Journal of Psychosomatic Research 79 (2015) 100–106

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Journal of Psychosomatic Research

Posttraumatic stress disorder and somatic symptoms among child and adolescent survivors following the Lushan earthquake in China: A six-month longitudinal study☆ Jun Zhang a, Shenyue Zhu b, Changhui Du c, Ye Zhang a,⁎ a b c

Mental Health Center, West China Hospital, Sichuan University, Chengdu 610041, China Baoxing County Education Bureau, Yaan 625700, China Chengdu Center of Disease Control, Chengdu 610041, China

a r t i c l e

i n f o

Article history: Received 27 December 2014 Received in revised form 1 June 2015 Accepted 3 June 2015 Keywords: Posttraumatic stress disorder Somatic Predictors Child Earthquake

a b s t r a c t Objective: To explore somatic conditions in a sample of 2299 child and adolescent survivors of an earthquake and their relationship to posttraumatic stress disorder (PTSD) symptoms. Methods: The Children's Revised Impact of Event Scale, the Patient Health Questionnaire (PHQ)-13 scale, a short version of PHQ-15 scale that omits two items involving sexual pain/problems and menstrual problems, and a project-developed questionnaire were administered to participants three and six months after the earthquake. Results: Among child and adolescent survivors, the prevalence rates of probable PTSD were 37.4 and 24.2% three and six months, respectively, after the earthquake. The most common somatic symptoms were trouble sleeping (58.4 and 48.4%), feeling tired or having low energy (52.0 and 46.1%), and stomach pain (45.8 and 45.4%) after three and six months, respectively. Several specific somatic symptoms evaluated three months after the earthquake including trouble sleeping, headache, and shortness of breath were predictors of the overall PTSD symptoms evaluated six months after the earthquake. Additionally, the symptom of hyperarousal evaluated after three months could predict the overall somatic symptoms evaluated after six months. Conclusions: PTSD and somatic symptoms were common after the earthquake, and a longitudinal association between PTSD and somatic symptoms was detected among child and adolescent survivors. These findings have implications in China and possibly elsewhere. © 2015 Elsevier Inc. All rights reserved.

Introduction On the 20th of April in 2013, a 7.0 Richter-scale earthquake erupted in Sichuan province, China. The epicenter was located in the Lushan County of Yaan, which had also been affected by the Wenchuan Earthquake in 2008 (Fig. 1). Only five years separated these two catastrophic disasters. The Lushan earthquake resulted in 196 deaths, 21 lost, and at least 11,470 injured, with more than 968 seriously injured [1]. It also caused psychological changes among survivors [2]. Additionally, a large number of buildings and houses were destroyed, forcing many local inhabitants to reside in temporary settlements. Posttraumatic stress disorder (PTSD) is the most common psychological sequelae among children and adolescents following an earthquake [3–5]. For example, three years after the Wenchuan earthquake, the prevalence of PTSD was 29.6% among 373 students from two junior

☆ This work was conducted at Mental Health Center, West China Hospital, Sichuan University. ⁎ Corresponding author. Tel.: +86 15681187337; fax: +86 28 85422632. E-mail addresses: [email protected] (J. Zhang), [email protected] (S. Zhu), [email protected] (C. Du), [email protected] (Y. Zhang).

http://dx.doi.org/10.1016/j.jpsychores.2015.06.001 0022-3999/© 2015 Elsevier Inc. All rights reserved.

high schools in Mao County [6]. Additionally, six and twelve months after the Wenchuan earthquake, the prevalence rates were 11.2 and 13.4%, respectively, among the children in the town of Qushan in Beichuan County [7]. Furthermore, the prevalence of PTSD was 35.7% among the surviving children in the Municipality of Peristeri six to seven months after the 1999 Athens earthquake [8]. Variations in the prevalence of PTSD have been noted and attributed to differences in study measurements and assessing times, as well as different age, race and cultural background of the samples [8–10]. Previous studies conducted after a factory explosion [11], floods [12], a war [13,14], and an air plane crash [15] showed that individuals exposed to traumatic experiences often suffered from somatic symptoms [16–18]. For example, one study conducted in three US infantry brigade combat teams six months post-deployment showed that the most frequently reported physical health symptoms were sleep problems (32.8%), musculoskeletal pain (32.7%), fatigue (32.3%), and back pain (28.1%) among 1522 infantry soldiers [19]. The results of an additional study conducted in Rwanda 14 years after the genocide showed that the most common somatic symptoms were back pain (74.1%) and headache (72.5%) among survivors with PTSD [20]. The majority of the aforementioned results were derived from cross-sectional

