Archives of Psychiatric Nursing 28 (2014) 67–73
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Posttraumatic Stress Disorder and Posttraumatic Growth Among Adult Survivors of Wenchuan Earthquake After 1 Year: Prevalence and Correlates Yuchang Jin a, b, Jiuping Xu a,⁎, Hai Liu b, Dongyue Liu b a b
Uncertainty Decision-making Laboratory, Sichuan University, No. 24, South Section 1, Yihuan Road, Chengdu, Sichuan 610065, P. R. China College of Teacher Education, Sichuan Normal University. No. 5, Jingan Road, Jinjiang District, Chengdu, Sichuan 610068, P. R. China
a b s t r a c t This study investigates the prevalence and predictors for posttraumatic stress disorder (PTSD) and posttraumatic growth (PTG) in adult survivors 1 year after the 2008 Wenchuan earthquake. Questionnaires were used to collect the data. PTSD was assessed using the PTSD Check List-Civilian (PCL-C), and PTG was assessed using the Post Traumatic Growth Inventory (PTGI). A total of 2,300 individuals were involved in the survey with 2,080 completing the questionnaire, a response rate of 90.4%. The PTSD prevalence estimate in this study was found to be 40.1%, and the prevalence for PTG among the participants was measured at 51.1%. A bivariate correlation analysis indicated that there was a positive association between PTG and PTSD. In the conclusions, possible explanations for the findings and implications for future research are discussed. © 2014 Elsevier Inc. All rights reserved.
Natural disasters cause many problems such as loss of life, personal injury, and psychological morbidity (Peek & Milleti, 2002). Previous systematic reviews have documented that posttraumatic stress disorder (PTSD) is the most commonly studied and the most frequent psychopathology in the aftermath of disasters (Galea, Nandi, & Vlahov, 2005; Norris et al., 2002). Psychiatry ratified a PTSD diagnosis in 1980, chiefly in response to the belated recognition of its symptoms in Vietnam veterans whose problems had long been inadequately understood and treated (Mcnally, 2012). As knowledge about PTSD symptoms increased, similar symptoms were found to be prevalent both in veterans and in survivors of other traumatic events, such as rape, assault, or natural disasters (Elwood, Hahn, Olatunji, & Williams, 2009). The findings of many studies have demonstrated that PTSD symptoms are common in earthquake survivors (Basoglu, Kilic, Salcioglu, & Livanou, 2004; Shalev & Freedman, 2005; Xu & Song, 2011), with the rate of PTSD documented in earthquake survivors ranging from 10% to 87% (Lai, Chang, Connor, Lee, & Davidson, 2004; McMillen, North, & Smith, 2000). The common risk indicators for post-earthquake PTSD have been identified as: being female (Galea et al., 2005; Neria, Nandi, & Galea, 2008), having a lower education, experiencing fear during the earthquake, having less social support during the preceding year, and having a lower housing status (Chen et al., 2007). A higher degree of exposure to a disaster is consistently associated with the likelihood of PTSD (Basoglu, Salcioglu, & Livanou,
⁎ Corresponding Author: Jiuping Xu, PhD, Uncertainty Decision-making Laboratory, Sichuan University, No. 24, South Section 1, Yihuan Road, Chengdu, Sichuan 610065, P. R. China. E-mail addresses: [email protected] (Y. Jin), [email protected] (J. Xu), 0883-9417/1801-0005$34.00/0 – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.apnu.2013.10.010
2002; Galea et al., 2005; Neria et al., 2008). Previous studies have suggested that ethnic groups differ significantly in their PTSD prevalence (Perilla, Norris, & Lavizzo, 2002), with one study finding that the prevalence for both 1-month and life time PTSD was higher for American Indian samples than for Whites (Beals, Manson, & Shore, 2002). Among Northridge earthquake survivors, Asian Americans displayed significantly more psychiatric distress than their European American counterparts and were more than twice as likely to be classified as warranting clinical attention (Kulkarni & Pole, 2008). Given the health costs associated with severe trauma reactions such as anxiety, depression, and insomnia, it is not surprising that PTSD research has grown extensively. However, one consequence of this focus has been that relatively little has been done which focuses on the adult capacity to maintain healthy personal growth following a traumatic event (George, Sandro, Angela, & David, 2006). Posttraumatic growth (PTG) is the positive change an individual may experience following a traumatic event. This is generally measured through a focus on five major aspects of the individual's life: an improved relationship with others, an increased personal strength, the identification of new possibilities, a positive spiritual change, and an increased appreciation of life (Tedeschi & Calhoun, 1996, 2004). PTG is measured using the Post Traumatic Growth Inventory (PTGI) developed by Tedeschi in 1996 and has been observed in various trauma-exposed civilian populations, including survivors of serious medical illness (e.g., AIDS/HIV) (Linley & Joseph, 2004; Zoellner & Maercker, 2006), hurricanes (Kilmer & Gil-Rivas, 2010), earthquake disasters (Tang, 2006), rape and war as well as in bereaved individuals (Tedeschi & Calhoun, 1996, 2004; Yu et al., 2010). Research into the correlations and predictors of PTG has found that younger people, females, and those with a higher level of education are more likely to exhibit these positive aspects (Tang, 2006).
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Previous studies have also found that the level of exposure was related to positive post-disaster adjustment, although the association between the exposure and the degree of positive adjustment is not certain (Tang, 2006; Tedeschi & Calhoun, 1996; Zoellner & Maercker, 2006). Recent studies also found that PTSD symptoms were associated with posttraumatic growth (Tang, 2006; Xu & Liao, 2011). After the 2008 Wenchuan earthquake, a great deal of attention was paid to the mental health of the earthquake survivors. Although some significant research in this area has been done previously (Han, Chen, & Yao, 2009; Kun et al., 2009; Xu & Song, 2011), it is an area that still needs deeper insights. To be able to assess the mental health consequences of the 2008 Wenchuan earthquake, we conducted a survey in several severely affected counties. The goals of this study were (a) to describe the prevalence of PTSD and PTG among adult survivors 1 year after the earthquake, (b) to identify the relationship between PTSD and PTG, and (c) to identify the predictors for PTG. METHODS
later. A total of 2300 individuals were involved in the survey with 2080 completing the questionnaire, a response rate of 90.4%. Measure The self-report questionnaire included items on demographic characteristics, the level of traumatic exposure to earthquake, and symptoms of posttraumatic stress disorder and post traumatic growth. In order to determine the situation of the residents most affected by the earthquake, two heavily damaged counties were targeted. A pilot test was conducted on 118 residents, and from the feedback and the assistance of the psychology professors, minor modifications and adjustments were made to the PTGI. A few revisions were made to the designed PCL-C questionnaire. The final version of the questionnaire was used in the formal investigation. In this study, the internal consistency of the total scale was found to be .92, and the internal consistencies for re-experience, avoidance/numbing and hyper-arousal subscales were .90, .91 and .93, respectively.
