) 17 (100%)
3 8 1 1 13 31 (10.42)
17 0 0 0 17 23.47 (5.21)
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Overall 17 11 2 30 (100%) 12 (40%) 18 (60%) 30 (100%) 20 8 1 1 30 26.73 (8.62)
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Niitsu et al. Table 3. IES-R Median Score Comparisons Between Japanese and Non-Japanese Students. Median (Min, Max) IES-R Total IES-R Intrusion IES-R Avoidance IES-R Hyperarousal
Non-Japanese
Japanese
Mann–Whitney U test
8.00 (0.00, 26.00) 0.38 (0.00, 1.38) 0.25 (0.00, 2.50) 0.00 (0.00, 0.33)
7.00 (1.00, 40.00) 0.25 (0.13, 2.38) 0.50 (0.00, 1.75) 0.33 (0.00, 1.50)
94 (p = .488) 105 (p = .816) 89 (p = .363) 52.5 (p = .010)*
*p ≤ .05.
Table 4. Correlations of PTSD-Like Symptoms with Past Trauma, Sociocultural Factors, and Media Exposure.
Past trauma (Pearson) Life Event Checklist Sociocultural Factors (Pearson) Japanese Were in Japan Gone to Japan Friends Years in USA Media Exposure (Spearman) Hours Upset Helpful Wave Killed Escape Family
IES-R Total
IES-R Intrusion
IES-R Avoidance
.063
.111
.003
.202 .479* .114 .221 −.223
.115 .401* .118 .213 −.182
.078 .351* −.013 .044 −.069
.288 .207 .104 −.105 .082 −.024 .355
.173 .220 .101 −.172 .107 −.102 .182
.354* .175 .019 −.161 −.069 −.054 .364*
IES-R Hyperarousal .042 .444* .506* .260 .406* −.421* .300 .359* .413* .413* .363* .415* .441*
*p ≤ .05.
the risk factors (past experience, social factors, and media exposure) and the psychological impact outcome (IESR). No significant correlations between past trauma and IES-R scores were observed. Having Japanese citizenship was significantly associated with the IES hyperarousal, but not with total, intrusion, or avoidance scores. Those who were in Japan when the disaster occurred exhibited significantly higher psychological impact levels in all total, intrusion, avoidance, and hyperarousal subscales. More years spent in the United States was negatively associated with hyperarousal. There were significant positive correlations between media exposure and two IES-R subscales: avoidance and hyperarousal.
Discussion This pilot study provides additional evidence that a largescale disaster may have indirect psychological impact on the individuals who were not involved with the disaster first hand. The results are consistent with the Biological DoseResponse Model (Dohrenwend & Dohrenwend, 1974;
Wyler et al., 1971). Being in Japan when the disaster occurred was related to higher IES-R scores, which is congruent with findings from 9/11 studies (Gil & Caspi, 2006; Pollack et al., 2006) that the prevalence of PTSD is higher among those who were in close proximity to the disaster area compared with those who were in distant areas (Goenjian et al., 2005; Hoge et al., 2004). Japanese students scored significantly higher on the IES-R hyperarousal subscale (Table 4), suggesting that they may have had greater identification with the disaster. In other words, Japanese students may have related the event more personally to themselves compared with non-Japanese students. In this study, there was a significant positive relationship between having a friend or family member living in one of the prefectures affected by the disaster and IES-R hyperarousal (Table 3). This result supports the previous findings that individuals experience indirect exposure through significant others who were directly involved in or witnessed a traumatic event (Gil & Caspi, 2006; Zimering et al., 2006). This study also supports the findings from previous studies that indirect exposure through sensory impressions
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of traumatic events, such as watching events on television has psychological effects (Dougall et al., 2005; Nixon & Nishith, 2005; Pollack et al., 2006). The results showed the significant positive relationship between hours of media exposure as well as environmental stimuli (family members seeking for others) and IES-R avoidance scores (Table 4). This finding is congruent with Horowitz’s (2011) conceptualization of avoidance as a protective mechanism that limits the mental review of distressing, intrusive thoughts, and emotion in the early stages of stress responses. In addition, multiple media exposure variables are significantly positively related to the IES-R hyperarousal score (Table 4). This may imply that media exposure may affect viewers who are more susceptible to startle reactions (Schlenger et al., 2002; Schuster et al., 2001). Contrary to prediction, helpful media exposure was positively related to increased physiological arousal. Although most items on the IES-R hyperarousal subscale indicate emotional distress, participants may have responded to some items (e.g., I had trouble falling asleep) based on both negative and positive emotions. The findings suggest the clinical importance of using the symptom cluster triad of intrusion, avoidance, and hyperarousal when assessing stress responses of persons exposed to traumatic events. A suggested nursing intervention is to limit media exposure when a large-scale disaster occurs even if it is perceived as helpful as positive emotions (reassurance) may contribute