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Fig. 1. Geographical location of the Baoxing County in relation to the epicenters of the 2008 Wenchuan earthquake (purple dot) and the 2013 Lushan earthquake (red dot), China.

studies. Furthermore, most of the previous studies were conducted among adults, and little has been reported regarding somatic conditions in child and adolescent survivors after disasters. Individuals affected by disaster have greater odds of developing PTSD compared with those not affected by disaster [21], which is associated with possibly the highest frequency of somatic symptoms among psychiatric disorders [22,23]. The symptoms are primarily neurological and musculoskeletal, and can involve pain, respiratory, gastrointestinal, cardiovascular, and sleep disorders [24]. For example, one study conducted in diverse environments from inner-city Baltimore to rural Appalachia among 69 sexual assault survivors showed that the number of body regions with clinically significant new or worsening pain (CSNWP) and the number of somatic symptoms were positively correlated with PTSD symptom severity [25]. Musculoskeletal disorders associated with depression, PTSD, and poorer well-being were also reported as results of a study conducted in Australia among 1381 Australian veterans who served in the Gulf region during the period from August 2, 1990 to September 4, 1991 [26]. The results of an additional study conducted among 3600 conflict-affected civilians in Georgia indicated that somatic distress was highly correlated with PTSD [27]. Exploring the relationship between somatic symptoms and PTSD is a critical concern among survivors with traumatic experiences due to their demonstrated potential to impact the course of psychological distress and functional disability [22]. Most of these studies that reported an association between PTSD and somatic symptoms were conducted in adults. To our knowledge, there are limited data pertaining to the association between PTSD and somatic symptoms among children and adolescents. Based on the aforementioned research findings, we hypothesized that child and adolescent survivors of the Lushan earthquake might develop PTSD and various somatic symptoms, and that the overall somatic symptoms and overall PTSD symptoms would be associated with each other. In addition, we hypothesized that several specific somatic symptoms would contribute to the subsequent overall PTSD symptoms. Likewise, several specific previous PTSD sub-symptoms may be predictors of subsequent overall somatic symptoms. Therefore, the aims of the

present study were to evaluate the PTSD and somatic conditions among child and adolescent survivors of the Lushan earthquake longitudinally across six months, as well as to explore the relationship between specific somatic symptoms and PTSD.

Method Participants and procedure This was a longitudinal study conducted three and six months after the earthquake. Participants were students from 21 primary and secondary schools in the County of Baoxing severely affected by the earthquake. A total of 3053 children and adolescents participated in the initial survey conducted after three months, and 75.3% (n = 2299) of the original sample completed the second assessment after six months. In the present study, we analyzed the data from the 2299 students who completed all study assessments. In the present study, both PTSD and somatic symptoms were evaluated among child and adolescent survivors three and six months after the earthquake using the Children's Revised Impact of Event Scale (CRIES) and the Patient Health Questionnaire (PHQ)-13 scale, which is a short version of the PHQ-15 scale without the two items involving sexual pain/problems and menstrual problems. Demographic variables including age, gender, and ethnicity were also evaluated after three and six months using a project-developed questionnaire. This study was approved by the Ethics Committee of the West China Hospital of Sichuan University, and the authors obtained permission and support from both the Education Bureau of Baoxing County and the Department of Health of Sichuan Province. Written informed consent was obtained from school principals and teachers. Before conducting this study, investigators described the experimental procedures to children and informed them that they could join the study voluntarily and had a right to withdraw. Written informed consent was obtained from each student in the questionnaire. Under the supervision of trained individuals with master's degrees in psychology, participants completed the

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Chinese Version of the CRIES, the PHQ-13 scale, and the projectdeveloped questionnaire in their classrooms.