Procedure Demographics The study was designed in accordance with the tenets of the Declaration of Helsinki and was approved by the Sichuan University ethics committee. The investigation complies with the principle of voluntariness. Data collection for the present study was conducted 1 year after the Wenchuan earthquake from May, 12th, 2009 to September, 17th, 2009 in 19 severely affected counties. The survey was conducted in 2 stages, and stratified random sampling was used to screen the subjects (both the 118 and the 2080). The inclusion criteria were a high degree of exposure to the earthquake and experience of the complete earthquake process. With the assistance of the local civil affairs department and the Bureau of Statistics, we gathered data about the local community populations. From these data, a stratification random sampling strategy was used to gain a fair distribution of sex, age, and place. Survey teams were temporarily established and were then divided into 19 smaller teams with one team in charge of data collection in one county. The teams participated in a 5-day training program given by a psychologist, a statistics expert and three psychiatrists from the West China School of Public Health Sichuan University. Before conducting the formal investigation, initial pilot evaluations were carried out in 4 counties to test the original questionnaire, after which it was adjusted to match the local conditions. To ensure data confidentiality, it was guaranteed that none of the subjects' personal information would be revealed. From July to September 2009, the trained groups were assigned to the counties based on a previously arranged schedule. Residents who lived in both their original houses or in temporary accommodations were randomly selected to be visited on the basis of the total number. Participants were told about the study's purpose, and oral consent was obtained before each interview. One respondent within each selected house or temporary accommodation was randomly selected according to their birth date. Those who experienced the earthquake and were ages 18 to 65 years were interviewed. If residents declined to be interviewed because they were wary of such surveys or wished to avoid talking about the event, the next closest resident was invited. Those with mental retardation and major psychoses (e.g. schizophrenia, major depressive disorder, organic mental disorders), however, were excluded. Very few respondents were found to have a low level of education or literacy problems, but for those who did, the group members assisted them in noting down the answers and stayed with them while they completed the survey. To ensure privacy, participants were encouraged to have the interviews and to complete the questionnaire in private. Each research group in each county distributed the questionnaire packages and collected them 4 hours
Basic demographic information was elicited using the questionnaire and included items for gender, age, ethnicity, educational level and monthly income. Degree of Exposure to Earthquake The degree of exposure to the earthquake was assessed using a 2point scale (yes = 1 and no = 0) to measure whether participants experienced the following nine events: personal injury, the death of family members, relatives or friends, injuries to family members, relatives or friends, loss of or damage to personal or family property, being a witness to other people who were seriously injured or killed, the employment situation after the earthquake, perceived threats, agency support and temporary shelter relocation. The total score for earthquake-related exposure was 9 (yes = 1, no = 0), with higher scores demonstrating a greater level of exposure. Participants whose scores were higher than 3 (including 3) were considered to be suffering from a moderate degree of earthquake-related exposure. In terms of the degree of exposure to the earthquake, there was a difference of opinion among the research teams as to how many groups should be classified with some teams feeling that three groups were more accurate and other teams feeling that two groups were sufficient. In the analysis in this paper we have used a two group classification which we felt adequately explained the difference between the heavily exposed group and the less severely exposed group. We regarded this variable as a continuous variable to enable an inspection of the relationships between all dependent variables and the degree of exposure. Posttraumatic Stress Disorder PTSD symptoms were assessed using the PTSD Check List-Civilian Version (PCL-C), which has 17 items corresponding to the symptoms discussed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), PTSD criteria B, C, and D (Cadell, Regehr, & Hemsworth, 2003; Joseph & Linley, 2005; Wu et al., 2006). The response options for each item on the PCL-C were recorded on a five-point Likert scale ranging from 1 (not at all) to 5 (extremely), which indicated the degree to which a respondent had been bothered by a particular symptom over the previous month. A symptom was deemed present when a respondent reported an item as experienced moderately, quite a bit, or extremely (3, 4, or 5, respectively) in the past month (Wu et al., 2006). In this study, PTSD was defined using the Diagnostic and Statistical Manual-IV criteria. To be categorized as
Y. Jin et al. / Archives of Psychiatric Nursing 28 (2014) 67–73
having symptoms consistent with a PTSD diagnosis, a respondent needed to report at least one criterion B symptom (re-experience), three criterion C symptoms (avoidance/numbing), and two criterion D symptoms (hyper-arousal) (Cadell et al., 2003). Scores were summed with a final range of 17 to 85. In accordance with previous studies, a score of 50 or higher was considered consistent with PTSD symptoms (Wu et al., 2006). The PCL-C was shown to have good internal consistency. The internal consistency of the total scale was .939, and the internal consistencies for the re-experience, avoidance/ numbing and hyper-arousal subscales were .935, .820, and .839, respectively (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996). In this study, the internal consistency of the total scale was .95, and internal consistencies for the re-experience, avoidance/numbing and hyper-arousal subscales were .88, .87, and .86, respectively. Posttraumatic Growth The PTG was assessed using the Posttraumatic Growth Inventory (PTGI) (Tedeschi & Calhoun, 1996). This inventory consists of 21 items across five major domains: relating to others (7 items), new possibilities (5 items), personal strength (4 items) spiritual change (2 items), and appreciation of life (3 items). A pilot study was conducted, and two items were excluded from this study (“A better understanding of spiritual matters” and “I have a stronger religious faith”), as only few participants were found to have religious beliefs in the pilot test. Participants responded on a 5-point Likert scale ranging from 0 (no change) to 4 (complete change). The total PTGI score was the sum of the 19 items, with a total possible score of 95. Different studies have used different cutoff points for this inventory. For example, in Tang's (2006) study, average mean scores above 3 on the PTGI were considered indicative of moderate levels of posttraumatic growth. In the same study, the cutoff point for the subscales was 21 for relating to others, 15 for new possibilities, 12 for personal strength, and 9 for appreciation of life. According to Yu et al. (2010), total scores above the 60th percentile were considered to have probable PTG. In this study, scores above 57 (including 57) were considered to indicate a moderate level of posttraumatic growth. This inventory has demonstrated a good internal and test–retest reliability for both western (Tedeschi & Calhoun, 1996) and Asian samples (Solomon & Dekel, 2007). In this study, the validity of the PTGI was .83, and the internal reliability was .88. The internal reliabilities for the four subscales were .83, .79, .81, and 80, respectively. Statistical Analysis General descriptive statistics (frequencies and percentages) were used to describe the prevalence of PTSD and PTG. One-way ANOVA analyses were performed to compare the PTSD and PTG in the different participant groups. Simultaneous multiple regression analyses were conducted to identify the PTSD associated risk factors, and the PTG predictors and bivariate correlation analyses were performed to examine the relationship between PTSD and PTG. All tests were 2-tailed, and the significance was set at 0.01. All statistical procedures were completed using the SPSS 16.0 Statistical Package for Social Science.
RESULTS Demographic Characteristics The mean age of the sample was 38.24 ± 8.82 years. 59% of the sample were male. The Han ethnic group accounted for the majority (80.3%), with the Qiang ethnic group somewhat less than the Han (10.1%), but higher than other ethnic minorities in the survey. Overall, 52.6% of the respondents had a relatively low educational level, and
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64.8% had a monthly income of $150 to $300. These demographic characteristics are presented in Table 1. Prevalence of PTSD and PTG Of 2080 participants, the prevalence estimate for probable PTSD in our sample was 1181 (40.1%) (based on the DSM-IV criteria). One thousand two hundred twenty (58.7%) of the respondents reported that they suffered from at least 1 re-experience symptom; 986(47.4%) suffered from 3 or more avoidance symptoms; and 1027(49.4%) suffered from 2 or more arousal symptoms (Table 2). The number of subjects who met the criteria (a score of 21 or more) of improvement in “relating to others” was quite high (74.9%). As shown in Table 2, 51.1% of respondents were considered to have PTG. For the PTG subscales, 74.9% of respondents noted an improvement in relating to others, 30.5% an improvement in their personal life, 26.1% were open to new possibilities, and 24.5% showed an increased appreciation for life. Difference Between the Subgroups for PTSD and PTG Chi-square tests were performed to compare the prevalence of PTSD and PTG in different participant groups. The diagnosis of probable PTSD was found to be significantly related to gender (x 2 = 7.96, df = 1, p b 0.01), age (x 2 = 19.66, df = 3, p b 0.001), educational level (x 2 = 43.13, df = 2, p b 0.001), and exposure (x 2 = 13.47, df = 1, p b 0.001). Similarly, the prevalence of PTG was significantly related to age (x 2 = 14.8, df = 3, p b 0.001), ethnicity (x 2 = 12.71, df = 3, p b 0.001), and educational level (x 2 = 18.17, df = 2, p b 0.001). Post-hoc testing confirmed that PTSD symptoms were more common among females, F(1, 2078) = 8.62, p b 0.001, than males. Younger participants, F(3, 2076) = 9.67, p b 0.001, or those with a lower level of education, F(2, 2077) = 8.99, p b 0.001, were also more likely to have these symptoms. PTSD symptoms were also more common among respondents with a higher degree of earthquake exposure, F(1, 2078) = 9.58, p b 0.001 (Table 3). For different age groups, younger survivors reported a higher rate of PTG. Specifically, survivors aged from 18 to 30, F(3, 2076) = 12.29,
Table 1 Demographic Characteristics of the Study Sample (N = 2080).
