Psychiatry 77(3) Fall 2014
289
PTSD, Psychiatric Comorbidity, and the 2010 Flood in Pakistan Chung et al.
Posttraumatic Stress Disorder and Psychiatric Comorbidity Following the 2010 Flood in Pakistan: Exposure Characteristics, Cognitive Distortions, and Emotional Suppression Man Cheung Chung, Sabeena Jalal, and Najib Ullah Khan This study investigated the extent of posttraumatic stress disorder (PTSD) and psychiatric comorbidity among the 2010 flood victims in Pakistan and its relationship with disaster exposure characteristics, cognitive distortions, and emotional suppression. One hundred and thirty-one (F = 89, M = 42) flood victims were assessed using the Posttraumatic Diagnostic Scale, the General Health Questionnaire-28, the Cognitive Distortion Scales, and the Courtauld Emotional Control Scale. The results showed that all victims met the diagnostic criteria for PTSD and scored above the cut-off for psychiatric caseness. Partial least squares modelling showed that disaster exposure characteristics were significantly correlated with PTSD and psychiatric comorbidity. Disaster exposure characteristics were also significantly associated with cognitive distortions which in turn were also significantly associated with PTSD and psychiatric comorbidity. Cognitive distortions were also correlated with emotional suppression which, however, was not associated with PTSD or psychiatric comorbidity. To conclude, the flood victims reported PTSD and psychiatric comorbid symptoms which were related to their subjective exposure to the flood. Such exposure led to the development of dysfunctional thinking patterns which in turn influenced distress symptoms. In 2010, flooding killed approximately 2,000 people and caused injury to over 3,000 in Pakistan. Over 20 million people were affected in different provinces (Congressional Research Service, 2010; United Nations Office, 2010). Following flooding, PTSD ranging from 5 to 71% (e.g., Li et al., 2010; Liu et al., 2006; Mason, Andrews, & Upton, 2010; North, Kawasaki, Spitznagel, & Hong, 2004) can develop alongside
depression, anxiety, and somatization (e.g., Mason et al., 2010; North et al., 2004). Risk factors for PTSD following flood include demographic variables (gender and age) (Liu et al., 2006; Norris, Kaniasty, Conrad, Inman, & Murphy, 2002), disaster exposure characteristics such as flood type (Liu et al., 2006), losses sustained (Waelde, Koopman, Rierdan, & Spiegel, 2001), and vacating of home during the flood (Mason et al., 2010).
Man Cheung Chung, Ph.D., is affiliated with the Department of Natural Science and Public Health at Zayed University in Abu Dhabi, United Arab Emirates. Sabeena Jalal, Ph.D., is affiliated with Dow University of Health Sciences, Karachi, Pakistan. Najib Ullah Khan, Ph.D., is affiliated with Abbasi Shaheed Hospital, Karachi, Pakistan. Address correspondence to Professor M. C. Chung, Zayed University, Department of Natural Science and Public Health, P.O. Box 144534, Abu Dhabi, United Arab Emirates. E-mail: [email protected] © 2014 Washington School of Psychiatry
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PTSD, Psychiatric Comorbidity, and the 2010 Flood in Pakistan
It is unclear whether cognitive distortions following flooding could act as another risk factor for PTSD and psychiatric comorbid outcomes (Owens & Chard, 2006). A cognitive model of PTSD (Ehlers & Clark, 2000) suggests that trauma characteristics can influence the way people process their trauma and its consequences. They can develop cognitive distortions by creating negative appraisals of it (external threat: viewing the world as a dangerous place; or internal threat: viewing themselves as incapable) which, in turn, trigger a sense of current threat accompanied by PTSD and comorbid psychiatric responses. In other words, the relationship between trauma characteristics, PTSD symptoms, and psychiatric comorbidities is mediated by negative appraisals. In the context of the aftermath of a devastating flood, victims could view the world as a dangerous place or view themselves as incapable of dealing with or controlling it. Cognitive distortions resulting from a devastating flood ultimately involve drastic changes in the schema with which victims perceive themselves and interpret external reality (Horowitz, 1986). People need to adapt to the schematic changes occurring within them, incorporating traumatic information into existing schemas. Such incongruity causes a great deal of emotional distress which is exacerbated by feelings of powerlessness. To prevent emotional exhaustion, people try to inhibit the flow of traumatic information to a tolerable level (Ihilevich & Gleser, 1993; McDougall, 1985; Thome, 1990). They try to control or suppress distressing emotions as a defense mechanism and inhibit emotional expressive behavior (Gross, 1998). However, in so doing, distressing emotions remain unresolved (Myers, Vetere, & Derakshan, 2004), leading to negative effects and PTSD symptoms (Amir et al., 1997). This is why emotional suppression and avoidance coping (i.e., avoiding processing emotions) (Gross & John, 2003) have been associated with increased psychiatric symptoms (Amstadter & Vernon, 2008),
including depression, anxiety, somatization (Tull, Gratz, Salters, & Roemer, 2004; Tull, Jakupcak, Paulson, & Gratz, 2007; Znoj & Lude, 2002), and poor quality of life (Kashdan, Morina, & Priebe, 2009) among trauma victims. This theoretical framework might set the backdrop for the distorted cognitions associated with PTSD following traumas, including child abuse (e.g., Ponce, Williams, & Allen, 2004; Lau & Kristensen, 2010), motor vehicle accident (e.g., Mayou, Ehlers, & Bryant, 2002) and hate-crime victimization (e.g., Herek, Gillis, & Cogan, 1999). Cognitive distortions are characterized by self-blame, helplessness, and hopelessness, alongside an over-estimation of the degree of danger in the world (Briere & Spinazzola, 2005; Owens & Chard, 2006). The foregoing passages indicate an integrated model outlining the interrelationship between cognitive distortions, emotional suppression, PTSD, and psychiatric comorbidity. This model sets the basis for the current study of flood victims in Pakistan. In such a study, it is important to consider the effects of disaster exposure characteristics and demographic variables, since the literature indicates an association with distress outcomes (Liu et al., 2006; Mason et al., 2010; Norris et al., 2002). The purpose of the study was to examine 1) the extent of PTSD and psychiatric comorbidity among flood victims in Pakistan and 2) the interrelationship between disaster exposure characteristics, cognitive distortions, emotional suppression, PTSD, and psychiatric comorbidity after controlling for demographic variables. Based on the literature presented, the hypotheses were: 1. There would be a high percentage of flood victims meeting the diagnostic criteria for PTSD and displaying psychiatric comorbid symptoms. 2. Controlling for demographic variables and disaster exposure characteristics would be positively associated with
Chung et al. 291
FIGURE 1. The Hypothesized Path Model Describing the Interrelationships Between Disaster Exposure Characteristics, Cognitive Distortions, Emotional Suppression, PTSD, and Psychiatric Comorbidity After Controlling for Demographic Variables.
