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Prevalence and predictors of posttraumatic stress disorder among Chinese youths after an earthquake.

On April 14, 2010, a destructive earthquake that registered 7.1 on the Richter scale struck Yushu Tibetan Autonomous Prefecture, Qinghai Province, in northwest China. During the earthquake, 2,698 people were killed, 270 were listed as missing, and 12,135 were injured with 1,434 in a serious condition (Chinese Information Office of the State Council, 2010). The earthquake destroyed thousands of buildings and at least 11 schools. Considering the harsh climatic and living conditions of the earthquake-affected areas, the government temporarily moved most of the local students with their teachers to other cities such as Xining, Tianjin, Shijiazhuang, or Chengdu. In the earthquake-affected areas, about 93% of the local population is of Tibetan ethnicity. There are 5.4 million people of Tibetan ethnicity in China, making this the tenth largest ethnic group in the country. Most Tibetans practice Tibetan Buddhism and live in northwest and southwest China, areas that are often hit by natural disasters. However, the psychological impact of disasters on Tibetans remains largely unresearched.

It has been documented that for youths, as for adults, exposure to natural disasters (earthquakes, tsunamis, hurricanes, floods, etc.) can lead to significant mental health problems (see e.g., La Greca, Silverman, Lai, & Jaccard, 2010; Roussos et al., 2005; Thienkrua et al., 2006). Posttraumatic stress disorder (PTSD) is a common form of adverse psychopathological consequences among children and adolescents following disasters (Hoven, Duarte, Turner, & Mandell, 2009). According to the fourth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994), PTSD is a psychiatric condition precipitated by exposure to extraordinarily traumatic events, and characterized by marked reexperiencing, avoidance and emotional numbing, and hyperarousal symptoms.

High prevalence rates of PTSD among disaster-exposed youths have been previously reported. For example, 9 and 21 months after the Hurricane Charley in the United States, 13% and 10% disaster-exposed children reported clinically relevant levels of PTSD, respectively (La Greca et al., 2010). The estimated rate of PTSD was 4.5% among children and adolescents six months after the 1999 earthquake in Ano Liosia, Greece (Roussos et al., 2005). Between 6 and 20 weeks after the 1999 earthquake in Turkey, a PTSD prevalence rate of 60% was reported among child and adolescent victims (Eksi et al., 2007). In areas in southern Thailand affected by the 2004 tsunami, between 10% and 13% of the children from displacement camps experienced PTSD (Thienkrua et al., 2006). In China, the reported prevalence rates of PTSD among youth survivors of the 2008 Wenchuan Earthquake ranged from 1.3% (Zhang et al., 2012) to 21.8% (Wang, Long, Li, & Armour, 2011). It should be noted, however, that the extant literature on disasters has been disproportionately focused on youths from developed countries, although it is well known that disasters mainly affect the poorest populations (Furr, Comer, Edmunds, & Kendall, 2010). Thus, to further extend contemporary understanding of the impact of natural disasters on the mental health of youths, empirical efforts focused on developing countries are needed.

Not everyone who has experienced a trauma eventually develops PTSD. It has been generally accepted that factors other than the traumatic event itself contribute to the prevalence of PTSD, and previous researchers have identified several demographic (e.g., gender), peritraumatic (e.g., trauma severity), and posttraumatic (e.g., lack of social support) factors that may predict subsequent PTSD after disasters (e.g., Brewin, Andrews, & Valentine, 2000; Keane, Marshall, & Taft, 2006). However, empirical findings are still inconsistent with regard to the risk factors of PTSD, especially among younger populations. In a recent meta-analysis, Trickey, Siddaway, Meiser-Stedman, Serpell, and Field (2012) examined 25 factors that they retrieved from 64 studies, and found that female gender, pre and postlife events, bereavement, and trauma severity yielded a small- to medium-size predictive effect on the prevalence of PTSD, while peritraumatic fear and perceived life threat were amongst the factors that yielded a large predictive effect on the prevalence of PTSD. Although some of Trickey et al.'s findings were in line with the claims of previous researchers (e.g., Cox, Kenardy, & Hendrikz, 2008), the pathological factors of PTSD have yet to be confirmed.