Gender Male Female Age groups 18 ~ 30 31 ~ 40 41 ~ 50 51 ~ 68 Ethnic group Han Tibetan Qiang Hui Education level Graduate Bachelor Professional college Middle school other Month income Very low b $150 Low $150 ~ 300 General $300 ~ 450 High N $450
n
%
1227 853
59.0 41.0
441 849 609 181
21.2 40.8 29.3 8.7
1670 156 210 44
80.3 7.5 10.1 2.1
47 938 770 288 37
2.3 45.1 37.0 13.8 1.8
379 1347 274 80
18.2 64.8 13.2 3.8
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Table 2 Prevalence of PTSD and PTG Reported One Year After the Wenchuan Earthquake (N = 2080).
Table 4 Multiple Regression Analysis in PTSD and PTG (N = 2080). PCL-Total score (PTSD)
Prevalence
PTSD-positive screen based on DSM-IV B. Re-experience b C. Avoidance and numbing c D. Arousal d Total score of PTGI-R ≥ 57 Relation to others ≥ 21 New possibilities ≥ 15 Personal of life ≥ 12 Appreciation ≥ 9
a
n
%
1181 1220 986 1027 1063 1558 543 634 509
40.1 58.7 47.4 49.4 51.1 74.9 26.1 30.5 24.5
a Subjects were screened positive for probable PTSD if they endorsed at least 1 of 5 reexperience symptoms, at least 3 of 7 avoidance symptoms, and at least 2 of 5 arousal symptoms with a rating of at least “moderately”. b One or more reexperience symptoms (a score of 3 or more). c One or more avoidance symptoms (a score of 3 or more). d One or more arousal symptoms (a score of 3 or more).
(constant) Gender Age Education level Monthly income Exposure R2
PTGI-Total score (PTG)
B
SEB
β
p
B
SEB
β
p
0.63 0.12 0.16 −0.29 −0.33 0.18 0.14
0.13 0.26 0.10 0.09 0.02 0.11
0.10 0.49 0.13 −0.26 −0.11 0.17
b0.01 b0.01 b0.01 N0.05 b0.01 b0.01
0.42 −0.32 0.19 0.03 0.11 0.34 0.18
0.11 0.04 0.08 0.03 0.03 0.03
0.13 −0.11 0.23 0.03 0.35 0.12
b0.01 N0.05 b0.02 N0.05 N0.05 b0.00
NOTE. B: coefficient, SEB: standardized error of coefficient, β: standardized regression coefficient.
For PTSD, the significant predictors were gender, age, educational level and degree of earthquake exposure. For PTG, the significant predictors were age and degree of earthquake exposure (Table 4). Analysis of Correlation Between PTSD and PTG
p b 0.001, reported the highest rate of PTG, while respondents aged from 51 to 68, F(2, 2076) = 9.22, p b 0.001, reported the lowest rate of PTG. The Tibetan ethnic group, F(3, 2076) = 9.88, p b 0.001, and the Qiang ethnic group, F(3, 2076) = 13.78, p b 0.001, were more likely to show PTG than the Han ethnic group. For educational level, survivors with above a bachelors degree, F(2, 2077) = 9.77, p b 0.001, reported the highest rate of PTG. Participants with a higher degree of earthquake exposure, F(1, 2078) = 11.80, p b 0.001, also reported a higher rate of PTG (Table 3). Predictors of PTSD and PTG As a number of variables were associated with PTSD and PTG, a multiple regression analysis was conducted to determine the best predictors. In the regression analysis for both PTSD and PTG, gender, age, educational level, monthly income and exposure were entered.
Table 5 shows the results of the bivariate correlation analysis. There were found to be moderate correlations between the PTGI-Total and the PCL-Total (r = .262), avoidance and numbing (r = .202), reexperience (r = .233), and arousal (r = .264). The PCL-Total was also associated with the PTG subscales of “relating to others” (r = .100), “new possibilities” (r = .213), “personal strength” (r = .537) and “appreciation of life” (r = .215). Specifically, there was a relatively high degree of correlation between “personal strength” and PTSD symptoms of avoidance and numbing (r = .475), re-experience (r = .510), and arousal (r = .435). DISCUSSION The findings of this study show widespread posttraumatic stress disorder and posttraumatic growth among survivors 1 year after the
Table 3 Difference of Subgroups in PTSD and PTG (ANOVA). PTSD
Gender Male (n = 1227) Female (n = 853) Age groups 18 ~ 30 (n = 441) 31 ~ 40 (n = 849) 41 ~ 50 (n = 609) 51 ~ 68 (n = 181) Ethnicity Han (n = 1670) Tibetan (n = 156) Qiang (n = 210) Hui (n = 44) Education level Above bachelor (n = 47) Bachelor (n = 938) Below bachelor (n = 1095) Monthly income Very low b $150 (n = 379) Low $150 ~ 300 (n = 1347) General $300 ~ 450 (n = 274) High N $450 (n = 80) Exposure Exposure+ (n = 819) Exposure- (n = 1261)
PTG
n (%)
F
df
p
n (%)
F
df
412 (33.6) 423 (49.6)
2.60 8.62
1,2078 1,2078
0.16 0.00⁎⁎
567 (46.2) 381 (44.7)
0.86 0.12
1,2078 1,2078
0.35 0.72
252 319 210 54
(57.1) (37.6) (34.5) (30.1)
9.67 2.84 4.99 2.05
3,2076 3,2076 3,2076 3,2076
0.00⁎⁎ 0.06 0.10 0.04
210 (47.6) 416 (49.0) 256 (42.0) 66 (36.4)
12.29 2.33 3.69 9.22
3,2076 3,2076 3,2076 3,2076
0.00⁎⁎ 0.15 0.03 0.00⁎⁎
719 43 59 14
(42.8) (27.6) (28.1) (31.8)
0.69 0.12 1.77 0.22
3,2076 3,2076 3,2076 3,2076
0.40 0.72 0.18 0.31
720 (43.1) 93 (59.6) 114 (54.3) 21 (47.7)
0.16 9.88 13.78 2.08
3,2076 3,2076 3,2076 3,2076
0.80 0.00⁎⁎ 0.00⁎⁎ 0.12
12 (25.5) 296 (31.6) 527 (48.1)
2.77 1.56 8.99
2,2077 2,2077 2,2077
0.02 0.18 0.00⁎⁎
26 (55.3) 410 (43.7) 485 (39.3)
9.77 0.87 2.03
2,2077 2,2077 2,2077
0.00⁎⁎ 0.36 0.15
166 592 60 17
(43.8) (43.9) (21.9) (21.2)
3.83 1.29 1.77 2.01
3,2076 3,2076 3,2076 3,2076
0.03 0.26 0.18 0.14
167 (44.0) 630 (46.8) 118 (43.1) 33 (41.3)
2.85 0.82 0.02 0.12
3,2076 3,2076 3,2076 3,2076
0.10 0.32 0.85 0.72
521 (63.6) 314 (24.9)
9.58 2.84
1,2078 1,2078
0.00⁎⁎ 0.06
407 (49.7) 541 (42.9)
11.80 3.20
1,2078 1,2078
0.00⁎⁎ 0.21
NOTE. “Exposure+” means the presence of earthquake-related exposure with a moderate or higher degree (a score 3). NOTE. “Exposure-” means the absence of earthquake-related exposure (a score b 3). ⁎⁎ p b 0.01 for post-hoc test.
p
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Table 5 Bivariate Correlations Analysis of Subscales in PTSD and PTG (Two-Tailed Test).
1 2 3 4 5 6 7 8 9
PTGI-Total Relating to others New possibilities Personal strength Appreciation of life PCL-Total Re-experience Avoidance and numbing Arousal
1
2
0.65⁎⁎ 0.54⁎⁎ 0.55⁎⁎ 0.37⁎⁎ 0.26⁎⁎ 0.23⁎⁎ 0.20⁎⁎ 0.26⁎⁎
−0.11⁎⁎ −0.01 −0.17⁎⁎ −0.10⁎⁎ −0.12⁎⁎ −0.14⁎⁎ −0.00
3
4
5
6
7
8
0.30⁎⁎ 0.40⁎⁎ 0.21⁎⁎ 0.20⁎⁎ 0.20⁎⁎ 0.16⁎⁎
0.27⁎⁎ 0.54⁎⁎ 0.51⁎⁎ 0.48⁎⁎ 0.44⁎⁎
0.22⁎⁎ 0.20⁎⁎ 0.20⁎⁎ 0.16⁎⁎
0.72⁎⁎ 0.68⁎⁎ 0.74⁎⁎
0.64⁎⁎ 0.51⁎⁎
0.49⁎⁎
9
⁎⁎ Correlation is significant at 0.01 level.