PTSD and psychiatric comorbidity following flooding. 3. Disaster exposure characteristics would positively associate with cognitive distortions which would positively associate with PTSD and psychiatric comorbidity. 4. Cognitive distortions would be positively associated with emotional suppression which in turn would be positively associated with PTSD and psychiatric comorbidity. Figure 1 depicts the hypothesized model. METHODS
the study would generate a power of 0.95 (critical F = 2.01). This was selected as the medium effect size (f2 = 0.19) sufficient to detect a clinical or substantively significant effect. One hundred and thirty-one flood victims (F = 89, M = 42) participated in the study. They were on average 32 years of age (M = 32.32, SD = 12.31), ranging from 18 to 80. Many (78%) were married and some widowed (17%), separated/divorced (3%), or single (2%). Most were Sindhi (90%). All were in the low income category defined according to occupation. The majority had received no education (82%) and had had no major or life-threatening illnesses (92%). None reported that they had received a diagnosis of cognitive impairment. Measures
Participants Power calculation showed that with a sample size of 128 and an alpha set at 0.05,
Demographic information recorded data on gender, age, marital status, ethnicity, income level, educational level, and whether
292
PTSD, Psychiatric Comorbidity, and the 2010 Flood in Pakistan
participants had previously been diagnosed as suffering from major life illnesses or cognitive impairment. Disaster exposure characteristics were measured separately in the form of questions on single items such as whether (0 = no, 1 = yes) they knew anyone who died in the flood and if so, who; injury sustained during the flood; whether they felt that they were going to die; and whether they were rescued and worry about further flooding. Participants were also asked to indicate the extent of loss of personal belongings, including own home (0 = not at all, 1 = a little bit, 2 = a lot, 3 = all of it) and the number of floods experienced in their lifetime. These questions were adopted from questionnaires used in previous disaster studies and adapted for the current study (e.g., Chung, Werrett, Farmer, Easthope, & Chung, 2000; Freh, Chung & Dallos, 2013). The Posttraumatic Stress Diagnostic Scale (PDS) (Foa, Cashman, Jaycox, & Perry, 1997) was used to measure PTSD symptoms following flooding. Along with a diagnosis of PTSD, the PDS also generates three symptom clusters based on the DSM-IV criteria: re-experiencing, avoidance, and hyperarousal. The reliability of the PDS scale was high (re-experience, a = 0.78; avoidance, a = 0.84; hyperarousal, a = 0.84). Based on the current sample, the reliability of PDS was also high (re-experiencing, a = 0.97, avoidance, a = 0.91, hyperarousal, a = 0.93). The General Health Questionnaire-28 (GHQ-28) (Goldberg & Hillier, 1979) estimates the likelihood of participants being diagnosed as suffering from general psychiatric morbidity at interview. The questions are scored using the scoring method of 0-0-1-1. As the total GHQ score exceeds the recommended cut-off point of 4, the probability of diagnosis increases. Analysis of the mean scores of the GHQ-28 was based on the rating scale of 1-2-3-4. The questionnaire yields four subscales: somatic problems, anxiety, social dysfunction, and depression. On the basis of the above cut-off, the GHQ-28 has shown a sensitivity value of 88% at a speci-
ficity of 84.2% and an overall misclassification rate of 14.5%. Reliability coefficients ranged from 0.78 to 0.95 (Goldberg & Bridges, 1987). Based on the current sample, the reliability of the four subscales was high (somatic problems, a = 0.94; anxiety, a = 0.92; social dysfunction, a = 0.95; depression, a = 0.94). Cognitive Distortion Scales (CDS) (Briere, 2000) is a 40-item test assessing dysfunctional cognitions characterized by selfcriticism, helplessness, hopelessness, selfblame, and preoccupation with danger using a 5-point scale ranging from 1 = never to 5 = very often. The reliability of the scale was high (self-criticism, a = 0.93; self-blame, a = 0.92; helplessness, a = 0.94; hopelessness, a = 0.97; preoccupation with danger, a = 0.89), as it was in our sample (self-criticism, a = 0.94; self-blame, a = 0.93; helplessness, a = 0.93; hopelessness, a = 0.92; preoccupation with danger, a = 0.94). The Courtauld Emotional Control Scale (CECS) (Watson & Greer 1983) is a 21-item questionnaire measuring the impact of suppressing anger, depression, and anxiety. Victims were asked to rate how often they suppressed these emotions, from almost never = 1 to almost always = 4. CECS obtained good test-retest reliability (anger = 0.60; depression = 0.90; anxiety = 0.84), good internal consistency for each subscale and concurrent validity, as was reflected in the present study (anger: α = 0.88; depression: α = 0.90; anxiety: α = 0.82). Procedure The flood victims were recruited from medical camps arranged by the Khidmat-eKhalq Foundation Medical Aid Committee in Pakistan. These camps were set up immediately after the flood specifically for providing medical treatment, first aid, and general support to victims. Victims who came to the camps for help approximately one month after the onset of the flood were invited to par-
Chung et al. 293
TABLE 1. Flood Exposure Characteristics and the Means and Standard Deviations of Posttraumatic Stress, Psychiatric Comorbidity, Cognitive Distortions, and Emotional Suppression Knew someone who died
N
%
67
51.1
Sustained injury
63
48.1
Thought that they were going to die
129
98.5
Being rescued
120
91.6
Worried about another flood
129
98.5
Experienced more than one flood
29
22.1
Mean
SD
Loss of belongings
2.82
0.38
Re-experiencing
13.73
2.32
Avoidance
18.70
3.28
Hyperarousal
13.57
2.40
Somatic problems
25.89
3.08
Anxiety
25.48
3.12
Social dysfunction
24.38
3.50
Depression
21.19
5.77 7.38
Hopelessness
32.94
Helplessness
35.00
6.36
Self-critical
30.67
8.12
Self-blame
30.71
8.02
Preoccupied with danger
32.32
7.52
Suppressing anger
24.35
5.45
Suppressing depression
22.61
4.94
Suppressing anxiety
22.19
5.26
ticipate in the research. They confirmed that they had been affected by the flood. After obtaining informed consent, victims were interviewed using the measures described above. Victims were screened consecutively until we reached the sample size of 130. All victims were willing to be interviewed. Although the questionnaires used were self-report in design, we decided to interview victims due to high rates of illiteracy and the need for the study to be as inclusive as possible. The inclusion criteria were 1) adults (18+) and 2) adults who had been affected by the flood at least 4 weeks prior to the study. Karachi Medical and Dental College granted ethical approval for the study.
Data Analysis Plan Descriptive statistics were used to describe victims’ demographic information, disaster exposure characteristics, and scores on the PDS, GHQ-28, CDS, and CECS. Partial least squares modelling (Smart PLS) was used to examine the hypothesized model (Ringle, Wende, & Will, 2005). PLS has been described in detail in recent PTSD studies (e.g., Carpenter & Chung, 2011; Chung, Walsh, & Dennis, 2011; Hunkin & Chung, 2012). Mediation analyses were carried out using PROCESS (Hayes, 2013). These strategies controlled for the possible influence of covariates in the model, namely, age, education, and major illness.
294
PTSD, Psychiatric Comorbidity, and the 2010 Flood in Pakistan
TABLE 2. Indicators and Constructs Loading
Weight
SE
t
Helplessness
Indicators
0.948
—
0.013
68.30
Hopelessness
0.943
—
0.015
60.93 167.20
Constructs Cognitive distortions
Emotional suppression
PTSD
Psychiatric comorbidity
Preoccupied with danger
0.979
—
0.005
Self-blame
0.961
—
0.010
94.04
Self-critical
0.966
—
0.008
112.16
Anger
0.925
—
0.018
49.62
Depression
0.907
—
0.025
36.17
Anxiety
0.836
—
0.048
17.07
Re-experiencing
0.957
—
0.015
61.50
Avoidance
0.958
—
0.013
72.18
Hyperarousal
0.949
—
0.017
52.87
Somatic problems
0.877
—
0.028
31.20
Anxiety
0.892
—
0.022
40.15
Social dysfunction
0.917
—
0.017
51.81
Depression
0.862
—
0.029
29.22
—
0.598
0.127
9.38
Disaster exposurea
Knowing someone who died Loss of belongings/property
—
0.674
0.100
7.76
Demographic variablesb
Age
—
0.625
0.178
4.78
Education
—
0.562
0.219
3.57
Major illness
—
0.433
0.180
1.91
Items deleted from the model were: who died during the flood, whether they were injured, whether they felt that they were going to die, whether they were rescued, whether they were worried about another flood, and the number of floods that they had experienced in their lifetime. bItems deleted from the model were: gender, marital status, and ethnicity.
a
RESULTS
Regarding flooding exposure characteristics, just over half knew someone who had died during the flood, whether relatives (18%), neighbors (14%), parents (6%), siblings (5%), spouses (3%), or children (3%). Almost half sustained injury, most of whom needed rescuing. Almost all thought that they were going to die and worried about another flood. The victims reported a high mean score for loss of personal belongings or property. Less than one quarter had experienced another flood about 20 years ago (see Table 1). Table 1 also shows the descriptive results for PTSD symptoms, psychiatric comorbidity, cognitive distortions, and emotional suppression. Using the PDS, all
participants met the diagnostic criteria for PTSD. They all scored above the cut-off for psychiatric caseness, which meant a high probability of receiving diagnosis of a general psychiatric disorder. Turning to cognitive distortions, within-subject ANOVA showed that there were significant within-subject effects [Greenhouse-Geisser: F(2.64, 343.21) = 71.51, p < 0.001, η2 = 0.35]. Pairwise comparisons (LSD) showed that all five dysfunction cognitions were significantly different from each other except for self-criticism and self-blame. They reported significantly (p < 0.001 or better) more helplessness than the other dysfunctional cognitions. With regard to emotional suppression, within-subject ANOVA also showed that there were significant within-subject effects [GreenhouseGeisser: F(1.68, 219.53) = 19.85, p < 0.001, η2 = 0.13]. Victims suppressed anger signifi-
0.87
0.86
0.87
0.90
0.56
0.45
0.48
0.73
0.73
0.70
0.71
0.69
0.68
0.74
0.47
0.48
0.27
0.35
0.15
2 Helpless
3 Self-C
4 Self-B
5 Danger
6 Supp-A
7 Supp-D
8 Supp-An
9 Reexper
10 Avoid
11 Arousal
12 Soma
13 Anx
14 SocialD
15 Depress
16 Die
17 Belong
18 Age
19 Edu
20 Illness
0.06
0.26
0.19
0.58
0.48
0.60
0.62
0.66
0.66
0.75
0.73
0.75
0.45
0.44
0.60
0.93
0.85
0.87
1
2
0.04
0.31
0.26
0.46
0.46
0.65
0.64
0.64
0.63
0.67
0.66
0.62
0.50
0.44
0.56
0.93
0.97
1
3
0.06
0.31
0.27
0.47
0.45
0.64
0.62
0.63
0.62
0.65
0.66
0.61
0.49
0.45
0.56
0.92
1
4
0.07
0.29
0.26
0.50
0.46
0.69
0.69
0.71
0.68
0.72
0.71
0.71
0.45
0.43
0.56
1
5
-0.09
0.34
0.17
0.49
0.30
0.45
0.40
0.47
0.43
0.53
0.49
0.56
0.62
0.82
1
6
-0.09
0.35
0.11
0.40
0.18
0.40
0.30
0.32
0.33
0.39
0.37
0.43
0.62
1
7
-0.16
0.37
0.26
0.35
0.23
0.45
0.32
0.36
0.38
0.48
0.47
0.44
1
8
0.04
0.21
0.19
0.60
0.42
0.54
0.58
0.70
0.70
0.86
0.88
1
9
0.07
0.21
0.23
0.50
0.44
0.53
0.57
0.67
0.63
0.86
1
10
0.04
0.23
0.22
0.52
0.38
0.47
0.51
0.65
0.57
1
11
0.12
0.24
0.28
0.48
0.42
0.66
0.72
0.72
1
12
0.11
0.18
0.24
0.45
0.42
0.64
0.79
1
13
0.21
0.18
0.17
0.35
0.51
0.74
1
14
0.23
0.36
0.28
0.33
0.48
1
15
0.13
0.05
0.14
0.23
1
16
0.06
0.09
0.10
1
17
-0.10
0.22
1
18
0.00
1
19
1
20
Hopeless = hopelessness; Helpless = helplessness; Self-C = self-criticism; Self-B = self-blame; Danger = preoccupation with danger; Supp-A = suppressed anger; Supp-D = suppressed depression; Supp-An = suppressed anxiety; Reexper = re-experiencing; Avoid = avoidance; Arousal = hyperarousal; Soma = somatic problems; Anx = anxiety; SocialD = social dysfunction; Depress = depression; Die = thought that they were going to die; Belong = loss of personal belongings or property; Age = age of participants; Edu = education; Illness = past major life illness. All the correlations were significant at either p < 0.01 or 0.05 except: age with Supp-A, Supp-D, Die, and Belong; Edu with Die and Belong. Illness was not significantly correlated with any of the variables except SocialD and Depress.