Six months after the Yushu earthquake in China, for the purpose of assessing disaster-related mental health needs and implementing effective psychological assistance, we conducted a mental health survey among youths who were temporarily relocated from Yushu to Tianjin and Shijiazhuang (two cities in North China, about 2,500 kilometers from Yushu). The main aims in this study were to estimate the prevalence of PTSD among these youths, and to identify its predictors. Based on previous empirical studies on the risk factors of PTSD among children and adolescents, we selected the following variables to test if they could be used to predict the prevalence and severity of PTSD in the current study: demographic variables (including gender, age, and ethnicity), exposure to the disaster, and peritraumatic (at or near the time of the trauma) subjective experience.

Method

Participants

The present sample comprised 753 middle school students who were temporarily relocated from Yushu to Tianjin and Shijiazhuang. The mean age was 13.9 years (SD = 1.7, range: 9-18 years). Of the participants, 749 (99.5%) were of Tibetan ethnicity, 2 (0.3%) were of Hui ethnicity, and 1 (0.1%) was of Han ethnicity. All the participants had experienced the disaster personally.

Measures

Participants were asked to provide demographic characteristics including age, sex, and ethnicity. Exposure to the disaster was assessed by asking participants three questions: (a) if they were injured during the earthquake; (b) if their family members died from the earthquake; and (c) if they witnessed a death of someone during or immediately after the earthquake.

The University of California, Los Angeles PTSD Reaction Index (UCLA PTSD Reaction Index; Steinberg, Brymer, Decker, & Pynoos, 2004) was used to evaluate possible PTSD. The UCLA PTSD Reaction Index is one of the most frequently used PTSD measures for youths in trauma-related clinical and research settings, and has been translated into many languages (Hawkins & Radcliffe, 2006). Six items adopted from Part II of the child version were used to evaluate subjective responses of participants during or right after the earthquake, including fear, helplessness, disgust, upset, confusion, and derealization (an alteration in the perception or experience of the external world so that it seems unreal). Each item was rated as 0 (absent) or 1 (present). Symptoms of PTSD were measured using Part III of the index. It is a 20-item self-report scale closely matched to the DSM-IV PTSD criteria. Each item is rated on a 5-point Likert scale ranging from 0 (none of the time) to 4 (most of the time), reflecting the frequency of occurrence of a particular symptom during the past month. The Chinese version of the UCLA PTSD Reaction Index was adapted using a back-translation procedure that has been validated and widely used in Chinese populations (e.g., Chen & Wu, 2006; Jia et al., 2010; Wu, Chen, Weng, & Wu, 2009). In the present study, participants were instructed to complete the index in relation to their experiences of the earthquake, and Cronbach's a was 0.88 for the PTSD symptom scale in the current study.

Procedure

The survey was conducted about six months after the earthquake and was administered to the participants by trained clinical psychologists and psycho-therapists. All students present at the school participated in the survey. As the participants were relocated with their teachers only and not their family members, the teachers then acted as their guardians. Before administering the self-report questionnaires to the participants, the investigators introduced the aim and significance of the survey in detail, and obtained written consent from teachers and oral informed consent from the participants. The study protocol was approved by the ethics committee of the Institute of Psychology at the Chinese Academy of Sciences.

Data Analysis

All statistical analyses were conducted using SPSS version 11.5. Univariate descriptive statistics were computed for demographic characteristics, objective exposure indicators, peritraumatic subjective experience, and PTSD symptomatology. Bivariate associations between probable PTSD and each of the predictors were tested using univariate logistic regression. Predictive variables with univariate logistic regression and a significance level of p < .05 were further submitted to a simultaneous multivariate logistic regression to identify the independent role of each predictor for probable PTSD.