Wenchuan earthquake. The probable PTSD prevalence estimate (based on the DSM-IV criteria) in our sample was 40.1% indicating that posttraumatic symptoms were quite common among the respondents. This PTSD prevalence was relatively high compared with PTSD rates reported in previous post-earthquake studies. The PTSD rate reported in previous research was 23% 14 months after an earthquake (Basoglu et al., 2004), and 20.9% 2 years after an earthquake (Chen et al., 2007). The rates for earthquake-related PTSD measured in Wang et al., 2000 was found to be 18.8% within 3 months of the earthquake and 24.2% within 9 months. In the present study, the prevalence of posttraumatic growth in the participants was 51.1%, which is considered relatively high compared with previous research findings (Tang, 2006; Tedeschi & Calhoun, 1996, 2004). The result in the current study is consistent with one possible mode of the association between PTSD and PTG, that is, the higher the distress, the more the growth (Solomon & Dekel, 2007). It has been argued that individuals have an intrinsic motivation for positive growth and will search for different ways to enable positive outcomes following trauma and adversity (Joseph & Linley, 2005; Tedeschi & Calhoun, 1996). The results might also be partially attributed to the way in which the population was assessed or the result of differing experiences during the earthquake. The results showed that females, a younger age, a lower education and a higher earthquake exposure were significant predictors of PTSD, which was consistent with previous studies (Basoglu et al., 2002; Chen et al., 2007; Galea et al., 2005; Neria et al., 2008). Females were more likely to show symptoms of PTG than males. When interpreting this finding, it needs to be considered that females may be more willing or better able to express their personal growth experiences. Many studies have documented the relationship between minorities and PTSD in the aftermath of disaster (Beals et al., 2002; Kulkarni & Pole, 2008). However, unlike previous studies, the results of the follow-up tests in the one-way ANOVA analysis suggested that the Han ethnic group was more likely to develop PTSD than other ethnic minorities, although the difference was not very significant. The reason may be the favorable minority policies in China and the fact that these minorities were more likely to receive higher social support, and both central and local governments focus on developing and implementing many ethnic minority policies which center on care and assistance. After the Wenchuan earthquake, ethnic minorities received more support, care and help from the government, aid organizations, and volunteers (Xu & Song, 2011). The inverse relationship between perceived support and PTSD (i.e., those reporting more support showed lower rates in the meeting of the diagnostic criteria or a lower level of symptoms) was strongest in studies where more time had elapsed between the traumatic event and the PTSD assessment (Ozer, Best, Lipsey, & Weiss, 2008). When considering monthly income, it was found that survivors with a lower monthly income were more likely to show PTSD symptoms, but monthly income was not found to be a significant predictor of PTSD after the multiple regression analysis was
conducted. In line with previous studies (Cadell et al., 2003; Solomon & Dekel, 2007), our results showed that a younger age was a significant predictor of posttraumatic growth. However, being female was not found to be a significant predictor of PTG, which is in opposition to previous studies (Tang, 2006; Tedeschi & Calhoun, 1996). This may be partly due to cultural factors. Females in traditional societies such as China tend to be more dependent, having a greater emotional attachment to their families than males. Among all the ethnic groups, the Tibetans and the Qiang reported a higher rate of PTG than the Han. One possible reason for this might be that the former ethnic groups normally have a strongly cohesive community, which could have had a more positive effect following the disaster and may have contributed to the positive adjustment. Besides this consideration, the Tibetan and Qiang ethnicities also tend to hold strong religious beliefs which could be beneficial following such a disaster and could therefore contribute to a more positive adjustment. Earthquake exposure was also found to be a significant predictor of PTG, which was consistent with previous studies (Tang, 2006; Yu et al., 2010). One possible explanation for this might be that survivors who were exposed to a higher degree were more likely to ask as well as receive emotional support and help from families, friends and the government, which would result in a positive psychological adjustment. In our study, we failed to document the relationship between the level of monthly income and PTG. The results of the bivariate correlation analysis indicated that there was a positive association between PTG and PTSD in the present study, with a moderate degree of correlation (r = .262). One explanation for this positive association is that PTG occurs when the trauma has been upsetting enough to promote engagement in a positive outlook about the event, but not too overwhelming for survivors to handle (Tedeschi & Calhoun, 1996, 2004). These findings suggest that PTG and PTSD possibly have a shared psychological "engine" that sets them in motion. We speculate that PTG may reflect a cognitive adaptation process among those who experience post-traumatic stress disorders in response to their disaster (a positive reinterpretation) (Elwood, Hahn, Olatunji, & Williams, 2009). This process may enable earthquake survivors to reframe their experience as a transition and perceive the potential benefits, such as an improved relationship with others, new possibilities, increased personal strength, spiritual change or a new appreciation of life. According to the growth model suggested by Janoff-Bulman in 2004, people can become aware of their previously undiscovered strengths and develop new coping skills that assist them in finding new possibilities in life after a trauma. They posited that strength through suffering is similar to the “no pain, no gain” motto. Trauma survivors can make sense of the event and become psychologically prepared. Research indicates that when persons who have experienced severe trauma have been compared with those who do not report trauma, positive personal changes are reported at a reliably higher level among the trauma survivors (Tedeschi & Calhoun, 1996). However, even persons who have not experienced trauma report some growth, indicating that
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there may be a tendency to perceive oneself as changing positively in general, and not only as a result of lessons learned from traumatic events (McFarland & Alvaro, 2000). These results may also suggest that personal strength can make a contribution to a positive relationship between PTSD and PTG. The limitations of this study lie in that no comparison was made with the pre-disaster condition due to a lack of data, so it is difficult to categorically come to conclusion about the extent of the effect of the earthquake on the respondents. The participants in this study were mainly workers from various fields, but a full survey of the affected population in the rural and remote areas was unavailable. More representative samples are needed to examine the generalizability of our findings. Further, a self-report instrument was used, which means that those considered minors may have faced reading or comprehension problems, so people under the age of 18 were excluded. Also, older people with a lower education, or who were suffering from mental incompetence or poor vision, were unable to complete the survey. Besides these exclusions, some of the potential subjects refused to do the survey. Therefore, our sample did not cover all age ranges. Another limitation is that this study is a cross-sectional survey, but we did not have information about the respondents' relevant characteristics before the earthquake, which could have affected the results. Because of this lack of pre-disaster data, it is difficult to come to firm conclusions as to the extent of the effect of the earthquake on the respondents. Furthermore, we did not conduct surveys in nondisaster areas, thus a comparison based on regional differences was not available. CONCLUSION Despite its limitations, this study showed the Wenchuan earthquake survivors' prevalence and risk factors for probable PTSD and PTG in different counties. The prevalence of probable PTSD was found to be 40.1%. Females, those of a young age, those having a lower education and those with a higher earthquake exposure were found to be significant PTSD predictors. While 51.1% of subjects were considered to have PTG, this case emphasizes the need to consider alternative paradigms for sequelae arising out of trauma, including positive change. Future research should pay more attention to the positive outcomes arising from earthquake experiences and similar traumas rather than just focusing on the negative outcomes. For future directions, the design of research methodologies to validate reports of growth and to determine whether growth is an actual process, with accompanying behavioral corroboration versus an “illusory” adjustment mechanism, is critical. It is highly recommended that governments and social institutions pay more attention to the survivor subgroups, especially those who are female, have a lower level of education, a lower level of income and have a higher level of earthquake exposure. In closing, the present study adds to the current literature on the relationship between PTG and PTSD by showing that growth is possibly related to PTSD. What is crucial is clinical application, as it is important to realize that moderate levels of PTSD seem to facilitate greater growth. Future research into both positive and negative outcomes concurrently would be appropriate. Acknowledgment The research is supported by the Major Program of National Social Science Foundation of China (Grant No. 12 & ZD217), Si chuan Provinci al Soci al Sci ence Foundati on of China (Grant No. SC13ZD06) and the research funding of Sichuan University (Grant No. SKG2013001). We appreciated these support both in finance and in spirit.