1
1 Hopeless
1
TABLE 3. Correlation Matrix for the Indicators Used in the Modeling
Chung et al. 295
1
0.62**
0.20*
5 Psych
6 Demo
0.38*
0.78**
0.76**
0.59**
1
2
0.29*
0.49**
0.55**
1
3
0.29*
0.70**
1
4
0.41*
1
5
1
6
—
0.93
0.96
0.91
0.98
—
CR
—
0.91
0.95
0.86
0.97
—
α
—
0.78
0.91
0.79
0.92
—
AVE
—
0.88
0.95
0.89
0.96
—
√AVE
0.37
0.78
0.91
0.79
0.92
0.61
Communality
0.37
0.78
0.91
0.79
0.91
0.61
CV-com
—
0.45
0.48
0.27
0.38
—
Redundancy
—
0.51
0.57
0.25
0.38
—
CV-red
Exposure = disaster exposure characteristics; CD = cognitive distortions; Suppress = emotional suppression; PTSD = posttraumatic stress disorder; Psych = psychiatric comorbidity; Demo = demographic variables; CR = composite reliability; α = Cronbach’s alpha; AVE = average variance extracted; √AVE = square root of average variance extracted (discriminant validity); CV-com = CV-communality; CV-red = CV-redundancy. *p < 0.05. **p < 0.01.
0.48**
0.64**
3 Suppress
4 PTSD
0.64**
2 CD
1Exposure
1
Correlations
TABLE 4. Results of the Correlations Between Constructs, Composite Reliability, Cronbach’s Alpha, Average Variance Extracted, Discriminant Validity, Communality, and Redundancy
296 PTSD, Psychiatric Comorbidity, and the 2010 Flood in Pakistan
Chung et al. 297
FIGURE 2. The Results of the Final PLS Model With Significant Paths at 5% or Better (Dotted Arrows Denote Non-Significant Paths).
cantly (p < 0.001 or better) more than depression and anxiety. Examining the hypothesized model using PLS, disaster exposure characteristics, who died during the flood, whether they were injured, whether they felt that they were going to die, whether they were rescued, whether they were worried about another flood, and the number of floods that they had experienced previously were dropped from the PLS modelling. For demographic variables, gender, marital status, and ethnicity were dropped. The reason for dropping these indicators was that they did not relate to the constructs at the appropriate level of significance (p < 0.05) based on t tests (see Table 2). The correlation matrix for the indicators used in the modelling is shown in Table 3. Table 4 shows the outer model results. The values of composite reliability and Cronbach’s alpha were over the minimum threshold of 0.70, indicating the reliability of these scales. The AVE for all constructs was above 0.50, indicating convergent validity
throughout. There was also evidence for satisfactory discriminant validity in that all the square root of AVE values were greater than the correlations between any of the paired constructs in the model. The inner model results of the path coefficients for relationships between constructs are shown in the final PLS structural model (see Figure 2). Disaster exposure characteristics were significantly correlated with PTSD (B = 0.24, SE = 0.10, t = 2.34, p < 0.05, 95% CI [0.03, 0.44], f2 = 0.09) and psychiatric comorbidity (B = 0.20, SE = 0.09, t = 2.40, p < 0.05, 95% CI [0.03, 0.38], f2 = 0.07), with both effect sizes being small. Disaster exposure characteristics were also significantly associated with cognitive distortions (B = 0.64, SE = 0.07, t = 8.70, p < 0.01, 95% CI [0.50, 0.78], f2 = 0.32), which in turn was also significantly associated with PTSD (B = 0.53, SE = 0.11, t = 4.73, p < 0.01, 95% CI [0.30, 0.75], f2 = 0.34) and psychiatric comorbidity (B = 0.59, SE = 0.11, t = 5.58, p < 0.01, 95% CI [0.37, 0.80], f2 = 0.44). The effect sizes were either large or close to being
298
PTSD, Psychiatric Comorbidity, and the 2010 Flood in Pakistan
TABLE 5. Mediation of the Significant Indirect Effects of Disaster Exposure Variables on PTSD and Psychiatric Comorbidity Through Cognitive Distortions After Controlling for Demographic Variables Total Effect
SE
t
P
Direct Effect
SE
t
Indirect Effect
Boot SE
Ns
4.80
1.04
3.17
7.32
0.00
5.97
1.52
3.39
9.48
0.54
1.10
3.22
P
Boot LL CIa
Boot UL CI
Effects of knowing someone who died on PTSD through cognitive distortions 6.23
1.20
5.18
0.00
1.42
1.02
1.38
Effects of losing belongings/property on PTSD through cognitive distortions 10.67
1.43
7.43
0.00
4.69
1.31
3.57
Effects of knowing someone who died on psychiatric comorbidity through cognitive distortions 2.14
0.54
3.91
0.00
0.17
0.50
0.35
Ns
1.97
Effects of losing belongings/property on psychiatric comorbidity through cognitive distortions 3.68
0.67
5.42
0.00
1.16
0.66
1.76
Ns
2.51
0.74
1.18
4.23
1.10
Ns
2.33
1.03
0.46
4.56
1.10
Ns
3.50
1.57
0.45
6.63
2.71
0.00
3.41
1.57
0.95
7.02
0.77
0.81
3.87
1.25
1.24
6.45
Effects of knowing someone who died on PTSD through hopelessness 6.23
1.20
5.18
0.00
1.08
0.97
Effects of knowing someone who died on PTSD through helplessness 6.23
1.20
5.18
0.00
1.08
0.97
Effects of losing belongings/property on PTSD through hopelessness 10.67
1.43
7.43
0.00
3.66
1.35
Effects of knowing someone who died on psychiatric comorbidity through preoccupation with danger 2.14
0.54
3.91
0.00
0.19
0.48
0.40
Ns
2.05
Effects of losing belongings/property on psychiatric comorbidity through preoccupation with danger 3.68
0.67
5.42
0.00
1.08
0.68
1.58
Ns
3.11
Bias-corrected and accelerated confidence intervals.
a
large. Cognitive distortions were also correlated with emotional suppression (B = 0.59, SE = 0.08, t = 6.64, p < 0.01, 95% CI [0.41, 0.76], f2 = 0.12) with close to a medium effect size which, however, was associated with neither PTSD (B = 0.12, SE = 0.10, t = 1.20, ns) nor psychiatric comorbidity (B = 0.00, SE = 0.09, t = 0.04, ns). Demographic variables were associated significantly with psychiatric comorbidity only (B = 0.14, SE = 0.06, t = 2.25, p < 0.05, 95% CI [0.01, 0.26], f2 = 0.08), with a small effect size. The R2 values for the endogenous variables of cognitive distortions, emotional suppression, psychiatric comorbidity, and PTSD were 0.41, 0.35, 0.65, and 0.63 respectively. These were moderate values, although psychiatric comorbidity and PTSD approached substantial. The average R2 was 0.51.