Measures The evaluation tools for this study included two parts. The first part assessed demographic variables including age, ethnicity, and gender using a project-developed questionnaire. The second part evaluated somatic and PTSD symptoms. The PHQ-15 is a 15 items self-report scale used to measure somatic symptoms. Participants report the extent of their somatic symptoms on a threepoint scale ranging from ‘not bothered at all’ (0) to ‘bothered a lot’ (2). The maximum score is 28 for men and 30 for women, as one item pertains to menstrual problems [28]. Because the participants in this study were students from primary and secondary schools, we used the PHQ-13 scale, a short version of the PHQ-15 scale without the two items pertaining to menstruation and sexuality. The maximum score of the PHQ-13 used in this study is 26 for both boys and girls. Each somatic symptom was dichotomized using ‘bothered a lot or bothered a little’/‘not bothered at all’ as the cut-off. The Chinese version of the PHQ-15 has demonstrated a satisfactory level of internal consistency and reliability in the general population of China [29]. In the present study, the Cronbach's alphas of the PHQ-13 scales were 0.859 and 0.884 three and six months after the earthquake. The CRIES is a 13 item self-report scale to measure children's traumatic symptoms including aspects of intrusion, avoidance, and hyperarousal. Participants report the extent of their traumatic symptoms on a four-point scale ranging from ‘not at all’ (0) to ‘often’ (5). Therefore, the highest possible total score is 65. Higher scores are indicative of higher levels of traumatic symptoms. Individuals with total scores ≥ 30 are considered as probable PTSD/at high risk for PTSD [30,31]. In the current study, individuals with CRIES scores ≥ 30 after both three and six months were considered as the early-onset probable PTSD group. An early decrease probable PTSD group included the individuals with CRIES scores ≥ 30 after three months and b 30 after six months. The late-onset probable PTSD group included individuals with CRIES scores b 30 after three months and ≥ 30 after six months. Individuals with CRIES scores b 30 after both three and six months were in the no PTSD group. The CRIES has shown good validity and reliability in assessing adolescents' traumatic symptoms in China [32,33]. In the present study, the Cronbach's alphas of the scales were 0.886 and 0.894 three and six months after the earthquake.

Fig. 2. Prevalence rates of somatic symptoms and probable PTSD among child and adolescent survivors; somatic symptoms are derived from the total PHQ-13 score and PTSD symptoms are derived from the total CRIES score; *, p b 0.05; **, p b 0.01; ***, p b 0.001. Prevalence rates of psychosomatic symptoms As shown in Fig. 2, the prevalence of probable PTSD after three months was higher than that after six months (37.4% vs. 24.2%, respectively) among the child and adolescent survivors. Somatic symptoms were also common and included trouble sleeping (58.4 and 48.4%), feeling tired or having low energy (52.0 and 46.1%), stomach pain (45.8 and 45.4%), headache (41.7 and 37.6%), dizziness (41.9 and 34.8%), pain in the arms, legs, or joints (25.6 and 28.3%), nausea, gas, or indigestion (28.8 and 28.1%), the sensation of a pounding or racing heart (30.3 and 22.8%), constipation, loose bowels, or diarrhea (20.5 and 20.0%), back pain (18.0 and 18.8%), shortness of breath (18.2 and 15.2%), chest pain (13.0 and 13.7%), and fainting spells (7.9 and 7.5%) after three and six months, respectively. The prevalence rates of trouble sleeping, feeling tired or having low energy, headache, dizziness, the sensation of a pounding or racing heart, and shortness of breath after six months were significantly decreased as compared with those after three months. Conversely, the prevalence of pain in the arms, legs, or joints was significantly increased six months after the earthquake as compared with that three months after the earthquake. The prevalence of each somatic symptom was significantly higher in the probable PTSD group than that in the no PTSD group after both three and six months (Table S1). In the early-onset probable PTSD group, except for a sensation of heart pounding or racing, the prevalence rates of somatic symptoms were either increased or at the same level from three to six months. The prevalence of each somatic symptom decreased from three to six months in the early decrease probable PTSD group, with the exception of back pain, which did not differ significantly. In the no PTSD before six months group, the prevalence rates of several somatic symptoms including headache, dizziness, fainting spells, a sensation of

Statistical analysis Descriptive statistics were computed for categorical variables. Chisquare tests were used to compare the differences in the prevalence rates of psychosomatic symptoms between the groups evaluated three and six months after the earthquake. Spearman and Pearson correlation analyses were used to detect relationships between demography, as well as somatic and PTSD symptoms. A stepwise multiple linear regression analysis was used to detect the predictive effects of somatic symptoms on PTSD, as well as for PTSD on somatic symptoms. Statistical analyses and calculations were performed using the Statistical Package for the Social Sciences for Windows (version 19.0) with two-tailed p values b 0.05 considered as statistically significant.