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Contents lists available at ScienceDirect
Archives of Psychiatric Nursing journal homepage: www.elsevier.com/locate/apnu
Posttraumatic Stress Disorder and Posttraumatic Growth Among Adult Survivors of Wenchuan Earthquake After 1 Year: Prevalence and Correlates Yuchang Jin a, b, Jiuping Xu a,⁎, Hai Liu b, Dongyue Liu b a b
Uncertainty Decision-making Laboratory, Sichuan University, No. 24, South Section 1, Yihuan Road, Chengdu, Sichuan 610065, P. R. China College of Teacher Education, Sichuan Normal University. No. 5, Jingan Road, Jinjiang District, Chengdu, Sichuan 610068, P. R. China
a b s t r a c t This study investigates the prevalence and predictors for posttraumatic stress disorder (PTSD) and posttraumatic growth (PTG) in adult survivors 1 year after the 2008 Wenchuan earthquake. Questionnaires were used to collect the data. PTSD was assessed using the PTSD Check List-Civilian (PCL-C), and PTG was assessed using the Post Traumatic Growth Inventory (PTGI). A total of 2,300 individuals were involved in the survey with 2,080 completing the questionnaire, a response rate of 90.4%. The PTSD prevalence estimate in this study was found to be 40.1%, and the prevalence for PTG among the participants was measured at 51.1%. A bivariate correlation analysis indicated that there was a positive association between PTG and PTSD. In the conclusions, possible explanations for the findings and implications for future research are discussed. © 2014 Elsevier Inc. All rights reserved.
Natural disasters cause many problems such as loss of life, personal injury, and psychological morbidity (Peek & Milleti, 2002). Previous systematic reviews have documented that posttraumatic stress disorder (PTSD) is the most commonly studied and the most frequent psychopathology in the aftermath of disasters (Galea, Nandi, & Vlahov, 2005; Norris et al., 2002). Psychiatry ratified a PTSD diagnosis in 1980, chiefly in response to the belated recognition of its symptoms in Vietnam veterans whose problems had long been inadequately understood and treated (Mcnally, 2012). As knowledge about PTSD symptoms increased, similar symptoms were found to be prevalent both in veterans and in survivors of other traumatic events, such as rape, assault, or natural disasters (Elwood, Hahn, Olatunji, & Williams, 2009). The findings of many studies have demonstrated that PTSD symptoms are common in earthquake survivors (Basoglu, Kilic, Salcioglu, & Livanou, 2004; Shalev & Freedman, 2005; Xu & Song, 2011), with the rate of PTSD documented in earthquake survivors ranging from 10% to 87% (Lai, Chang, Connor, Lee, & Davidson, 2004; McMillen, North, & Smith, 2000). The common risk indicators for post-earthquake PTSD have been identified as: being female (Galea et al., 2005; Neria, Nandi, & Galea, 2008), having a lower education, experiencing fear during the earthquake, having less social support during the preceding year, and having a lower housing status (Chen et al., 2007). A higher degree of exposure to a disaster is consistently associated with the likelihood of PTSD (Basoglu, Salcioglu, & Livanou,
⁎ Corresponding Author: Jiuping Xu, PhD, Uncertainty Decision-making Laboratory, Sichuan University, No. 24, South Section 1, Yihuan Road, Chengdu, Sichuan 610065, P. R. China. E-mail addresses: [email protected] (Y. Jin), [email protected] (J. Xu), 0883-9417/1801-0005$34.00/0 – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.apnu.2013.10.010
2002; Galea et al., 2005; Neria et al., 2008). Previous studies have suggested that ethnic groups differ significantly in their PTSD prevalence (Perilla, Norris, & Lavizzo, 2002), with one study finding that the prevalence for both 1-month and life time PTSD was higher for American Indian samples than for Whites (Beals, Manson, & Shore, 2002). Among Northridge earthquake survivors, Asian Americans displayed significantly more psychiatric distress than their European American counterparts and were more than twice as likely to be classified as warranting clinical attention (Kulkarni & Pole, 2008). Given the health costs associated with severe trauma reactions such as anxiety, depression, and insomnia, it is not surprising that PTSD research has grown extensively. However, one consequence of this focus has been that relatively little has been done which focuses on the adult capacity to maintain healthy personal growth following a traumatic event (George, Sandro, Angela, & David, 2006). Posttraumatic growth (PTG) is the positive change an individual may experience following a traumatic event. This is generally measured through a focus on five major aspects of the individual's life: an improved relationship with others, an increased personal strength, the identification of new possibilities, a positive spiritual change, and an increased appreciation of life (Tedeschi & Calhoun, 1996, 2004). PTG is measured using the Post Traumatic Growth Inventory (PTGI) developed by Tedeschi in 1996 and has been observed in various trauma-exposed civilian populations, including survivors of serious medical illness (e.g., AIDS/HIV) (Linley & Joseph, 2004; Zoellner & Maercker, 2006), hurricanes (Kilmer & Gil-Rivas, 2010), earthquake disasters (Tang, 2006), rape and war as well as in bereaved individuals (Tedeschi & Calhoun, 1996, 2004; Yu et al., 2010). Research into the correlations and predictors of PTG has found that younger people, females, and those with a higher level of education are more likely to exhibit these positive aspects (Tang, 2006).
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Previous studies have also found that the level of exposure was related to positive post-disaster adjustment, although the association between the exposure and the degree of positive adjustment is not certain (Tang, 2006; Tedeschi & Calhoun, 1996; Zoellner & Maercker, 2006). Recent studies also found that PTSD symptoms were associated with posttraumatic growth (Tang, 2006; Xu & Liao, 2011). After the 2008 Wenchuan earthquake, a great deal of attention was paid to the mental health of the earthquake survivors. Although some significant research in this area has been done previously (Han, Chen, & Yao, 2009; Kun et al., 2009; Xu & Song, 2011), it is an area that still needs deeper insights. To be able to assess the mental health consequences of the 2008 Wenchuan earthquake, we conducted a survey in several severely affected counties. The goals of this study were (a) to describe the prevalence of PTSD and PTG among adult survivors 1 year after the earthquake, (b) to identify the relationship between PTSD and PTG, and (c) to identify the predictors for PTG. METHODS
later. A total of 2300 individuals were involved in the survey with 2080 completing the questionnaire, a response rate of 90.4%. Measure The self-report questionnaire included items on demographic characteristics, the level of traumatic exposure to earthquake, and symptoms of posttraumatic stress disorder and post traumatic growth. In order to determine the situation of the residents most affected by the earthquake, two heavily damaged counties were targeted. A pilot test was conducted on 118 residents, and from the feedback and the assistance of the psychology professors, minor modifications and adjustments were made to the PTGI. A few revisions were made to the designed PCL-C questionnaire. The final version of the questionnaire was used in the formal investigation. In this study, the internal consistency of the total scale was found to be .92, and the internal consistencies for re-experience, avoidance/numbing and hyper-arousal subscales were .90, .91 and .93, respectively.