Blindfolding results (omission distance G = 30 blocks) showed that most of the blocks had high values for the cv-communality index and were over and above zero, indicating a high quality of the measurement model for each block. The average communality was 0.72. On the contrary, all the values for the cv-redundancy index—which measures the quality of the structural model for each endogenous block—were lower, taking into account the measurement model. The average redundancy was 0.42. In addition, the GoF index was 0.60, which indicated an acceptable fit. The PLS results revealed that disaster exposure characteristics influenced PTSD and psychiatric comorbidity directly as well as indirectly through cognitive distortions. To verify mediational relationships,
Chung et al. 299
PROCESS was used (Hayes, 2013). Table 5 shows the total, direct, and indirect effects of disaster exposure characteristics (whether they knew some of the people who died in the flood or the extent of loss of belongings/ property) on PTSD and psychiatric comorbidity through cognitive distortions, after controlling for age, education, and major illness. These were significant positive indirect effects in that knowing some of the people who died in the flood and losing belongings/ property led to greater cognitive distortions, which in turn led to greater severity of PTSD and psychiatric comorbid symptoms. To examine the role of each of the distorted cognitions, there were significant positive indirect effects, in that knowing some of the people who died in the flood led to greater hopelessness and helplessness, which in turn led to greater PTSD severity. Losing belongings/property also led to greater hopelessness, which in turn led to greater PTSD severity. Knowing some of the deceased and losing belongings/property led to greater preoccupation with danger, which in turn led to greater severity of psychiatric comorbidity. DISCUSSION
This study examined the extent of PTSD and psychiatric comorbidity among flood victims in Pakistan and investigated the interrelationship between disaster exposure characteristics, cognitive distortions, emotional suppression, PTSD, and psychiatric comorbidity. In support of hypothesis one, all the participants met the diagnostic criteria for PTSD and scored above the cut-off for psychiatric caseness, indicating a substantial likelihood of receiving a diagnosis of a general psychiatric disorder. In support of hypothesis two, after controlling for demographic variables, disaster exposure characteristics were significantly and positively correlated with PTSD and psychiatric comorbidity. In support of hypothesis three, disaster expo-
sure characteristics were also significantly and positively associated with cognitive distortions, which in turn were significantly and positively associated with PTSD and psychiatric comorbidity. As was predicted in hypothesis four, cognitive distortions were also correlated significantly and positively with emotional suppression which, contrary to our hypothesis, was not associated with PTSD or psychiatric comorbidity. All the victims in this study met the diagnostic criteria for PTSD. This contradicts studies claiming that even with the most devastating disasters, the incidence of PTSD is rarely greater than 50% (McFarlane, 1990). Victims in this study were recruited from medical camps where they voluntarily sought treatment. In other words, these were vulnerable and traumatized individuals who were still affected by the flood at the time of the study. This might explain the high incidence of PTSD. The Conservation of Resources (COR) theory suggests that people have an innate tendency to develop, conserve, and protect the resources important for survival and well-being. These include object resources (shelter), stable resources (relationship with others or stable employment), personal resources (sense of personal efficacy), and energy resources (money). People can experience extreme stress when these important resources are lost or when they are unable to gain resources despite continuous investment into developing them (Hobfoll, Freedy, Green, & Solomon, 1996). Arguably, the victims in the present study were those who had lost resources (i.e., their homes, family/ friends in some cases, their ability to control their current situation, and financial resources). The magnitude of these losses became even greater when they were already poor prior to the flood (Lohano, 2009) and when they were predominately living in a collectivist community. The notion of interdependence was important for these people, and they identified themselves as collectively fo-
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cusing on the goals of the community. They focused on how they fit into the community and in so doing, they gained their sense of identity (Islam, 2004). To a large extent, the flooding destroyed a large part of this collective identity. According to the COR theory, this could result in extreme stress characterized by PTSD and psychiatric comorbidity. Consistent with the literature (Liu et al., 2006; Mason et al., 2010; Waelde et al., 2001), disaster exposure characteristics were related to PTSD and psychiatric comorbidity following the flood. This finding provides further support for the idea that trauma exposure characteristics are important factors for understanding the phenomenology of PTSD (Baker et al., 2005; Keane, Marshall, & Taft, 2006; Neria, Nandi, & Galea, 2008; Parslow, Jorm, & Christensen, 2006). The knowledge of losing someone they knew and the degree of loss in personal belongings or property were related to distress outcomes, which supported the finding of a recent study focusing on earthquake victims (Wang et al., 2011). According to self psychologists, the loss of people they knew and the loss of personal belongings/property constitute external objects which complete the self and are necessary for normal functioning (Kohut, 1971). This idea is likely to be one with which the victims from the aforementioned collectivist culture would agree. Thus, the disappearance of these external objects in their immediate surroundings would likely have a significant impact on their completion of self, which in turn would affect normal functioning, measured in the current study in terms of PTSD and psychiatric comorbidity. Disaster exposure characteristics were found to be associated with cognitive distortions, which in turn were associated with PTSD and psychiatric comorbidity. This is in line with existing literature (e.g., Lau & Kristensen, 2010; Mayou et al., 2002; Ponce et al., 2004). The mediators of hopelessness and helplessness carried the influence of knowing some of the people who died in the
flood and losing belongings or property onto the increased PTSD severity, although helplessness did not mediate the path between losing belongings or property and PTSD. Preoccupation with danger, on the other hand, carried the effect of knowing some of the people who died in the flood and losing belongings or property onto the increased severity of psychiatric comorbidity. This coincides with the postulate that PTSD symptoms can only be meaningfully understood as one takes account of a vulnerable sense of self. Following a traumatic event, people can develop a vulnerable self in which they view themselves as helpless and powerless—unable to protect themselves and others or to prevent negative events from happening to them and be in control. In addition to helplessness and powerlessness, people can also develop low self-esteem and feel that there is no future or hope (Brewin, 2003). According to the results of the current study, this notion of the vulnerable self did not adequately capture the distress of the flood victims. First, in addition to feeling helpless and hopeless, they were also preoccupied with danger. Their sense of danger might well have been exacerbated by the scale of the destruction or loss of life during the disaster. Second, the vulnerable characteristics of the self (i.e., helplessness, hopelessness, preoccupation with danger) brought the effects of trauma exposure characteristics onto specific outcomes. That is, helplessness and hopelessness brought the influence of trauma exposure into the severity of PTSD but not psychiatric comorbidity. Meanwhile, preoccupation with danger did that for psychiatric comorbidity but not PTSD. In other words, these vulnerable characteristics of the self are not generic mediators governing the relationship between trauma exposure and psychiatric outcomes. To put it another way, trauma exposure characteristics following flood could trigger specific vulnerable characteristics of the self, which in turn serve a function to affect specific psychiatric symptoms. In
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other words, it could be the case that there is no one cognitive distortion, as a mediator, which can be considered a “generalized biological vulnerability” for people exposed to flood, or to other traumatic events for that matter. As hypothesized, distorted cognitions were correlated with emotional suppression. This supported the postulate that cognitive distortions following a traumatic event led to the arousal of emotional distress that victims had to control or suppress. Unexpectedly however, emotional suppression was not significantly associated with PTSD and psychiatric comorbidity. This contradicted literature suggesting a strong link between emotional suppression and psychiatric symptoms (e.g., Amstadter & Vernon, 2008; Gross & John, 2003; Kashdan et al., 2009; Roemer, Litz, Orsillo, & Wagner, 2001; Tull et al., 2004; Znoj & Lude, 2002). In looking at this unexpected result, one could question whether it was due in part to how soon after the event emotional suppression was measured. Studies have argued that emotional suppression could be maladaptive over time (Classen, Koopman, Angell, & Spiegel, 1996; Gross & John, 2002; Gross & Levenson, 1997; John & Gross, 2004). It is not clear, however, how long this “over time” period needs to be. Since we only measured emotional suppression one month after the event, it might be that it was too soon for the negative effects of emotional suppression to start having any significant impact on distress outcomes. Had emotional suppression been measured again, the results might have been different. Also, it is possible that at the time of the interview, victims were trying to detach themselves from the devastating situation, trying not to react to the event with strong emotion in order to reduce stress and the intensity of PTSD symptoms (Mason et al., 2010; Strelau & Zawadzki, 2005). If that
is the case, according to the associative network model, they were in fact trying not to activate the emotion associated with the memory of the distressing event. In so doing, they were not activating the memory network and therefore the related re-experiencing and hyperarousal symptoms (Bower, 1981, 1987). There were limitations to the study that need to be mentioned. First, the questionnaires we used were designed as self-report questionnaires. However, we interviewed the victims using the questionnaires. The reasons for doing so were explained in the procedure section. Second, the sample might have been biased. As mentioned earlier, the whole sample met the diagnostic criteria for PTSD, which meant that we were investigating a group of highly traumatized individuals. In addition, there was a lack of socioeconomic diversity in the sample. All the participants came from a low-income background, and a large proportion was uneducated. Third, we did not collect information on previous traumatic life events and consequently were unable to control for the effects of cumulative traumas. Given that 1% to 12% of people in the general population have had PTSD at some point during their lives (Norris & Slone, 2007), this may have exacerbated the impact of their PTSD following flood. To conclude, following the 2010 flood in Pakistan, all victims recruited for the study had developed PTSD and psychiatric comorbid symptoms. The severity of these symptoms was influenced by victims’ subjective experiences of the flood, particularly knowing some of the people who died and losing personal belongings or property. Their subjective experience could have allowed dysfunctional thinking patterns to develop which in turn affected their psychiatric symptoms.