Results Demographic characteristics Of the 2299 participants, 1199 (52.2%) were female, 2012 (87.6%) were Han Chinese and 284 (12.4%) were Chinese minorities. Their ages ranged from 8 to 19 years with a mean of 11.75 ± 2.56 years.

Table 1 Association between somatic symptoms evaluated after three months and PTSD symptoms evaluated after six months. PTSD symptoms evaluated after six months

Gender Age Ethnicity Stomach pain Back pain Chest pain Pain in arms, legs, or joints Headache Dizziness Fainting spells Feeling your heart pound or race Shortness of breath Constipation, loose bowels, or diarrhea Nausea, gas, or indigestion Feeling tired or having low energy Trouble sleeping

r

p

0.131 0.031 0.022 0.201 0.120 0.163 0.173 0.222 0.206 0.059 0.228 0.192 0.166 0.235 0.238 0.310

b0.001 0.134 0.281 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 0.005 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001

J. Zhang et al. / Journal of Psychosomatic Research 79 (2015) 100–106 Table 2 Association between sub-symptoms of PTSD evaluated after three months and somatic symptoms evaluated after six months. Somatic symptoms evaluated after six months

Gender Age Ethnicity Intrusive Avoidance Hyper arousal

r

p

0.092 0.130 0.045 0.261 0.147 0.334

b0.001 b0.001 0.032 b0.001 b0.001 b0.001

heart pounding or racing, shortness of breath, feeling tired or having low energy, and trouble sleeping were significantly decreased from three to six months. The prevalence of each somatic symptom was significantly increased from three to six months in the late onset probable PTSD group (Table S2). Association between PTSD and somatic symptoms Each somatic symptom evaluated after three months was significantly and positively associated with subsequent overall PTSD symptoms evaluated after six months, with correlation coefficients ranging from 0.059 to 0.310 (Table 1). Each sub-symptom of PTSD evaluated after three months including intrusion, avoidance, and hyperarousal was significantly and positively associated with subsequent overall somatic symptoms evaluated after six months, with correlation coefficients ranging from 0.147 to 0.334 (Table 2). Predictors of somatic and PTSD symptoms Several stepwise multiple regression models were used to explore the predictive effects of PTSD on somatic symptoms, as well as the effects of somatic symptoms on PTSD. As shown in Fig. 3, after controlling for the effects of demographic variables and somatic symptoms evaluated after three months, the overall PTSD symptoms evaluated after three months could significantly predict subsequent overall somatic symptoms evaluated after 6 months with a Beta value of 0.132. Furthermore, after controlling for the effects of demographic variables and PTSD symptoms evaluated after three months, the overall somatic symptoms evaluated after three months significantly predicted subsequent overall PTSD symptoms evaluated after six months with a Beta value of 0.128. Additional regression analyses were conducted in order to further explore which somatic symptoms evaluated after three months could predict subsequent overall PTSD symptoms evaluated after six months, as well as which sub-symptoms of PTSD evaluated after three months could predict subsequent overall somatic symptoms evaluated after six months. After controlling for the effects of demographic variables and PTSD symptoms evaluated after three months, several somatic symptoms evaluated after three months including headache, trouble sleeping, and shortness of breath could significantly predict subsequent overall PTSD symptoms evaluated after six months with Beta values of 0.061, 0.068, and 0.069, respectively (Table 3). Lastly, after controlling for the effects of demographic variables and somatic symptoms evaluated after three months, only hyperarousal symptoms evaluated after three months could significantly predict subsequent

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Table 3 Several specific somatic symptoms evaluated after three months are predictors of PTSD symptoms evaluated after six months.