Results

Participants' demographic data, disaster exposure indicators, and peritraumatic subjective experiences are summarized in Table 1. Regarding symptom severity of PTSD, the mean score on the PTSD symptom scale was 25.9 (SD = 11.9, range: 0-62). According to Steinberg et al. (2004), a clinical cutoff of 40 on the scale was used to identify probable PTSD cases. On the basis of this criterion, a total of 101 (13.4%) participants were classified as probable PTSD cases. Except for age, bereavement, scared, disgust, and upset, all other variables had significant effects in predicting probable PTSD (all p < .05).

To determine the independent role of each variable as a predictor of PTSD, significant predictive variables identified in bivariate analyses were subsequently included in a multivariate logistic regression model. The multivariate analysis results presented in Table 2 show that female gender, having been injured, having witnessed death, and having experienced derealization were significant independent predictors of probable PTSD (all p < .05).

Discussion

This study was the first in which the psychological impact of natural disasters was investigated in a sample consisting mainly of Tibetan (99.5%) youths. The prevalence of probable PTSD was 13.4% in our sample of youth survivors six months after the 2010 Yushu earthquake. The results were comparable to those gained in previous studies of disaster-exposed youths in other areas (Eksi et al., 2007; La Greca et al., 2010; Liu et al., 2011; Roussos et al., 2005; Thienkrua et al., 2006), and suggest that PTSD is also a common mental health consequence in the aftermath of natural disaster among Tibetan youths.

Regarding the demographic predictors of PTSD, it was found that sex, but not age, was a significant predictor for PTSD. It has been widely documented that females are more likely to develop PTSD than are males (e.g., Hizli, Taskintuna, Isikli, Kilic, & Zileli, 2009; Kilpatrick et al., 2003; Liu et al., 2011; Ma et al., 2011). In a meta-analysis conducted by Tolin and Foa (2008), the probability of females suffering from PTSD was found to be almost twice that for males across the lifespan. To date, the underlying mechanisms of sex disparity in PTSD remain uncertain, although in several studies it has been suggested that this disparity might be due to differences in biological bases (Ressler et al., 2011; Yehuda, 1999), psychosocial factors (Nemeroff et al., 2006; Tolin & Foa, 2008), and cognitive and behavioral variables (Tolin & Foa, 2002). This topic obviously needs further research. Reported findings regarding the age effect on PTSD are mixed, with some researchers indicating there are no age differences (e.g., Liu et al., 2011; Thienkrua et al., 2006), some indicating that younger children are more vulnerable to PTSD than older ones (e.g., Roussos et al., 2005), and some indicating that older youths are at an increased risk for PTSD compared to younger youths (e.g., Fan, Zhang, Yang, Mo, & Liu, 2011). In two more recent meta-analyses (Furr et al., 2010; Trickey et al., 2012), it was found that there was no evident association between age and PTSD.

With respect to the disaster exposure indicators, in the current study we found that being injured and witnessing death during and immediately after the earthquake were significant predictors of PTSD. These findings were generally consistent with those gained in previous reports (e.g., Eksi et al., 2007; Fan et al., 2011; Liu et al., 2011), and suggest that youths who have experienced more traumatic events are more likely to develop PTSD. However, contrary to previous findings (e.g., Jia et al., 2010; Thienkrua et al., 2006; Trickey et al., 2012), no significant association was found between bereavement and PTSD in this study. According to Mercer, Ager, and Ruwanpura (2005) this discrepancy may be due to Tibetans' traditional beliefs, such as karma, which have a strong influence on everything in their lives including experiences of trauma. Karma is a religious belief that everything happens for a reason, and it is the gods who decide what happens to people (Mercer et al., 2005). In Tibetans' beliefs, death is not an eternal state, as there is rebirth after death. These beliefs may reduce and ease feelings of loss and grief of individuals who have experienced the death of a family member. Our finding in regard to the lack of a significant association between bereavement and PTSD suggests that cultural factors may require special consideration in understanding the association between trauma exposure and mental health and in identifying individuals at high risk of developing PTSD.