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Posttraumatic Stress Disorder and Psychiatric Comorbidity Following the 2010 Flood in Pakistan: Exposure Characteristics, Cognitive Distortions, and Emotional Suppression Man Cheung Chung, Sabeena Jalal, and Najib Ullah Khan This study investigated the extent of posttraumatic stress disorder (PTSD) and psychiatric comorbidity among the 2010 flood victims in Pakistan and its relationship with disaster exposure characteristics, cognitive distortions, and emotional suppression. One hundred and thirty-one (F = 89, M = 42) flood victims were assessed using the Posttraumatic Diagnostic Scale, the General Health Questionnaire-28, the Cognitive Distortion Scales, and the Courtauld Emotional Control Scale. The results showed that all victims met the diagnostic criteria for PTSD and scored above the cut-off for psychiatric caseness. Partial least squares modelling showed that disaster exposure characteristics were significantly correlated with PTSD and psychiatric comorbidity. Disaster exposure characteristics were also significantly associated with cognitive distortions which in turn were also significantly associated with PTSD and psychiatric comorbidity. Cognitive distortions were also correlated with emotional suppression which, however, was not associated with PTSD or psychiatric comorbidity. To conclude, the flood victims reported PTSD and psychiatric comorbid symptoms which were related to their subjective exposure to the flood. Such exposure led to the development of dysfunctional thinking patterns which in turn influenced distress symptoms. In 2010, flooding killed approximately 2,000 people and caused injury to over 3,000 in Pakistan. Over 20 million people were affected in different provinces (Congressional Research Service, 2010; United Nations Office, 2010). Following flooding, PTSD ranging from 5 to 71% (e.g., Li et al., 2010; Liu et al., 2006; Mason, Andrews, & Upton, 2010; North, Kawasaki, Spitznagel, & Hong, 2004) can develop alongside
depression, anxiety, and somatization (e.g., Mason et al., 2010; North et al., 2004). Risk factors for PTSD following flood include demographic variables (gender and age) (Liu et al., 2006; Norris, Kaniasty, Conrad, Inman, & Murphy, 2002), disaster exposure characteristics such as flood type (Liu et al., 2006), losses sustained (Waelde, Koopman, Rierdan, & Spiegel, 2001), and vacating of home during the flood (Mason et al., 2010).
Man Cheung Chung, Ph.D., is affiliated with the Department of Natural Science and Public Health at Zayed University in Abu Dhabi, United Arab Emirates. Sabeena Jalal, Ph.D., is affiliated with Dow University of Health Sciences, Karachi, Pakistan. Najib Ullah Khan, Ph.D., is affiliated with Abbasi Shaheed Hospital, Karachi, Pakistan. Address correspondence to Professor M. C. Chung, Zayed University, Department of Natural Science and Public Health, P.O. Box 144534, Abu Dhabi, United Arab Emirates. E-mail: [email protected] © 2014 Washington School of Psychiatry
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It is unclear whether cognitive distortions following flooding could act as another risk factor for PTSD and psychiatric comorbid outcomes (Owens & Chard, 2006). A cognitive model of PTSD (Ehlers & Clark, 2000) suggests that trauma characteristics can influence the way people process their trauma and its consequences. They can develop cognitive distortions by creating negative appraisals of it (external threat: viewing the world as a dangerous place; or internal threat: viewing themselves as incapable) which, in turn, trigger a sense of current threat accompanied by PTSD and comorbid psychiatric responses. In other words, the relationship between trauma characteristics, PTSD symptoms, and psychiatric comorbidities is mediated by negative appraisals. In the context of the aftermath of a devastating flood, victims could view the world as a dangerous place or view themselves as incapable of dealing with or controlling it. Cognitive distortions resulting from a devastating flood ultimately involve drastic changes in the schema with which victims perceive themselves and interpret external reality (Horowitz, 1986). People need to adapt to the schematic changes occurring within them, incorporating traumatic information into existing schemas. Such incongruity causes a great deal of emotional distress which is exacerbated by feelings of powerlessness. To prevent emotional exhaustion, people try to inhibit the flow of traumatic information to a tolerable level (Ihilevich & Gleser, 1993; McDougall, 1985; Thome, 1990). They try to control or suppress distressing emotions as a defense mechanism and inhibit emotional expressive behavior (Gross, 1998). However, in so doing, distressing emotions remain unresolved (Myers, Vetere, & Derakshan, 2004), leading to negative effects and PTSD symptoms (Amir et al., 1997). This is why emotional suppression and avoidance coping (i.e., avoiding processing emotions) (Gross & John, 2003) have been associated with increased psychiatric symptoms (Amstadter & Vernon, 2008),
including depression, anxiety, somatization (Tull, Gratz, Salters, & Roemer, 2004; Tull, Jakupcak, Paulson, & Gratz, 2007; Znoj & Lude, 2002), and poor quality of life (Kashdan, Morina, & Priebe, 2009) among trauma victims. This theoretical framework might set the backdrop for the distorted cognitions associated with PTSD following traumas, including child abuse (e.g., Ponce, Williams, & Allen, 2004; Lau & Kristensen, 2010), motor vehicle accident (e.g., Mayou, Ehlers, & Bryant, 2002) and hate-crime victimization (e.g., Herek, Gillis, & Cogan, 1999). Cognitive distortions are characterized by self-blame, helplessness, and hopelessness, alongside an over-estimation of the degree of danger in the world (Briere & Spinazzola, 2005; Owens & Chard, 2006). The foregoing passages indicate an integrated model outlining the interrelationship between cognitive distortions, emotional suppression, PTSD, and psychiatric comorbidity. This model sets the basis for the current study of flood victims in Pakistan. In such a study, it is important to consider the effects of disaster exposure characteristics and demographic variables, since the literature indicates an association with distress outcomes (Liu et al., 2006; Mason et al., 2010; Norris et al., 2002). The purpose of the study was to examine 1) the extent of PTSD and psychiatric comorbidity among flood victims in Pakistan and 2) the interrelationship between disaster exposure characteristics, cognitive distortions, emotional suppression, PTSD, and psychiatric comorbidity after controlling for demographic variables. Based on the literature presented, the hypotheses were: 1. There would be a high percentage of flood victims meeting the diagnostic criteria for PTSD and displaying psychiatric comorbid symptoms. 2. Controlling for demographic variables and disaster exposure characteristics would be positively associated with
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FIGURE 1. The Hypothesized Path Model Describing the Interrelationships Between Disaster Exposure Characteristics, Cognitive Distortions, Emotional Suppression, PTSD, and Psychiatric Comorbidity After Controlling for Demographic Variables.