to hyperarousal. Limiting media exposure such as limiting access to the TV or Internet coverage of disasters in schools may have public policy implications. Avoidance was related to dose response of media coverage and also possible type of visual images (i.e., seeing family members search). This may be related to identification with family members or emotional responses to interpersonal relationships. Because avoidance functions as a protective mechanism in the early stages adapting to traumatic events, clinicians can view it as a coping mechanism that contributes to the person’s safety, which is a basic need and the first stage of recovery (Herman, 1997; Wheeler, 2008). By assessing the person’s symptom presentation of intrusion, avoidance, and hyperarousal, clinicians can assess and facilitate the person’s movement to the later stages of recovery, which involves reconstructing the traumatic story and necessitates experiencing more intense emotions, and finally restoring the connection between the survivor and his/her community and a sense of equilibrium (Herman, 1997; Horowitz, 2011). For future research continued study about the mental health effects of indirect exposure through the media to a large-scale disaster and other variables on stress response is needed. The contribution of culture/ethnicity to mental health responses to indirect exposure to large-scale
disasters would be an important variable to consider. Interestingly, in this study, Japanese students who lived longer in the United States also reported less hyperarousal in response to the earthquake and tsunami. Possibly, this response reflects not only distance from the disaster in terms of time and space, but the influence of cultural environment on perceptions. Japanese culture is group-oriented whereas American culture emphasizes individuality. Possibly, in addition to a national identification with Japan, Japanese students reporting less time in the United States may have had a greater distress response because of their group-orientation. Because of the limited number of Japanese students in the United States and the length of time since the disaster, a followup qualitative study to describe Japanese students’ retrospective perceptions of how culture influenced their responses to the earthquake and tsunami may provide additional knowledge about cultural influences on stress responses to disasters. The domains presented in the Cultural Formulation Interview (CFI) in DSM-5 (APA, 2013) can inform the development of the qualitative questions. Finally, the unexpected finding that helpful media exposure was related to hyperarousal is noteworthy. Additional study about how the types of media and the dose and time of exposure affect psychological and physiologic stress responses may provide a better understanding about the effects of indirect media exposure on health.
Limitations This pilot study has several limitations. First, due to difficulties in obtaining approval from the three campuses in the university system to invite student participation, the survey was conducted later than expected (during the final weeks of the spring semester) and produced a poor response rate (3%). Second, due to the small sample size, we could not assess the prevalence rate of PTSD symptoms among Japanese and non-Japanese respondents as originally planned. Last, due to the small sample size and the imbalanced male-to-female ratio, the non-Japanese students may not have been a representative control group. Therefore, considerable caution is needed when interpreting the results.
Conclusion This pilot study investigated long-term psychological impact of the 2011 earthquake among Japanese and nonJapanese college students living in the United States. Japanese students scored significantly higher on the IES-R hyperarousal subscale compared with non-Japanese students. No significant correlations between past trauma and IES-R scores were observed. Those who were in
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Niitsu et al. Japan when the disaster occurred exhibited significantly higher psychological distress levels. There were significant correlations between media exposure and two IES-R subscales: avoidance and hyperarousal. The results support the finding from 9/11 studies that indirect exposure is associated with negative psychological responses. Author Roles Mr. Niitsu and Dr. Watanabe-Galloway conceptualized the project. Mr. Niitsu developed the research proposal and collected the data under the supervision of Dr. Watanabe-Galloway and Dr. Rice. Mr. Sayles assisted with data analysis and interpretation. Drs. Rice, Watanabe-Galloway, and Houfek participated in data interpretation and overall manuscript construction and review.
Acknowledgments We express our gratitude to supportive students, staff, and faculty of the University of Nebraska Medical Center who devoted their time and effort to the Nebraska Standing with Japan Project, and the research participants for their contributions to this work.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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