Model Step 1 PTSD Step 2 PTSD Headache Step 3 PTSD Headache Trouble sleeping Step 4 PTSD Headache Trouble sleeping Female Step 5 PTSD Headache Trouble sleeping Female Shortness of breath

B

BE

Beta

0.456

0.018

0.482⁎⁎

0.429 2.401

0.019 0.492

0.454⁎⁎ 0.096⁎⁎

0.398 1.975 1.629

0.021 0.506 0.472

0.421⁎⁎ 0.079⁎⁎ 0.077⁎

0.394 1.839 1.612

0.021 0.507 0.471

0.417⁎⁎ 0.074⁎⁎ 0.076⁎

1.828

0.552

0.063⁎

0.385 1.517 1.434

0.021 0.518 0.474

0.408⁎⁎ 0.061⁎ 0.068⁎

2.049 1.820

0.557 0.637

0.070⁎⁎ 0.069⁎

Adjusted

Partial

R2

△R2

Correlation

0.232

0.233

646.495⁎⁎ 0.482

0.240

0.008 0.446 0.105

0.244

F

0.004

338.586⁎⁎

230.860⁎⁎

0.386 0.084 0.075 0.248

176.694⁎⁎

0.004 0.383 0.078 0.074 0.072

0.250

0.003

143.464⁎⁎

0.372 0.063 0.065 0.080 0.062

⁎ p b 0.01. ⁎⁎ p b 0.001.

overall somatic symptoms evaluated after six months with a Beta value of 0.155 following the earthquake (Table 4).

Discussion To our knowledge, the present study is the first longitudinal research to simultaneously investigate the prevalence rates of probable PTSD and somatic symptoms, and the relationships between somatic and PTSD symptoms among child and adolescent survivors after an earthquake in China. Our results showed that probable PTSD and somatic symptoms were common three and six months after the earthquake. Additionally, our results also showed the longitudinal relationship between the overall somatic symptoms and PTSD. Furthermore, headache, trouble

Fig. 3. Association between overall somatic symptoms and overall PTSD symptoms; Beta, standardized regression coefficient; *, p b 0.001.

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Table 4 Hyperarousal evaluated after three months is a predictor for somatic symptoms evaluated after six months.

Model Step 1 Somatic symptoms Step 2 Somatic symptoms Hyper arousal Step 3 Somatic symptoms Hyper arousal Age

Adjusted

Partial

R2

△R2

Correlation

0.177

0.177

B

BE

Beta

0.435

0.020

0.421⁎⁎

0.345

0.024

0.334⁎⁎

0.105

0.015

0.161⁎⁎

0.341

0.024

0.331⁎⁎

0.102

0.015

0.155⁎⁎

0.144

0.068

0.034

0.040⁎

0.044

F 460.485⁎⁎

0.421 0.195

259.663⁎⁎

0.018 0.299 0.149

0.196

174.723⁎⁎

0.002

are difficult to explain, as they are based on limited evidence. Therefore, further studies will be required in order to more fully elucidate the mechanism underlying the increased prevalence of pain in the arms, legs, or joints over time. Somatic symptoms that are likely part of PTSD but not among the diagnostic criteria and appear to be comorbid with PTSD have been reported in previous studies [20,24]. Galovski et al. [36] revealed the significant mitigation of somatic symptoms after successful treatment for PTSD. Our results showed that the onset or dissipation of PTSD symptoms was accompanied by the onset or dissipation of somatic symptoms. We speculated that the onset or dissipation of PTSD symptoms and medically unexplained somatic symptoms may have similar mechanisms.