Procedure Demographics The study was designed in accordance with the tenets of the Declaration of Helsinki and was approved by the Sichuan University ethics committee. The investigation complies with the principle of voluntariness. Data collection for the present study was conducted 1 year after the Wenchuan earthquake from May, 12th, 2009 to September, 17th, 2009 in 19 severely affected counties. The survey was conducted in 2 stages, and stratified random sampling was used to screen the subjects (both the 118 and the 2080). The inclusion criteria were a high degree of exposure to the earthquake and experience of the complete earthquake process. With the assistance of the local civil affairs department and the Bureau of Statistics, we gathered data about the local community populations. From these data, a stratification random sampling strategy was used to gain a fair distribution of sex, age, and place. Survey teams were temporarily established and were then divided into 19 smaller teams with one team in charge of data collection in one county. The teams participated in a 5-day training program given by a psychologist, a statistics expert and three psychiatrists from the West China School of Public Health Sichuan University. Before conducting the formal investigation, initial pilot evaluations were carried out in 4 counties to test the original questionnaire, after which it was adjusted to match the local conditions. To ensure data confidentiality, it was guaranteed that none of the subjects' personal information would be revealed. From July to September 2009, the trained groups were assigned to the counties based on a previously arranged schedule. Residents who lived in both their original houses or in temporary accommodations were randomly selected to be visited on the basis of the total number. Participants were told about the study's purpose, and oral consent was obtained before each interview. One respondent within each selected house or temporary accommodation was randomly selected according to their birth date. Those who experienced the earthquake and were ages 18 to 65 years were interviewed. If residents declined to be interviewed because they were wary of such surveys or wished to avoid talking about the event, the next closest resident was invited. Those with mental retardation and major psychoses (e.g. schizophrenia, major depressive disorder, organic mental disorders), however, were excluded. Very few respondents were found to have a low level of education or literacy problems, but for those who did, the group members assisted them in noting down the answers and stayed with them while they completed the survey. To ensure privacy, participants were encouraged to have the interviews and to complete the questionnaire in private. Each research group in each county distributed the questionnaire packages and collected them 4 hours
Basic demographic information was elicited using the questionnaire and included items for gender, age, ethnicity, educational level and monthly income. Degree of Exposure to Earthquake The degree of exposure to the earthquake was assessed using a 2point scale (yes = 1 and no = 0) to measure whether participants experienced the following nine events: personal injury, the death of family members, relatives or friends, injuries to family members, relatives or friends, loss of or damage to personal or family property, being a witness to other people who were seriously injured or killed, the employment situation after the earthquake, perceived threats, agency support and temporary shelter relocation. The total score for earthquake-related exposure was 9 (yes = 1, no = 0), with higher scores demonstrating a greater level of exposure. Participants whose scores were higher than 3 (including 3) were considered to be suffering from a moderate degree of earthquake-related exposure. In terms of the degree of exposure to the earthquake, there was a difference of opinion among the research teams as to how many groups should be classified with some teams feeling that three groups were more accurate and other teams feeling that two groups were sufficient. In the analysis in this paper we have used a two group classification which we felt adequately explained the difference between the heavily exposed group and the less severely exposed group. We regarded this variable as a continuous variable to enable an inspection of the relationships between all dependent variables and the degree of exposure. Posttraumatic Stress Disorder PTSD symptoms were assessed using the PTSD Check List-Civilian Version (PCL-C), which has 17 items corresponding to the symptoms discussed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), PTSD criteria B, C, and D (Cadell, Regehr, & Hemsworth, 2003; Joseph & Linley, 2005; Wu et al., 2006). The response options for each item on the PCL-C were recorded on a five-point Likert scale ranging from 1 (not at all) to 5 (extremely), which indicated the degree to which a respondent had been bothered by a particular symptom over the previous month. A symptom was deemed present when a respondent reported an item as experienced moderately, quite a bit, or extremely (3, 4, or 5, respectively) in the past month (Wu et al., 2006). In this study, PTSD was defined using the Diagnostic and Statistical Manual-IV criteria. To be categorized as
Y. Jin et al. / Archives of Psychiatric Nursing 28 (2014) 67–73
having symptoms consistent with a PTSD diagnosis, a respondent needed to report at least one criterion B symptom (re-experience), three criterion C symptoms (avoidance/numbing), and two criterion D symptoms (hyper-arousal) (Cadell et al., 2003). Scores were summed with a final range of 17 to 85. In accordance with previous studies, a score of 50 or higher was considered consistent with PTSD symptoms (Wu et al., 2006). The PCL-C was shown to have good internal consistency. The internal consistency of the total scale was .939, and the internal consistencies for the re-experience, avoidance/ numbing and hyper-arousal subscales were .935, .820, and .839, respectively (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996). In this study, the internal consistency of the total scale was .95, and internal consistencies for the re-experience, avoidance/numbing and hyper-arousal subscales were .88, .87, and .86, respectively. Posttraumatic Growth The PTG was assessed using the Posttraumatic Growth Inventory (PTGI) (Tedeschi & Calhoun, 1996). This inventory consists of 21 items across five major domains: relating to others (7 items), new possibilities (5 items), personal strength (4 items) spiritual change (2 items), and appreciation of life (3 items). A pilot study was conducted, and two items were excluded from this study (“A better understanding of spiritual matters” and “I have a stronger religious faith”), as only few participants were found to have religious beliefs in the pilot test. Participants responded on a 5-point Likert scale ranging from 0 (no change) to 4 (complete change). The total PTGI score was the sum of the 19 items, with a total possible score of 95. Different studies have used different cutoff points for this inventory. For example, in Tang's (2006) study, average mean scores above 3 on the PTGI were considered indicative of moderate levels of posttraumatic growth. In the same study, the cutoff point for the subscales was 21 for relating to others, 15 for new possibilities, 12 for personal strength, and 9 for appreciation of life. According to Yu et al. (2010), total scores above the 60th percentile were considered to have probable PTG. In this study, scores above 57 (including 57) were considered to indicate a moderate level of posttraumatic growth. This inventory has demonstrated a good internal and test–retest reliability for both western (Tedeschi & Calhoun, 1996) and Asian samples (Solomon & Dekel, 2007). In this study, the validity of the PTGI was .83, and the internal reliability was .88. The internal reliabilities for the four subscales were .83, .79, .81, and 80, respectively. Statistical Analysis General descriptive statistics (frequencies and percentages) were used to describe the prevalence of PTSD and PTG. One-way ANOVA analyses were performed to compare the PTSD and PTG in the different participant groups. Simultaneous multiple regression analyses were conducted to identify the PTSD associated risk factors, and the PTG predictors and bivariate correlation analyses were performed to examine the relationship between PTSD and PTG. All tests were 2-tailed, and the significance was set at 0.01. All statistical procedures were completed using the SPSS 16.0 Statistical Package for Social Science.
RESULTS Demographic Characteristics The mean age of the sample was 38.24 ± 8.82 years. 59% of the sample were male. The Han ethnic group accounted for the majority (80.3%), with the Qiang ethnic group somewhat less than the Han (10.1%), but higher than other ethnic minorities in the survey. Overall, 52.6% of the respondents had a relatively low educational level, and
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64.8% had a monthly income of $150 to $300. These demographic characteristics are presented in Table 1. Prevalence of PTSD and PTG Of 2080 participants, the prevalence estimate for probable PTSD in our sample was 1181 (40.1%) (based on the DSM-IV criteria). One thousand two hundred twenty (58.7%) of the respondents reported that they suffered from at least 1 re-experience symptom; 986(47.4%) suffered from 3 or more avoidance symptoms; and 1027(49.4%) suffered from 2 or more arousal symptoms (Table 2). The number of subjects who met the criteria (a score of 21 or more) of improvement in “relating to others” was quite high (74.9%). As shown in Table 2, 51.1% of respondents were considered to have PTG. For the PTG subscales, 74.9% of respondents noted an improvement in relating to others, 30.5% an improvement in their personal life, 26.1% were open to new possibilities, and 24.5% showed an increased appreciation for life. Difference Between the Subgroups for PTSD and PTG Chi-square tests were performed to compare the prevalence of PTSD and PTG in different participant groups. The diagnosis of probable PTSD was found to be significantly related to gender (x 2 = 7.96, df = 1, p b 0.01), age (x 2 = 19.66, df = 3, p b 0.001), educational level (x 2 = 43.13, df = 2, p b 0.001), and exposure (x 2 = 13.47, df = 1, p b 0.001). Similarly, the prevalence of PTG was significantly related to age (x 2 = 14.8, df = 3, p b 0.001), ethnicity (x 2 = 12.71, df = 3, p b 0.001), and educational level (x 2 = 18.17, df = 2, p b 0.001). Post-hoc testing confirmed that PTSD symptoms were more common among females, F(1, 2078) = 8.62, p b 0.001, than males. Younger participants, F(3, 2076) = 9.67, p b 0.001, or those with a lower level of education, F(2, 2077) = 8.99, p b 0.001, were also more likely to have these symptoms. PTSD symptoms were also more common among respondents with a higher degree of earthquake exposure, F(1, 2078) = 9.58, p b 0.001 (Table 3). For different age groups, younger survivors reported a higher rate of PTG. Specifically, survivors aged from 18 to 30, F(3, 2076) = 12.29,
Table 1 Demographic Characteristics of the Study Sample (N = 2080).