It has been reported that peritraumatic fear is one of the most important predictors of PTSD (e.g., Furr et al., 2010; Trickey et al., 2012). In this study, we investigated five peritraumatic emotions (fear, helplessness, disgust, upset, and confusion) and one peritraumatic cognitive reaction (derealization). In contrast to findings in previous reports, we found that derealization, rather than other peritraumatic reactions, was an independent predictor of PTSD. It is worth considering these findings in the context of current concerns regarding the exact role of peritraumatic responses in defining traumatic stress and in development of subsequent PTSD (Bovin & Marx, 2011; Friedman, Resick, Bryant, & Brewin, 2011; Karam et al., 2010). According to the DSM-IV, a PTSD diagnosis requires an individual to experience intense feelings of fear, helplessness, or horror during or immediately after a traumatic event (Criterion A2). The exclusive focus on the three peritraumatic emotions has been widely criticized (e.g., Brewin, Andrews, & Rose, 2000; Weathers & Keane, 2007). Indeed, in a number of empirical and theoretical studies, researchers have failed to support the unique role of these peritraumatic emotions in predicting PTSD (e.g., Bovin & Marx, 2011; Brewin et al., 2000; Lancaster, Melka, & Rodriguez, 2011; Weathers & Keane, 2007). The results in the present study also demonstrate that the Criterion A2 emotions (specifically, fear and helplessness) were weakly predictive of subsequent PTSD, and call into serious question the predictive validity of the current Criterion A2 of PTSD in the DSM-IV. These findings are pertinent given that the DSM-5 PTSD task force is considering removing the A2 criterion from PTSD diagnosis (cf. Friedman et al., 2011; Scheeringa, Zeanah, & Cohen, 2011). On the other hand, the finding that peritraumatic dissociation may serve as an important predictor of subsequent PTSD, which is congruent with findings in a number of previous reports (e.g., Breh & Seidler, 2007; Ozer, Best, Lipsey, & Weiss, 2003; van der Hart, van Ochten, van Son, Steele, & Lensvelt-Mulders, 2008), also offers empirical support for an alternative revision to the current Criterion A2. According to several researchers (e.g., Bovin & Marx, 2011), ignoring an individual's perception and reaction to an event is problematic when defining traumatic stress. Recently, Bovin and Marx reviewed empirical studies relevant to individuals' responses to extreme environment events, and asserted that peritraumatic responses are organized in a complex and coordinated manner, involving the individual's appraisals, emotions, additional cognitions, physiological responses, and behaviors. Bovin and Marx further summarized empirical support for associations between these responses and the subsequent development of PTSD, and proposed that for the purpose of more accurately defining and understanding traumatic stress, the current Criterion A2 should be broadened rather than simply removed.

Several limitations to the present study should be noted. First, given the utilization of a convenience sample of participants who were relocated from Yushu to Tianjin and Shijiazhuang, it is uncertain as to the extent to which our findings could be generalized to all youths who had experienced the same natural disaster. According to several researchers (Furr et al., 2010), relocation may be also a traumatic event for youths. However, as additional samples were unavailable to us, no further investigation was undertaken of the psychological effect of relocation. Second, self-report questionnaires were used to assess clinical symptoms, and these do not allow for clarification of clinical judgment. Furthermore, peritraumatic experience was evaluated retrospectively which may inevitably lead to some potential biases and errors, as has been commented by several researchers (see e.g., Weathers & Keane, 2007). Third, in the current study we included only a limited number of features of exposure to the disaster, especially peritraumatic responses. Given that revision to the current Criterion A2 of PTSD in the DSM-IV is underway, more research is needed to examine the role of a range of peritraumatic responses in defining traumatic stress and in development of subsequent PTSD.

http://dx.doi.org/10.2224/sbp.2013.41.10.1613

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YUE WEI, LI WANG, RICHU WANG, CHENGQI CAO, ZHANBIAO SHI, AND JIANXIN ZHANG

Chinese Academy of Sciences

Yue Wei, Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, and Graduate University of Chinese Academy of Sciences; Li Wang, Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences; Richu Wang and Chengqi Cao, Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, and Graduate University of Chinese Academy of Sciences; Zhanbiao Shi and Jianxin Zhang, Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences.