0.296

⁎ p b 0.05 ⁎⁎ p b 0.001.

sleeping, and shortness of breath evaluated after three months could significantly predict the overall PTSD symptoms evaluated after six months, and hyperarousal symptom evaluated after three months could significantly predict the overall somatic symptoms evaluated after six months among child and adolescent survivors. Prevalence rates of psychosomatic symptoms The prevalence rates of probable PTSD were 37.4 and 24.2% after three and six months, respectively. Previous studies showed that the prevalence of PTSD among child and adolescent survivors of earthquakes ranged from 4.5 to 95% [34]. For example, 15 and 36 months after the Wenchuan earthquake, the prevalence rates of PTSD were 12.4 and 10.7%, respectively, in a sample of 596 children and adolescents aged 8–16 years [35]. Somatic symptoms were also common after the Lushan earthquake. Similar findings have been reported among post-deployment soldiers [19] and genocide survivors [20]. These results derived from different countries which have different cultural backgrounds have indicated that the somatic symptoms are commonly seen, but it is necessary to emphasize the potential cultural impact on the results in future studies. As for the level of confidence in the evaluation, whether or not the somatic symptoms were actually resulting of physical ailments requires interpretation, whereas the PHQ-15 focuses on somatic symptoms regardless of cause without clinical evaluation. Therefore, results from the PHQ-15 may be confounded by somatic symptoms of a medical origin rather than psychological factors [27]. The prevalence rates of headache, dizziness, a sensation of heart pounding or racing, shortness of breath, feeling tired or having low energy, and trouble sleeping after six months were significantly decreased as compared with those after three months, suggesting that these somatic symptoms among child and adolescent survivors may gradually or spontaneously improve in the early stage after the earthquake. Child and adolescent survivors may receive useful information and emotional support from families, teachers, and the government which may also alleviate the somatic symptoms. It should be noted that only the prevalence of pain in the arms, legs, or joints was significantly increased from 25.6 to 28.3% from three to six months after the earthquake. Our results are similar to those from a recent longitudinal study conducted among sexual assault survivors, which found that the prevalence rates of pain in the arms and pain in the legs increased from 11.0 to 19.0% and from 18.0 to 21.0%, respectively, while the prevalence rates of headache, chest pain, abdomen pain, back pain, and genital pain were decreased or remained at the same level from six weeks to three months following the assault [25]. These findings

Association between the overall somatic symptoms and overall PTSD symptoms A longitudinal relationship between the overall somatic symptoms and overall PTSD symptoms was found in the current study, which may have been attributable to a decreased responsiveness to external stimuli combined with an increase in the awareness of internal stimuli found among individuals with PTSD [11,37], however, the association between PTSD and somatic symptoms cannot uncover whether the somatic symptoms resulted in PTSD, whether PTSD resulted in somatic symptoms, or whether somatic symptoms and PTSD both result from other factors [11]. However, it is important to note that Andreski et al. [22] found that PTSD increased the risk for abridged somatization, whereas the risk for new PTSD cases was not elevated in individuals with a history of abridged somatization. These results are in accordance with the hypothesis that psychological stress resulting from PTSD may cause an increase in personal vulnerability towards experiencing somatic symptoms [11,22]. Specific somatic symptoms as predictors for PTSD symptoms Trouble sleeping evaluated after three months may be a predictor for the overall PTSD symptoms evaluated after six months among child and adolescent survivors. This result supports previous findings indicating that both subjective and objective sleep disturbances are associated with a greater risk of developing subsequent PTSD [24], and that insufficient sleep mediated by activation of the neuroendocrine stress systems can sensitize individuals to PTSD [38]. As for headache, the results from several studies have suggested the presence of comorbid PTSD in up to 75% of patients with posttraumatic headache [39,40]. The results from other studies have also shown a high prevalence of PTSD in posttraumatic headache patients as compared with patients with migraine (22–30%) or the general population (6.8%) [41,42]. Based these findings, patients with headache were more likely to suffer from PTSD, which was also reported in our study among children and adolescents. Shortness of breath, a common respiratory symptom, associated with dust cloud exposure and dust in residences, was reported by children after 9/11 [43]. Previous studies also found that respiratory symptoms comorbid with probable PTSD in adults [44,45], as well as anxiety disorder induced respiratory illnesses, such as asthma, in children [46,47]. Our results showed the predictive effect of shortness of breath on PTSD, but should be interpreted with caution; it is important to note that shortness of breath in our study may also be partly attributed to building destruction as opposed to psychological factors. Specific sub-PTSD symptoms as predictors of the overall somatic symptoms Among the three sub-PTSD symptoms, only hyperarousal evaluated after three months could significantly predict the overall somatic symptoms evaluated after six months. This finding may be attributable to the hypervigilance, irritability or anger outbursts, exaggerated startle