Gender Male Female Age groups 18 ~ 30 31 ~ 40 41 ~ 50 51 ~ 68 Ethnic group Han Tibetan Qiang Hui Education level Graduate Bachelor Professional college Middle school other Month income Very low b $150 Low $150 ~ 300 General $300 ~ 450 High N $450
n
%
1227 853
59.0 41.0
441 849 609 181
21.2 40.8 29.3 8.7
1670 156 210 44
80.3 7.5 10.1 2.1
47 938 770 288 37
2.3 45.1 37.0 13.8 1.8
379 1347 274 80
18.2 64.8 13.2 3.8
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Table 2 Prevalence of PTSD and PTG Reported One Year After the Wenchuan Earthquake (N = 2080).
Table 4 Multiple Regression Analysis in PTSD and PTG (N = 2080). PCL-Total score (PTSD)
Prevalence
PTSD-positive screen based on DSM-IV B. Re-experience b C. Avoidance and numbing c D. Arousal d Total score of PTGI-R ≥ 57 Relation to others ≥ 21 New possibilities ≥ 15 Personal of life ≥ 12 Appreciation ≥ 9
a
n
%
1181 1220 986 1027 1063 1558 543 634 509
40.1 58.7 47.4 49.4 51.1 74.9 26.1 30.5 24.5
a Subjects were screened positive for probable PTSD if they endorsed at least 1 of 5 reexperience symptoms, at least 3 of 7 avoidance symptoms, and at least 2 of 5 arousal symptoms with a rating of at least “moderately”. b One or more reexperience symptoms (a score of 3 or more). c One or more avoidance symptoms (a score of 3 or more). d One or more arousal symptoms (a score of 3 or more).
(constant) Gender Age Education level Monthly income Exposure R2
PTGI-Total score (PTG)
B
SEB
β
p
B
SEB
β
p
0.63 0.12 0.16 −0.29 −0.33 0.18 0.14
0.13 0.26 0.10 0.09 0.02 0.11
0.10 0.49 0.13 −0.26 −0.11 0.17
b0.01 b0.01 b0.01 N0.05 b0.01 b0.01
0.42 −0.32 0.19 0.03 0.11 0.34 0.18
0.11 0.04 0.08 0.03 0.03 0.03
0.13 −0.11 0.23 0.03 0.35 0.12
b0.01 N0.05 b0.02 N0.05 N0.05 b0.00
NOTE. B: coefficient, SEB: standardized error of coefficient, β: standardized regression coefficient.
For PTSD, the significant predictors were gender, age, educational level and degree of earthquake exposure. For PTG, the significant predictors were age and degree of earthquake exposure (Table 4). Analysis of Correlation Between PTSD and PTG
p b 0.001, reported the highest rate of PTG, while respondents aged from 51 to 68, F(2, 2076) = 9.22, p b 0.001, reported the lowest rate of PTG. The Tibetan ethnic group, F(3, 2076) = 9.88, p b 0.001, and the Qiang ethnic group, F(3, 2076) = 13.78, p b 0.001, were more likely to show PTG than the Han ethnic group. For educational level, survivors with above a bachelors degree, F(2, 2077) = 9.77, p b 0.001, reported the highest rate of PTG. Participants with a higher degree of earthquake exposure, F(1, 2078) = 11.80, p b 0.001, also reported a higher rate of PTG (Table 3). Predictors of PTSD and PTG As a number of variables were associated with PTSD and PTG, a multiple regression analysis was conducted to determine the best predictors. In the regression analysis for both PTSD and PTG, gender, age, educational level, monthly income and exposure were entered.
Table 5 shows the results of the bivariate correlation analysis. There were found to be moderate correlations between the PTGI-Total and the PCL-Total (r = .262), avoidance and numbing (r = .202), reexperience (r = .233), and arousal (r = .264). The PCL-Total was also associated with the PTG subscales of “relating to others” (r = .100), “new possibilities” (r = .213), “personal strength” (r = .537) and “appreciation of life” (r = .215). Specifically, there was a relatively high degree of correlation between “personal strength” and PTSD symptoms of avoidance and numbing (r = .475), re-experience (r = .510), and arousal (r = .435). DISCUSSION The findings of this study show widespread posttraumatic stress disorder and posttraumatic growth among survivors 1 year after the
Table 3 Difference of Subgroups in PTSD and PTG (ANOVA). PTSD
Gender Male (n = 1227) Female (n = 853) Age groups 18 ~ 30 (n = 441) 31 ~ 40 (n = 849) 41 ~ 50 (n = 609) 51 ~ 68 (n = 181) Ethnicity Han (n = 1670) Tibetan (n = 156) Qiang (n = 210) Hui (n = 44) Education level Above bachelor (n = 47) Bachelor (n = 938) Below bachelor (n = 1095) Monthly income Very low b $150 (n = 379) Low $150 ~ 300 (n = 1347) General $300 ~ 450 (n = 274) High N $450 (n = 80) Exposure Exposure+ (n = 819) Exposure- (n = 1261)
PTG
n (%)
F
df
p
n (%)
F
df
412 (33.6) 423 (49.6)
2.60 8.62
1,2078 1,2078
0.16 0.00⁎⁎
567 (46.2) 381 (44.7)
0.86 0.12
1,2078 1,2078
0.35 0.72
252 319 210 54
(57.1) (37.6) (34.5) (30.1)
9.67 2.84 4.99 2.05
3,2076 3,2076 3,2076 3,2076
0.00⁎⁎ 0.06 0.10 0.04
210 (47.6) 416 (49.0) 256 (42.0) 66 (36.4)
12.29 2.33 3.69 9.22
3,2076 3,2076 3,2076 3,2076
0.00⁎⁎ 0.15 0.03 0.00⁎⁎
719 43 59 14
(42.8) (27.6) (28.1) (31.8)
0.69 0.12 1.77 0.22
3,2076 3,2076 3,2076 3,2076
0.40 0.72 0.18 0.31
720 (43.1) 93 (59.6) 114 (54.3) 21 (47.7)
0.16 9.88 13.78 2.08
3,2076 3,2076 3,2076 3,2076
0.80 0.00⁎⁎ 0.00⁎⁎ 0.12
12 (25.5) 296 (31.6) 527 (48.1)
2.77 1.56 8.99
2,2077 2,2077 2,2077
0.02 0.18 0.00⁎⁎
26 (55.3) 410 (43.7) 485 (39.3)
9.77 0.87 2.03
2,2077 2,2077 2,2077
0.00⁎⁎ 0.36 0.15
166 592 60 17
(43.8) (43.9) (21.9) (21.2)
3.83 1.29 1.77 2.01
3,2076 3,2076 3,2076 3,2076
0.03 0.26 0.18 0.14
167 (44.0) 630 (46.8) 118 (43.1) 33 (41.3)
2.85 0.82 0.02 0.12
3,2076 3,2076 3,2076 3,2076
0.10 0.32 0.85 0.72
521 (63.6) 314 (24.9)
9.58 2.84
1,2078 1,2078
0.00⁎⁎ 0.06
407 (49.7) 541 (42.9)
11.80 3.20
1,2078 1,2078
0.00⁎⁎ 0.21
NOTE. “Exposure+” means the presence of earthquake-related exposure with a moderate or higher degree (a score 3). NOTE. “Exposure-” means the absence of earthquake-related exposure (a score b 3). ⁎⁎ p b 0.01 for post-hoc test.
p
Y. Jin et al. / Archives of Psychiatric Nursing 28 (2014) 67–73
71
Table 5 Bivariate Correlations Analysis of Subscales in PTSD and PTG (Two-Tailed Test).
1 2 3 4 5 6 7 8 9
PTGI-Total Relating to others New possibilities Personal strength Appreciation of life PCL-Total Re-experience Avoidance and numbing Arousal
1
2
0.65⁎⁎ 0.54⁎⁎ 0.55⁎⁎ 0.37⁎⁎ 0.26⁎⁎ 0.23⁎⁎ 0.20⁎⁎ 0.26⁎⁎
−0.11⁎⁎ −0.01 −0.17⁎⁎ −0.10⁎⁎ −0.12⁎⁎ −0.14⁎⁎ −0.00
3
4
5
6
7
8
0.30⁎⁎ 0.40⁎⁎ 0.21⁎⁎ 0.20⁎⁎ 0.20⁎⁎ 0.16⁎⁎
0.27⁎⁎ 0.54⁎⁎ 0.51⁎⁎ 0.48⁎⁎ 0.44⁎⁎
0.22⁎⁎ 0.20⁎⁎ 0.20⁎⁎ 0.16⁎⁎
0.72⁎⁎ 0.68⁎⁎ 0.74⁎⁎
0.64⁎⁎ 0.51⁎⁎
0.49⁎⁎
9
⁎⁎ Correlation is significant at 0.01 level.