PTSD and psychiatric comorbidity following flooding. 3. Disaster exposure characteristics would positively associate with cognitive distortions which would positively associate with PTSD and psychiatric comorbidity. 4. Cognitive distortions would be positively associated with emotional suppression which in turn would be positively associated with PTSD and psychiatric comorbidity. Figure 1 depicts the hypothesized model. METHODS
the study would generate a power of 0.95 (critical F = 2.01). This was selected as the medium effect size (f2 = 0.19) sufficient to detect a clinical or substantively significant effect. One hundred and thirty-one flood victims (F = 89, M = 42) participated in the study. They were on average 32 years of age (M = 32.32, SD = 12.31), ranging from 18 to 80. Many (78%) were married and some widowed (17%), separated/divorced (3%), or single (2%). Most were Sindhi (90%). All were in the low income category defined according to occupation. The majority had received no education (82%) and had had no major or life-threatening illnesses (92%). None reported that they had received a diagnosis of cognitive impairment. Measures
Participants Power calculation showed that with a sample size of 128 and an alpha set at 0.05,
Demographic information recorded data on gender, age, marital status, ethnicity, income level, educational level, and whether
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participants had previously been diagnosed as suffering from major life illnesses or cognitive impairment. Disaster exposure characteristics were measured separately in the form of questions on single items such as whether (0 = no, 1 = yes) they knew anyone who died in the flood and if so, who; injury sustained during the flood; whether they felt that they were going to die; and whether they were rescued and worry about further flooding. Participants were also asked to indicate the extent of loss of personal belongings, including own home (0 = not at all, 1 = a little bit, 2 = a lot, 3 = all of it) and the number of floods experienced in their lifetime. These questions were adopted from questionnaires used in previous disaster studies and adapted for the current study (e.g., Chung, Werrett, Farmer, Easthope, & Chung, 2000; Freh, Chung & Dallos, 2013). The Posttraumatic Stress Diagnostic Scale (PDS) (Foa, Cashman, Jaycox, & Perry, 1997) was used to measure PTSD symptoms following flooding. Along with a diagnosis of PTSD, the PDS also generates three symptom clusters based on the DSM-IV criteria: re-experiencing, avoidance, and hyperarousal. The reliability of the PDS scale was high (re-experience, a = 0.78; avoidance, a = 0.84; hyperarousal, a = 0.84). Based on the current sample, the reliability of PDS was also high (re-experiencing, a = 0.97, avoidance, a = 0.91, hyperarousal, a = 0.93). The General Health Questionnaire-28 (GHQ-28) (Goldberg & Hillier, 1979) estimates the likelihood of participants being diagnosed as suffering from general psychiatric morbidity at interview. The questions are scored using the scoring method of 0-0-1-1. As the total GHQ score exceeds the recommended cut-off point of 4, the probability of diagnosis increases. Analysis of the mean scores of the GHQ-28 was based on the rating scale of 1-2-3-4. The questionnaire yields four subscales: somatic problems, anxiety, social dysfunction, and depression. On the basis of the above cut-off, the GHQ-28 has shown a sensitivity value of 88% at a speci-
ficity of 84.2% and an overall misclassification rate of 14.5%. Reliability coefficients ranged from 0.78 to 0.95 (Goldberg & Bridges, 1987). Based on the current sample, the reliability of the four subscales was high (somatic problems, a = 0.94; anxiety, a = 0.92; social dysfunction, a = 0.95; depression, a = 0.94). Cognitive Distortion Scales (CDS) (Briere, 2000) is a 40-item test assessing dysfunctional cognitions characterized by selfcriticism, helplessness, hopelessness, selfblame, and preoccupation with danger using a 5-point scale ranging from 1 = never to 5 = very often. The reliability of the scale was high (self-criticism, a = 0.93; self-blame, a = 0.92; helplessness, a = 0.94; hopelessness, a = 0.97; preoccupation with danger, a = 0.89), as it was in our sample (self-criticism, a = 0.94; self-blame, a = 0.93; helplessness, a = 0.93; hopelessness, a = 0.92; preoccupation with danger, a = 0.94). The Courtauld Emotional Control Scale (CECS) (Watson & Greer 1983) is a 21-item questionnaire measuring the impact of suppressing anger, depression, and anxiety. Victims were asked to rate how often they suppressed these emotions, from almost never = 1 to almost always = 4. CECS obtained good test-retest reliability (anger = 0.60; depression = 0.90; anxiety = 0.84), good internal consistency for each subscale and concurrent validity, as was reflected in the present study (anger: α = 0.88; depression: α = 0.90; anxiety: α = 0.82). Procedure The flood victims were recruited from medical camps arranged by the Khidmat-eKhalq Foundation Medical Aid Committee in Pakistan. These camps were set up immediately after the flood specifically for providing medical treatment, first aid, and general support to victims. Victims who came to the camps for help approximately one month after the onset of the flood were invited to par-
Chung et al. 293
TABLE 1. Flood Exposure Characteristics and the Means and Standard Deviations of Posttraumatic Stress, Psychiatric Comorbidity, Cognitive Distortions, and Emotional Suppression Knew someone who died
N
%
67
51.1
Sustained injury
63
48.1
Thought that they were going to die
129
98.5
Being rescued
120
91.6
Worried about another flood
129
98.5
Experienced more than one flood
29
22.1
Mean
SD
Loss of belongings
2.82
0.38
Re-experiencing
13.73
2.32
Avoidance
18.70
3.28
Hyperarousal
13.57
2.40
Somatic problems
25.89
3.08
Anxiety
25.48
3.12
Social dysfunction
24.38
3.50
Depression
21.19
5.77 7.38
Hopelessness
32.94
Helplessness
35.00
6.36
Self-critical
30.67
8.12
Self-blame
30.71
8.02
Preoccupied with danger
32.32
7.52
Suppressing anger
24.35
5.45
Suppressing depression
22.61
4.94
Suppressing anxiety
22.19
5.26
ticipate in the research. They confirmed that they had been affected by the flood. After obtaining informed consent, victims were interviewed using the measures described above. Victims were screened consecutively until we reached the sample size of 130. All victims were willing to be interviewed. Although the questionnaires used were self-report in design, we decided to interview victims due to high rates of illiteracy and the need for the study to be as inclusive as possible. The inclusion criteria were 1) adults (18+) and 2) adults who had been affected by the flood at least 4 weeks prior to the study. Karachi Medical and Dental College granted ethical approval for the study.
Data Analysis Plan Descriptive statistics were used to describe victims’ demographic information, disaster exposure characteristics, and scores on the PDS, GHQ-28, CDS, and CECS. Partial least squares modelling (Smart PLS) was used to examine the hypothesized model (Ringle, Wende, & Will, 2005). PLS has been described in detail in recent PTSD studies (e.g., Carpenter & Chung, 2011; Chung, Walsh, & Dennis, 2011; Hunkin & Chung, 2012). Mediation analyses were carried out using PROCESS (Hayes, 2013). These strategies controlled for the possible influence of covariates in the model, namely, age, education, and major illness.
294
PTSD, Psychiatric Comorbidity, and the 2010 Flood in Pakistan
TABLE 2. Indicators and Constructs Loading
Weight
SE
t
Helplessness
Indicators
0.948
—
0.013
68.30
Hopelessness
0.943
—
0.015
60.93 167.20
Constructs Cognitive distortions
Emotional suppression
PTSD
Psychiatric comorbidity
Preoccupied with danger
0.979
—
0.005
Self-blame
0.961
—
0.010
94.04
Self-critical
0.966
—
0.008
112.16
Anger
0.925
—
0.018
49.62
Depression
0.907
—
0.025
36.17
Anxiety
0.836
—
0.048
17.07
Re-experiencing
0.957
—
0.015
61.50
Avoidance
0.958
—
0.013
72.18
Hyperarousal
0.949
—
0.017
52.87
Somatic problems
0.877
—
0.028
31.20
Anxiety
0.892
—
0.022
40.15
Social dysfunction
0.917
—
0.017
51.81
Depression
0.862
—
0.029
29.22
—
0.598
0.127
9.38
Disaster exposurea
Knowing someone who died Loss of belongings/property
—
0.674
0.100
7.76
Demographic variablesb
Age
—
0.625
0.178
4.78
Education
—
0.562
0.219
3.57
Major illness
—
0.433
0.180
1.91
Items deleted from the model were: who died during the flood, whether they were injured, whether they felt that they were going to die, whether they were rescued, whether they were worried about another flood, and the number of floods that they had experienced in their lifetime. bItems deleted from the model were: gender, marital status, and ethnicity.
a
RESULTS
Regarding flooding exposure characteristics, just over half knew someone who had died during the flood, whether relatives (18%), neighbors (14%), parents (6%), siblings (5%), spouses (3%), or children (3%). Almost half sustained injury, most of whom needed rescuing. Almost all thought that they were going to die and worried about another flood. The victims reported a high mean score for loss of personal belongings or property. Less than one quarter had experienced another flood about 20 years ago (see Table 1). Table 1 also shows the descriptive results for PTSD symptoms, psychiatric comorbidity, cognitive distortions, and emotional suppression. Using the PDS, all
participants met the diagnostic criteria for PTSD. They all scored above the cut-off for psychiatric caseness, which meant a high probability of receiving diagnosis of a general psychiatric disorder. Turning to cognitive distortions, within-subject ANOVA showed that there were significant within-subject effects [Greenhouse-Geisser: F(2.64, 343.21) = 71.51, p < 0.001, η2 = 0.35]. Pairwise comparisons (LSD) showed that all five dysfunction cognitions were significantly different from each other except for self-criticism and self-blame. They reported significantly (p < 0.001 or better) more helplessness than the other dysfunctional cognitions. With regard to emotional suppression, within-subject ANOVA also showed that there were significant within-subject effects [GreenhouseGeisser: F(1.68, 219.53) = 19.85, p < 0.001, η2 = 0.13]. Victims suppressed anger signifi-
0.87
0.86
0.87
0.90
0.56
0.45
0.48
0.73
0.73
0.70
0.71
0.69
0.68
0.74
0.47
0.48
0.27
0.35
0.15
2 Helpless
3 Self-C
4 Self-B
5 Danger
6 Supp-A
7 Supp-D
8 Supp-An
9 Reexper
10 Avoid
11 Arousal
12 Soma
13 Anx
14 SocialD
15 Depress
16 Die
17 Belong
18 Age
19 Edu
20 Illness
0.06
0.26
0.19
0.58
0.48
0.60
0.62
0.66
0.66
0.75
0.73
0.75
0.45
0.44
0.60
0.93
0.85
0.87
1
2
0.04
0.31
0.26
0.46
0.46
0.65
0.64
0.64
0.63
0.67
0.66
0.62
0.50
0.44
0.56
0.93
0.97
1
3
0.06
0.31
0.27
0.47
0.45
0.64
0.62
0.63
0.62
0.65
0.66
0.61
0.49
0.45
0.56
0.92
1
4
0.07
0.29
0.26
0.50
0.46
0.69
0.69
0.71
0.68
0.72
0.71
0.71
0.45
0.43
0.56
1
5
-0.09
0.34
0.17
0.49
0.30
0.45
0.40
0.47
0.43
0.53
0.49
0.56
0.62
0.82
1
6
-0.09
0.35
0.11
0.40
0.18
0.40
0.30
0.32
0.33
0.39
0.37
0.43
0.62
1
7
-0.16
0.37
0.26
0.35
0.23
0.45
0.32
0.36
0.38
0.48
0.47
0.44
1
8
0.04
0.21
0.19
0.60
0.42
0.54
0.58
0.70
0.70
0.86
0.88
1
9
0.07
0.21
0.23
0.50
0.44
0.53
0.57
0.67
0.63
0.86
1
10
0.04
0.23
0.22
0.52
0.38
0.47
0.51
0.65
0.57
1
11
0.12
0.24
0.28
0.48
0.42
0.66
0.72
0.72
1
12
0.11
0.18
0.24
0.45
0.42
0.64
0.79
1
13
0.21
0.18
0.17
0.35
0.51
0.74
1
14
0.23
0.36
0.28
0.33
0.48
1
15
0.13
0.05
0.14
0.23
1
16
0.06
0.09
0.10
1
17
-0.10
0.22
1
18
0.00
1
19
1
20
Hopeless = hopelessness; Helpless = helplessness; Self-C = self-criticism; Self-B = self-blame; Danger = preoccupation with danger; Supp-A = suppressed anger; Supp-D = suppressed depression; Supp-An = suppressed anxiety; Reexper = re-experiencing; Avoid = avoidance; Arousal = hyperarousal; Soma = somatic problems; Anx = anxiety; SocialD = social dysfunction; Depress = depression; Die = thought that they were going to die; Belong = loss of personal belongings or property; Age = age of participants; Edu = education; Illness = past major life illness. All the correlations were significant at either p < 0.01 or 0.05 except: age with Supp-A, Supp-D, Die, and Belong; Edu with Die and Belong. Illness was not significantly correlated with any of the variables except SocialD and Depress.