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response, and difficulty concentrating associated with individuals, with hyperarousal [24]. These individuals therefore may have deficits in regulating emotions resulting in bodily-focused attention or prolonged physiological stress, which may be important factors in the mechanisms underlying unexplained somatic symptoms [48]. To our knowledge, previous similar studies often focused on adults with traumatic experiences, and few studies have been conducted in child and adolescents. Kimerling et al. [49] also reported hyperarousal as a significant factor for predicting physical health complaints in female veterans, corroborated in a study by Woods on abused women [50]. Avoidance was also reported to be a significant predictor [50]. However, Zoellner et al. [51] found that only intrusion was predictive of reductions in quality of life among female veterans. The findings of the current study suggest that the association between hyperarousal and subsequent somatic symptoms should also be closely monitored in child and adolescents with traumatic experiences. These findings have implications for clinical practice and reinforce the assertion that there is a need to support those providing health services in China in the appropriate recognition of somatic symptoms, as well as to increase their understanding of the strong associations between somatic symptoms and PTSD. In order to recognize PTSD after an earthquake, those providing health services should not only focus on earthquake-related experiences such as witnessing a death in the earthquake [52], but also on somatic symptoms, such as headache, trouble sleeping and shortness of breath. This is particularly important given the long-term influence of PTSD among children and adults [53,54]. Particular attention should be given to individuals affected by traumatic experiences, especially children and adolescents who display hyperarousal symptoms. The importance of this issue for policy lies in the evidence of increased use of health services among people with somatic symptoms and/or PTSD that have been reported elsewhere. Thus, improved diagnosis and more appropriate management may improve the psychosomatic health and well-being of children and adolescents with somatic symptoms and/or PTSD, while simultaneously making effective and efficient use of the limited resources available for health care in earthquake areas. For patients, there is a growing need for a coordinated, multidisciplinary, holistic approach to gain a further understanding of the effects of trauma on the development and maintenance of psychosomatic symptoms [55,56], as well as the relationship between PTSD and somatic symptoms, which may be helpful in informing prevention and treatment practices [57]. Limitations This study had several limitations. First, although good validity and reliability of the CRIES for assessing adolescents' traumatic symptoms in China have been reported in previous studies [32,33], it measures PTSD using the older DSM-IV criteria as opposed to the newer DSM-V criteria. Therefore, further research using a tool specifically designed in accordance with the newer DSM-V criteria will be necessary. Second, we did not assess whether the somatic symptoms we observed were the result of organic disease. Third, the participants in our study were a convenient sample from 21 primary and secondary schools in Baoxing County that were severely affected by the Lushan earthquake. Therefore, it is unclear whether the findings of the present study are generalizable to other child and adolescent survivors of traumatic events. Conclusion The results of the present study indicate that PTSD and somatic symptoms among child and adolescent survivors of a traumatic event are common, and support a preliminary longitudinal relationship between somatic symptoms and PTSD among child and adolescent survivors of an earthquake. These findings have implications in China and possibly elsewhere. Further research focusing on other samples that have survived a traumatic event will be required in order to