Wenchuan earthquake. The probable PTSD prevalence estimate (based on the DSM-IV criteria) in our sample was 40.1% indicating that posttraumatic symptoms were quite common among the respondents. This PTSD prevalence was relatively high compared with PTSD rates reported in previous post-earthquake studies. The PTSD rate reported in previous research was 23% 14 months after an earthquake (Basoglu et al., 2004), and 20.9% 2 years after an earthquake (Chen et al., 2007). The rates for earthquake-related PTSD measured in Wang et al., 2000 was found to be 18.8% within 3 months of the earthquake and 24.2% within 9 months. In the present study, the prevalence of posttraumatic growth in the participants was 51.1%, which is considered relatively high compared with previous research findings (Tang, 2006; Tedeschi & Calhoun, 1996, 2004). The result in the current study is consistent with one possible mode of the association between PTSD and PTG, that is, the higher the distress, the more the growth (Solomon & Dekel, 2007). It has been argued that individuals have an intrinsic motivation for positive growth and will search for different ways to enable positive outcomes following trauma and adversity (Joseph & Linley, 2005; Tedeschi & Calhoun, 1996). The results might also be partially attributed to the way in which the population was assessed or the result of differing experiences during the earthquake. The results showed that females, a younger age, a lower education and a higher earthquake exposure were significant predictors of PTSD, which was consistent with previous studies (Basoglu et al., 2002; Chen et al., 2007; Galea et al., 2005; Neria et al., 2008). Females were more likely to show symptoms of PTG than males. When interpreting this finding, it needs to be considered that females may be more willing or better able to express their personal growth experiences. Many studies have documented the relationship between minorities and PTSD in the aftermath of disaster (Beals et al., 2002; Kulkarni & Pole, 2008). However, unlike previous studies, the results of the follow-up tests in the one-way ANOVA analysis suggested that the Han ethnic group was more likely to develop PTSD than other ethnic minorities, although the difference was not very significant. The reason may be the favorable minority policies in China and the fact that these minorities were more likely to receive higher social support, and both central and local governments focus on developing and implementing many ethnic minority policies which center on care and assistance. After the Wenchuan earthquake, ethnic minorities received more support, care and help from the government, aid organizations, and volunteers (Xu & Song, 2011). The inverse relationship between perceived support and PTSD (i.e., those reporting more support showed lower rates in the meeting of the diagnostic criteria or a lower level of symptoms) was strongest in studies where more time had elapsed between the traumatic event and the PTSD assessment (Ozer, Best, Lipsey, & Weiss, 2008). When considering monthly income, it was found that survivors with a lower monthly income were more likely to show PTSD symptoms, but monthly income was not found to be a significant predictor of PTSD after the multiple regression analysis was
conducted. In line with previous studies (Cadell et al., 2003; Solomon & Dekel, 2007), our results showed that a younger age was a significant predictor of posttraumatic growth. However, being female was not found to be a significant predictor of PTG, which is in opposition to previous studies (Tang, 2006; Tedeschi & Calhoun, 1996). This may be partly due to cultural factors. Females in traditional societies such as China tend to be more dependent, having a greater emotional attachment to their families than males. Among all the ethnic groups, the Tibetans and the Qiang reported a higher rate of PTG than the Han. One possible reason for this might be that the former ethnic groups normally have a strongly cohesive community, which could have had a more positive effect following the disaster and may have contributed to the positive adjustment. Besides this consideration, the Tibetan and Qiang ethnicities also tend to hold strong religious beliefs which could be beneficial following such a disaster and could therefore contribute to a more positive adjustment. Earthquake exposure was also found to be a significant predictor of PTG, which was consistent with previous studies (Tang, 2006; Yu et al., 2010). One possible explanation for this might be that survivors who were exposed to a higher degree were more likely to ask as well as receive emotional support and help from families, friends and the government, which would result in a positive psychological adjustment. In our study, we failed to document the relationship between the level of monthly income and PTG. The results of the bivariate correlation analysis indicated that there was a positive association between PTG and PTSD in the present study, with a moderate degree of correlation (r = .262). One explanation for this positive association is that PTG occurs when the trauma has been upsetting enough to promote engagement in a positive outlook about the event, but not too overwhelming for survivors to handle (Tedeschi & Calhoun, 1996, 2004). These findings suggest that PTG and PTSD possibly have a shared psychological "engine" that sets them in motion. We speculate that PTG may reflect a cognitive adaptation process among those who experience post-traumatic stress disorders in response to their disaster (a positive reinterpretation) (Elwood, Hahn, Olatunji, & Williams, 2009). This process may enable earthquake survivors to reframe their experience as a transition and perceive the potential benefits, such as an improved relationship with others, new possibilities, increased personal strength, spiritual change or a new appreciation of life. According to the growth model suggested by Janoff-Bulman in 2004, people can become aware of their previously undiscovered strengths and develop new coping skills that assist them in finding new possibilities in life after a trauma. They posited that strength through suffering is similar to the “no pain, no gain” motto. Trauma survivors can make sense of the event and become psychologically prepared. Research indicates that when persons who have experienced severe trauma have been compared with those who do not report trauma, positive personal changes are reported at a reliably higher level among the trauma survivors (Tedeschi & Calhoun, 1996). However, even persons who have not experienced trauma report some growth, indicating that
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Y. Jin et al. / Archives of Psychiatric Nursing 28 (2014) 67–73
there may be a tendency to perceive oneself as changing positively in general, and not only as a result of lessons learned from traumatic events (McFarland & Alvaro, 2000). These results may also suggest that personal strength can make a contribution to a positive relationship between PTSD and PTG. The limitations of this study lie in that no comparison was made with the pre-disaster condition due to a lack of data, so it is difficult to categorically come to conclusion about the extent of the effect of the earthquake on the respondents. The participants in this study were mainly workers from various fields, but a full survey of the affected population in the rural and remote areas was unavailable. More representative samples are needed to examine the generalizability of our findings. Further, a self-report instrument was used, which means that those considered minors may have faced reading or comprehension problems, so people under the age of 18 were excluded. Also, older people with a lower education, or who were suffering from mental incompetence or poor vision, were unable to complete the survey. Besides these exclusions, some of the potential subjects refused to do the survey. Therefore, our sample did not cover all age ranges. Another limitation is that this study is a cross-sectional survey, but we did not have information about the respondents' relevant characteristics before the earthquake, which could have affected the results. Because of this lack of pre-disaster data, it is difficult to come to firm conclusions as to the extent of the effect of the earthquake on the respondents. Furthermore, we did not conduct surveys in nondisaster areas, thus a comparison based on regional differences was not available. CONCLUSION Despite its limitations, this study showed the Wenchuan earthquake survivors' prevalence and risk factors for probable PTSD and PTG in different counties. The prevalence of probable PTSD was found to be 40.1%. Females, those of a young age, those having a lower education and those with a higher earthquake exposure were found to be significant PTSD predictors. While 51.1% of subjects were considered to have PTG, this case emphasizes the need to consider alternative paradigms for sequelae arising out of trauma, including positive change. Future research should pay more attention to the positive outcomes arising from earthquake experiences and similar traumas rather than just focusing on the negative outcomes. For future directions, the design of research methodologies to validate reports of growth and to determine whether growth is an actual process, with accompanying behavioral corroboration versus an “illusory” adjustment mechanism, is critical. It is highly recommended that governments and social institutions pay more attention to the survivor subgroups, especially those who are female, have a lower level of education, a lower level of income and have a higher level of earthquake exposure. In closing, the present study adds to the current literature on the relationship between PTG and PTSD by showing that growth is possibly related to PTSD. What is crucial is clinical application, as it is important to realize that moderate levels of PTSD seem to facilitate greater growth. Future research into both positive and negative outcomes concurrently would be appropriate. Acknowledgment The research is supported by the Major Program of National Social Science Foundation of China (Grant No. 12 & ZD217), Si chuan Provinci al Soci al Sci ence Foundati on of China (Grant No. SC13ZD06) and the research funding of Sichuan University (Grant No. SKG2013001). We appreciated these support both in finance and in spirit.
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