This study was partially funded by the National Key Technology Research and Development Program of China (No. 2013BAI08B02), the Key Research Program of the Chinese Academy of Sciences (No. KJZD-EW-L04), and the National Natural Science Foundation of China (No. 31271099).

Correspondence concerning this article should be addressed to: Li Wang, Institute of Psychology, Chinese Academy of Sciences, 16 Lincui Road, Beijing 100101, People's Republic of China. Email: wangli1@psych.ac.cn
Table 1. Bivariate Analysis of Associations Between Demographic, Trauma
Exposure, and Peritraumatic Experience Variables and Probable PTSD

                Total                    PTSD

Variables       N (%)        N (%)       OR (95% CI)         p

Sex             753
  Male          372 (49.4)   34 (9.1)    1                   < .001
  Female        381 (50.6)   67 (17.6)   2.12 (1.37-3.30)
Age             746 (a)
  9-13 years    309 (41.0)   46 (14.9)   1
  14-18 years   437 (58.0)   55 (12.6)   0.82 (0.54-.1.26)     .366
Being injured   743 (a)
  No            577 (76.6)   63 (10.9)   1
  Yes           166 (22.3)   36 (21.7)   2.26 (1.44-3.55)    < .001
Bereavement     745 (a)
  No            264 (35.1)   30 (11.4)   1
  Yes           481 (63.9)   70 (14.6)   1.33 (0.84-2.10)      .223
Witnessing      746 (a)
    death
  No            228 (30.3)   16 (7.0)    1
  Yes           518 (68.8)   85 (16.4)   2.60 (1.49-4.55)    < .001
Scare           749 (a)
  No             79 (10.5)   10 (12.7)   1
  Yes           670 (89.0)   91 (13.6)   1.08 (0.54-2.18)      .820
Helplessness    741 (a)
  No            218 (29.0)   19 (8.7)    1
  Yes           523 (69.5)   81 (15.5)   1.92 (1.13-3.25)      .015
Disgust         747 (a)
  No            188 (25.0)   21 (11.2)   1
  Yes           559 (74.2)   79 (14.1)   1.31 (0.78-2.19)      .303

Upset           743 (a)
  No            163 (21.6)   20 (12.3)   1
  Yes           580 (77.0)   81 (14.0)   1.16 (0.69-1.96)      .577
Confusion       739 (a)
  No            248 (32.9)   23 (9.3)    1
  Yes           491 (65.2)   76 (15.5)   1.79 (1.09-2.94)      .021
Derealization   748 (a)
  No            168 (22.3)   11 (6.5)    1
  Yes           580 (77.0)   88 (15.2)   2.55 (1.33-4.90)    < .005

Note. PTSD = posttraumatic stress disorder; OR = odds ratio;
CI = confidence interval.

(a) Numbers with categories may not add up to 753 due to
missing values.

Table 2. Multivariate Analysis of Associations Between
Demographic, Trauma Exposure, and Peritraumatic Experience
Variables and Probable PTSD

Variables          OR (95% CI)        p

Sex
  Male             1                  0.025
  Female           1.70 (1.07-2.70)
Being injured
  No               1
  Yes              1.85 (1.14-3.00)   0.013
Witnessing death
  No               1                  0.029
  Yes              1.91 (1.07-3.41)
Helplessness
  No               1                  0.273
  Yes              1.37 (0.78-2.42)
Confusion
  No               1
  Yes              1.35 (0.81-2.27)   0.254
Derealization
  No               1
  Yes              2.15 (1.07-4.30)   0.032

Note. PTSD = posttraumatic stress disorder;
OR = odds ratio; CI = confidence interval.
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Article Details
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Author:Wei, Yue; Wang, Li; Wang, Richu; Cao, Chengqi; Shi, Zhanbiao; Zhang, Jianxin
Publication:Social Behavior and Personality: An International Journal
Article Type:Report
Geographic Code:9CHIN
Date:Nov 1, 2013
Words:4697
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