1
1 Hopeless
1
TABLE 3. Correlation Matrix for the Indicators Used in the Modeling
Chung et al. 295
1
0.62**
0.20*
5 Psych
6 Demo
0.38*
0.78**
0.76**
0.59**
1
2
0.29*
0.49**
0.55**
1
3
0.29*
0.70**
1
4
0.41*
1
5
1
6
—
0.93
0.96
0.91
0.98
—
CR
—
0.91
0.95
0.86
0.97
—
α
—
0.78
0.91
0.79
0.92
—
AVE
—
0.88
0.95
0.89
0.96
—
√AVE
0.37
0.78
0.91
0.79
0.92
0.61
Communality
0.37
0.78
0.91
0.79
0.91
0.61
CV-com
—
0.45
0.48
0.27
0.38
—
Redundancy
—
0.51
0.57
0.25
0.38
—
CV-red
Exposure = disaster exposure characteristics; CD = cognitive distortions; Suppress = emotional suppression; PTSD = posttraumatic stress disorder; Psych = psychiatric comorbidity; Demo = demographic variables; CR = composite reliability; α = Cronbach’s alpha; AVE = average variance extracted; √AVE = square root of average variance extracted (discriminant validity); CV-com = CV-communality; CV-red = CV-redundancy. *p < 0.05. **p < 0.01.
0.48**
0.64**
3 Suppress
4 PTSD
0.64**
2 CD
1Exposure
1
Correlations
TABLE 4. Results of the Correlations Between Constructs, Composite Reliability, Cronbach’s Alpha, Average Variance Extracted, Discriminant Validity, Communality, and Redundancy
296 PTSD, Psychiatric Comorbidity, and the 2010 Flood in Pakistan
Chung et al. 297
FIGURE 2. The Results of the Final PLS Model With Significant Paths at 5% or Better (Dotted Arrows Denote Non-Significant Paths).
cantly (p < 0.001 or better) more than depression and anxiety. Examining the hypothesized model using PLS, disaster exposure characteristics, who died during the flood, whether they were injured, whether they felt that they were going to die, whether they were rescued, whether they were worried about another flood, and the number of floods that they had experienced previously were dropped from the PLS modelling. For demographic variables, gender, marital status, and ethnicity were dropped. The reason for dropping these indicators was that they did not relate to the constructs at the appropriate level of significance (p < 0.05) based on t tests (see Table 2). The correlation matrix for the indicators used in the modelling is shown in Table 3. Table 4 shows the outer model results. The values of composite reliability and Cronbach’s alpha were over the minimum threshold of 0.70, indicating the reliability of these scales. The AVE for all constructs was above 0.50, indicating convergent validity
throughout. There was also evidence for satisfactory discriminant validity in that all the square root of AVE values were greater than the correlations between any of the paired constructs in the model. The inner model results of the path coefficients for relationships between constructs are shown in the final PLS structural model (see Figure 2). Disaster exposure characteristics were significantly correlated with PTSD (B = 0.24, SE = 0.10, t = 2.34, p < 0.05, 95% CI [0.03, 0.44], f2 = 0.09) and psychiatric comorbidity (B = 0.20, SE = 0.09, t = 2.40, p < 0.05, 95% CI [0.03, 0.38], f2 = 0.07), with both effect sizes being small. Disaster exposure characteristics were also significantly associated with cognitive distortions (B = 0.64, SE = 0.07, t = 8.70, p < 0.01, 95% CI [0.50, 0.78], f2 = 0.32), which in turn was also significantly associated with PTSD (B = 0.53, SE = 0.11, t = 4.73, p < 0.01, 95% CI [0.30, 0.75], f2 = 0.34) and psychiatric comorbidity (B = 0.59, SE = 0.11, t = 5.58, p < 0.01, 95% CI [0.37, 0.80], f2 = 0.44). The effect sizes were either large or close to being
298
PTSD, Psychiatric Comorbidity, and the 2010 Flood in Pakistan
TABLE 5. Mediation of the Significant Indirect Effects of Disaster Exposure Variables on PTSD and Psychiatric Comorbidity Through Cognitive Distortions After Controlling for Demographic Variables Total Effect
SE
t
P
Direct Effect
SE
t
Indirect Effect
Boot SE
Ns
4.80
1.04
3.17
7.32
0.00
5.97
1.52
3.39
9.48
0.54
1.10
3.22
P
Boot LL CIa
Boot UL CI
Effects of knowing someone who died on PTSD through cognitive distortions 6.23
1.20
5.18
0.00
1.42
1.02
1.38
Effects of losing belongings/property on PTSD through cognitive distortions 10.67
1.43
7.43
0.00
4.69
1.31
3.57
Effects of knowing someone who died on psychiatric comorbidity through cognitive distortions 2.14
0.54
3.91
0.00
0.17
0.50
0.35
Ns
1.97
Effects of losing belongings/property on psychiatric comorbidity through cognitive distortions 3.68
0.67
5.42
0.00
1.16
0.66
1.76
Ns
2.51
0.74
1.18
4.23
1.10
Ns
2.33
1.03
0.46
4.56
1.10
Ns
3.50
1.57
0.45
6.63
2.71
0.00
3.41
1.57
0.95
7.02
0.77
0.81
3.87
1.25
1.24
6.45
Effects of knowing someone who died on PTSD through hopelessness 6.23
1.20
5.18
0.00
1.08
0.97
Effects of knowing someone who died on PTSD through helplessness 6.23
1.20
5.18
0.00
1.08
0.97
Effects of losing belongings/property on PTSD through hopelessness 10.67
1.43
7.43
0.00
3.66
1.35
Effects of knowing someone who died on psychiatric comorbidity through preoccupation with danger 2.14
0.54
3.91
0.00
0.19
0.48
0.40
Ns
2.05
Effects of losing belongings/property on psychiatric comorbidity through preoccupation with danger 3.68
0.67
5.42
0.00
1.08
0.68
1.58
Ns
3.11
Bias-corrected and accelerated confidence intervals.
a
large. Cognitive distortions were also correlated with emotional suppression (B = 0.59, SE = 0.08, t = 6.64, p < 0.01, 95% CI [0.41, 0.76], f2 = 0.12) with close to a medium effect size which, however, was associated with neither PTSD (B = 0.12, SE = 0.10, t = 1.20, ns) nor psychiatric comorbidity (B = 0.00, SE = 0.09, t = 0.04, ns). Demographic variables were associated significantly with psychiatric comorbidity only (B = 0.14, SE = 0.06, t = 2.25, p < 0.05, 95% CI [0.01, 0.26], f2 = 0.08), with a small effect size. The R2 values for the endogenous variables of cognitive distortions, emotional suppression, psychiatric comorbidity, and PTSD were 0.41, 0.35, 0.65, and 0.63 respectively. These were moderate values, although psychiatric comorbidity and PTSD approached substantial. The average R2 was 0.51.