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interpret whether the somatic symptoms we observed resulted from medical, as opposed to psychological factors. Such information may allow for a better understanding of the relationship between PTSD and somatic symptoms. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.jpsychores.2015.06.001. Conflict of interest The authors declare that they have no conflict of interest. Acknowledgments This research was supported by the Post-disaster Emergency Program of Sichuan University (Grant no. 2013SCU190). References [1] Tang B, Zhang L. Ya'an earthquake. Lancet 2013;381:1984–5. [2] Tang B, Kang P, Liu X, Liu Y, Liu Z, Wang B, et al. Post-traumatic psychological changes among survivors of the Lushan earthquake living in the most affected areas. Psychiatry Res 2014;220:384–90. [3] Ying LH, Wu XC, Lin CD, Chen C. Prevalence and predictors of posttraumatic stress disorder and depressive symptoms among child survivors 1 year following the Wenchuan earthquake in China. Eur Child Adolesc Psychiatry 2013;22:567–75. [4] Zhang Z, Ran MS, Li YH, Ou GJ, Gong RR, Li RH, et al. Prevalence of post-traumatic stress disorder among adolescents after the Wenchuan earthquake in China. Psychol Med 2012;42:1687–93. [5] Cenat JM, Derivois D. Long-term outcomes among child and adolescent survivors of the 2010 Haitian earthquake. Depress Anxiety 2015;32:57–63. [6] Pan X, Liu W, Deng G, Liu T, Yan J, Tang Y, et al. Symptoms of posttraumatic stress disorder, depression, and anxiety among junior high school students in worst-hit areas 3 years after the Wenchuan earthquake in china. Asia Pac J Public Health 2015;27:NP1985–94. [7] Liu M, Wang L, Shi Z, Zhang Z, Zhang K, Shen J. Mental health problems among children one-year after Sichuan earthquake in China: a follow-up study. PLoS ONE 2011;6 [e14706]. [8] Giannopoulou I, Strouthos M, Smith P, Dikaiakou A, Galanopoulou V, Yule W. Posttraumatic stress reactions of children and adolescents exposed to the Athens 1999 earthquake. Eur Psychiatry 2006;21:160–6. [9] Bryant-Davis T, Ullman S, Tsong Y, Anderson G, Counts P, Tillman S, et al. Healing pathways: longitudinal effects of religious coping and social support on PTSD symptoms in African American sexual assault survivors. J Trauma Dissociation 2015;16:114–28. [10] Adams ZW, Sumner JA, Danielson CK, McCauley JL, Resnick HS, Gros K, et al. Prevalence and predictors of PTSD and depression among adolescent victims of the Spring 2011 tornado outbreak. J Child Psychol Psychiatry 2014;55:1047–55. [11] Elklit A, Christiansen DM. Predictive factors for somatization in a trauma sample. Clin Pract Epidemiol Ment Health 2009;5:1. [12] North CS, Kawasaki A, Spitznagel EL, Hong BA. The course of PTSD, major depression, substance abuse, and somatization after a natural disaster. J Nerv Ment Dis 2004; 192:823–9. [13] Jakupcak M, Osborne T, Michael S, Cook J, Albrizio P, McFall M. Anxiety sensitivity and depression: mechanisms for understanding somatic complaints in veterans with posttraumatic stress disorder. J Trauma Stress 2006;19:471–9. [14] Thompson KE, Vasterling JJ, Benotsch EG, Brailey K, Constans J, Uddo M, et al. Early symptom predictors of chronic distress in Gulf War veterans. J Nerv Ment Dis 2004;192:146–52. [15] Spinhoven P, Verschuur M. Predictors of fatigue in rescue workers and residents in the aftermath of an aviation disaster: a longitudinal study. Psychosom Med 2006; 68:605–12. [16] Burton C. Beyond somatisation: a review of the understanding and treatment of medically unexplained physical symptoms (MUPS). Br J Gen Pract 2003;53:231–9. [17] Escobar JI, Hoyos-Nervi C, Gara M. Medically unexplained physical symptoms in medical practice: a psychiatric perspective. Environ Health Perspect 2002;110: 631–6. [18] Osorio C, Carvalho C, Fertout M, Maia A. Prevalence of post-traumatic stress disorder and physical health complaints among Portuguese Army Special Operations Forces deployed in Afghanistan. Mil Med 2012;177:957–62. [19] Toblin RL, Riviere LA, Thomas JL, Adler AB, Kok BC, Hoge CW. Grief and physical health outcomes in U.S. soldiers returning from combat. J Affect Disord 2012;136: 469–75. [20] Munyandamutsa N, Mahoro Nkubamugisha P, Gex-Fabry M, Eytan A. Mental and physical health in Rwanda 14 years after the genocide. Soc Psychiatry Psychiatr Epidemiol 2012;47:1753–61. [21] Ma X, Liu X, Hu X, Qiu C, Wang Y, Huang Y, et al. Risk indicators for post-traumatic stress disorder in adolescents exposed to the 5.12 Wenchuan earthquake in China. Psychiatry Res 2011;189:385–91. [22] Andreski P, Chilcoat H, Breslau N. Post-traumatic stress disorder and somatization symptoms: a prospective study. Psychiatry Res 1998;79:131–8.

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