Blindfolding results (omission distance G = 30 blocks) showed that most of the blocks had high values for the cv-communality index and were over and above zero, indicating a high quality of the measurement model for each block. The average communality was 0.72. On the contrary, all the values for the cv-redundancy index—which measures the quality of the structural model for each endogenous block—were lower, taking into account the measurement model. The average redundancy was 0.42. In addition, the GoF index was 0.60, which indicated an acceptable fit. The PLS results revealed that disaster exposure characteristics influenced PTSD and psychiatric comorbidity directly as well as indirectly through cognitive distortions. To verify mediational relationships,
Chung et al. 299
PROCESS was used (Hayes, 2013). Table 5 shows the total, direct, and indirect effects of disaster exposure characteristics (whether they knew some of the people who died in the flood or the extent of loss of belongings/ property) on PTSD and psychiatric comorbidity through cognitive distortions, after controlling for age, education, and major illness. These were significant positive indirect effects in that knowing some of the people who died in the flood and losing belongings/ property led to greater cognitive distortions, which in turn led to greater severity of PTSD and psychiatric comorbid symptoms. To examine the role of each of the distorted cognitions, there were significant positive indirect effects, in that knowing some of the people who died in the flood led to greater hopelessness and helplessness, which in turn led to greater PTSD severity. Losing belongings/property also led to greater hopelessness, which in turn led to greater PTSD severity. Knowing some of the deceased and losing belongings/property led to greater preoccupation with danger, which in turn led to greater severity of psychiatric comorbidity. DISCUSSION
This study examined the extent of PTSD and psychiatric comorbidity among flood victims in Pakistan and investigated the interrelationship between disaster exposure characteristics, cognitive distortions, emotional suppression, PTSD, and psychiatric comorbidity. In support of hypothesis one, all the participants met the diagnostic criteria for PTSD and scored above the cut-off for psychiatric caseness, indicating a substantial likelihood of receiving a diagnosis of a general psychiatric disorder. In support of hypothesis two, after controlling for demographic variables, disaster exposure characteristics were significantly and positively correlated with PTSD and psychiatric comorbidity. In support of hypothesis three, disaster expo-
sure characteristics were also significantly and positively associated with cognitive distortions, which in turn were significantly and positively associated with PTSD and psychiatric comorbidity. As was predicted in hypothesis four, cognitive distortions were also correlated significantly and positively with emotional suppression which, contrary to our hypothesis, was not associated with PTSD or psychiatric comorbidity. All the victims in this study met the diagnostic criteria for PTSD. This contradicts studies claiming that even with the most devastating disasters, the incidence of PTSD is rarely greater than 50% (McFarlane, 1990). Victims in this study were recruited from medical camps where they voluntarily sought treatment. In other words, these were vulnerable and traumatized individuals who were still affected by the flood at the time of the study. This might explain the high incidence of PTSD. The Conservation of Resources (COR) theory suggests that people have an innate tendency to develop, conserve, and protect the resources important for survival and well-being. These include object resources (shelter), stable resources (relationship with others or stable employment), personal resources (sense of personal efficacy), and energy resources (money). People can experience extreme stress when these important resources are lost or when they are unable to gain resources despite continuous investment into developing them (Hobfoll, Freedy, Green, & Solomon, 1996). Arguably, the victims in the present study were those who had lost resources (i.e., their homes, family/ friends in some cases, their ability to control their current situation, and financial resources). The magnitude of these losses became even greater when they were already poor prior to the flood (Lohano, 2009) and when they were predominately living in a collectivist community. The notion of interdependence was important for these people, and they identified themselves as collectively fo-
300
PTSD, Psychiatric Comorbidity, and the 2010 Flood in Pakistan
cusing on the goals of the community. They focused on how they fit into the community and in so doing, they gained their sense of identity (Islam, 2004). To a large extent, the flooding destroyed a large part of this collective identity. According to the COR theory, this could result in extreme stress characterized by PTSD and psychiatric comorbidity. Consistent with the literature (Liu et al., 2006; Mason et al., 2010; Waelde et al., 2001), disaster exposure characteristics were related to PTSD and psychiatric comorbidity following the flood. This finding provides further support for the idea that trauma exposure characteristics are important factors for understanding the phenomenology of PTSD (Baker et al., 2005; Keane, Marshall, & Taft, 2006; Neria, Nandi, & Galea, 2008; Parslow, Jorm, & Christensen, 2006). The knowledge of losing someone they knew and the degree of loss in personal belongings or property were related to distress outcomes, which supported the finding of a recent study focusing on earthquake victims (Wang et al., 2011). According to self psychologists, the loss of people they knew and the loss of personal belongings/property constitute external objects which complete the self and are necessary for normal functioning (Kohut, 1971). This idea is likely to be one with which the victims from the aforementioned collectivist culture would agree. Thus, the disappearance of these external objects in their immediate surroundings would likely have a significant impact on their completion of self, which in turn would affect normal functioning, measured in the current study in terms of PTSD and psychiatric comorbidity. Disaster exposure characteristics were found to be associated with cognitive distortions, which in turn were associated with PTSD and psychiatric comorbidity. This is in line with existing literature (e.g., Lau & Kristensen, 2010; Mayou et al., 2002; Ponce et al., 2004). The mediators of hopelessness and helplessness carried the influence of knowing some of the people who died in the
flood and losing belongings or property onto the increased PTSD severity, although helplessness did not mediate the path between losing belongings or property and PTSD. Preoccupation with danger, on the other hand, carried the effect of knowing some of the people who died in the flood and losing belongings or property onto the increased severity of psychiatric comorbidity. This coincides with the postulate that PTSD symptoms can only be meaningfully understood as one takes account of a vulnerable sense of self. Following a traumatic event, people can develop a vulnerable self in which they view themselves as helpless and powerless—unable to protect themselves and others or to prevent negative events from happening to them and be in control. In addition to helplessness and powerlessness, people can also develop low self-esteem and feel that there is no future or hope (Brewin, 2003). According to the results of the current study, this notion of the vulnerable self did not adequately capture the distress of the flood victims. First, in addition to feeling helpless and hopeless, they were also preoccupied with danger. Their sense of danger might well have been exacerbated by the scale of the destruction or loss of life during the disaster. Second, the vulnerable characteristics of the self (i.e., helplessness, hopelessness, preoccupation with danger) brought the effects of trauma exposure characteristics onto specific outcomes. That is, helplessness and hopelessness brought the influence of trauma exposure into the severity of PTSD but not psychiatric comorbidity. Meanwhile, preoccupation with danger did that for psychiatric comorbidity but not PTSD. In other words, these vulnerable characteristics of the self are not generic mediators governing the relationship between trauma exposure and psychiatric outcomes. To put it another way, trauma exposure characteristics following flood could trigger specific vulnerable characteristics of the self, which in turn serve a function to affect specific psychiatric symptoms. In
Chung et al. 301
other words, it could be the case that there is no one cognitive distortion, as a mediator, which can be considered a “generalized biological vulnerability” for people exposed to flood, or to other traumatic events for that matter. As hypothesized, distorted cognitions were correlated with emotional suppression. This supported the postulate that cognitive distortions following a traumatic event led to the arousal of emotional distress that victims had to control or suppress. Unexpectedly however, emotional suppression was not significantly associated with PTSD and psychiatric comorbidity. This contradicted literature suggesting a strong link between emotional suppression and psychiatric symptoms (e.g., Amstadter & Vernon, 2008; Gross & John, 2003; Kashdan et al., 2009; Roemer, Litz, Orsillo, & Wagner, 2001; Tull et al., 2004; Znoj & Lude, 2002). In looking at this unexpected result, one could question whether it was due in part to how soon after the event emotional suppression was measured. Studies have argued that emotional suppression could be maladaptive over time (Classen, Koopman, Angell, & Spiegel, 1996; Gross & John, 2002; Gross & Levenson, 1997; John & Gross, 2004). It is not clear, however, how long this “over time” period needs to be. Since we only measured emotional suppression one month after the event, it might be that it was too soon for the negative effects of emotional suppression to start having any significant impact on distress outcomes. Had emotional suppression been measured again, the results might have been different. Also, it is possible that at the time of the interview, victims were trying to detach themselves from the devastating situation, trying not to react to the event with strong emotion in order to reduce stress and the intensity of PTSD symptoms (Mason et al., 2010; Strelau & Zawadzki, 2005). If that
is the case, according to the associative network model, they were in fact trying not to activate the emotion associated with the memory of the distressing event. In so doing, they were not activating the memory network and therefore the related re-experiencing and hyperarousal symptoms (Bower, 1981, 1987). There were limitations to the study that need to be mentioned. First, the questionnaires we used were designed as self-report questionnaires. However, we interviewed the victims using the questionnaires. The reasons for doing so were explained in the procedure section. Second, the sample might have been biased. As mentioned earlier, the whole sample met the diagnostic criteria for PTSD, which meant that we were investigating a group of highly traumatized individuals. In addition, there was a lack of socioeconomic diversity in the sample. All the participants came from a low-income background, and a large proportion was uneducated. Third, we did not collect information on previous traumatic life events and consequently were unable to control for the effects of cumulative traumas. Given that 1% to 12% of people in the general population have had PTSD at some point during their lives (Norris & Slone, 2007), this may have exacerbated the impact of their PTSD following flood. To conclude, following the 2010 flood in Pakistan, all victims recruited for the study had developed PTSD and psychiatric comorbid symptoms. The severity of these symptoms was influenced by victims’ subjective experiences of the flood, particularly knowing some of the people who died and losing personal belongings or property. Their subjective experience could have allowed dysfunctional thinking patterns to develop which in turn affected their psychiatric symptoms.
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