Psychological Distress in Natural Disaster

Psychological Distress in a Natural Disaster

Among the many problems that humans encounter following a natural disaster is Post Traumatic Stress Disorder (PTSD). PTSD can result from natural disasters like floods, earthquakes, tsunamis, hurricanes, tornados among other frightening natural events that cause damage and result in serious injuries and loss of life. When humans are exposed to horrific natural disasters they may continue to carry the fearful events in their memories; those realistic recollections can haunt the individual to the point of causing serious psychological disorders. Hence, PTSD can become a very serious emotional problem that requires psychological help from professionals. This paper provides instances of PTSD research following natural disasters -- and studies that delve into the dynamics of PTSD that resulted from natural disasters, including the terrible flooding in Thailand in 2000

Literature Review -- Hat Yi Flood

When severe rains caused a dangerous flood that killed about 32 people in Thailand in November, 2000 (the Hat Yai flood), around 1,700 people were injured. There was certainly tremendous damage to property as well, but the focus of an article in the peer-reviewed journal Stress and Health is on the psychological problems that had a serious impact on citizens. According to the General Health Questionnaire (GHQ) that was given to survivors of the flood, and the Impact of the Event Scale (IES) that was also administered to survivors, about 40% of the 590 respondents who took the GHQ showed mental health issues associated with the flood (Assanangkornchai, 2004, p. 81).

The tests mentioned above were given to the Thai citizens ten weeks after the catastrophe, and it was determined that the health problems faced by these individuals included sleep disturbances and fear -- some people were terrified during the flood because they were not absolutely certain as to when the waters would actually subside (Assanangkornchai, 83). As to the results of the psychological testing, those individuals that had a "…positive GHQ score had a significantly higher mean IES score than those…" that didn't have a significant IES score on their test (Assanangkornchai, 85). What the authors conclude in the Discussion portion of the article is that respondents who believed their "personal loss" was "severe" -- or who knew someone that had lost important personal possessions -- were far more likely to score high on the GHQ, and to also have "higher" IES scores, Assanangkornchai continued (88).

Other studies following natural disasters show the same thing that the authors discovered in this research, and that is the severity of loss is among the most important variables that determines whether a victim is actually suffering from post traumatic stress disorder. Six months after Hurricane Mitch struck Nicaragua people suffered PTSD; hence, this problem of stress following a natural disaster -- in various places around the world -- is very serious and so there should be mental health services available for people following major natural disasters.

Literature Review -- Chi-Chi Earthquake Survivors in Taiwan

The peer-reviewed journal Psychiatry and Clinical Neurosciences published an article that reflects a study of PTSD earthquake survivors in Taiwan three years after the quake. The research originally conducted was done six months after the huge 7.3 magnitude earthquake. In that study, it was determined that 418 of those 1,756 survivors were suffering from PTSD. Three years later, the research shows that 38 of those 418 PTSD sufferers (that is 9.1%) were still showing strong signs of PTSD (Su, 2010, p. 239). And of the original 1,338 survivors that were diagnosed as not having symptoms of PTSD, three years later 40 of those individuals were indeed diagnosed with PTSD (Su, 239).

The authors point out that using DSM-IV diagnostic criteria, there are three "core psychopathologies" associated with PTSD. People tend to "re-experience" the frightening event; individuals experience a kind numbness and "avoidance"; and "hyper arousal" is the third component to PTSD (any event that reminds the person of that traumatic event arouses new fear) (Su, 239). The screening was done using the Disaster-related Psychological Screening Test (DRPST), which consisted of a list of questionnaires that were created by five psychiatrists and two public health officials, Su explains on page 241.

Eight "putative risk factors" were built into the screening by the psychiatrists to help evaluate the reasons for their PTSD diagnoses: a) household destruction; b) being physically injured during the earthquake in Taiwan; c) the loss or serious injury to a member of one's family; d) the emotional issues linked to a family member's death; e) a dramatic decrease in socially-related activities; f) loss of a job because of the quake; g) significant financial losses; and h) impairment on one's memory and attention span (Su, 241). Those eight putative factors were considered by the researchers to be more than just predictors of PTSD; in fact the eight factors were pivotal in determining "unresolved and delayed PTSD" in the group of 1,756 survivors (Su, 242).

Because of the fact that nearly 27% of the survivors had less than a primary school education, those agreeing to be interviewed 6 months and 3 years after the horrific event needed to be helped in terms of filling out the questionnaire (translators were on hand). The bottom line for Su and colleagues -- resulting from their findings three years after the fact -- is that when people are exposed to a massive earthquake, the clinical evaluation should include checking for PTSD symptoms and using the putative risk factors for PTSD (Su, 244). For many of those survivors that were originally evaluated, early mental health intervention may have prevented the continuing presence of PTSD. When PTSD is not resolved at the outset in some meaningful way, continuing pain (both physical and psychological) can result, causing social and personal impairment, Su explains (245).

Literature Review -- Floods and PTSD Studies

An article in the Journal of Family Violence reviews the extent of psychological trauma that was experienced by female victims in 1993 in the flooding of the Mississippi River. The authors invited 564 women to participate 6 months after the flood but only 36.3% were willing to participate. In fact some of the women who withdrew from consideration were told not to be part of the survey by their husbands and significant others (Taft, et al., 2009, p. 391). The assessments were made using the National Women's Study PTSD module, the Dyadic Adjustment Scale (DAS), the Verbal Aggression subscales of the Conflict Tactics Scale (CTS).

The assessments took place at the participants' homes (no male partners were present during the research); the participants filled out the questionnaire on laptop computers, they were verbally de-briefed afterwards by a Masters-level assessor, and were paid $25 for their willingness to participate (Taft, 391). This was a test of how much aggression (physical and psychological) women would experience or dish out following the floods. The results showed that women experienced an 8% rise in physical aggression from their spouses and a 74% rise in psychological aggression as well. But the women in this study also perpetrated aggression, due to the presence of PTSD symptoms, Taft explains on 392-93. Women perpetrated a 9% rise in physical aggression six months after the horrific flooding and a 55% rise in psychological aggression (Taft, 392).

The bottom line in this research is that relationships suffer when a major natural disaster takes place, and when there is a relationship that isn't strong in the first place, a disaster can cause one or both parties (that had suffered from PTSD) to behave very badly and even violently.

Using the Harvard Trauma Questionnaire (trauma and symptoms that are associated with PTSD), and the Hopkins Symptom Checklist (to evaluate anxiety and depression) the authors in a peer-reviewed article (Psychology, Health & Medicine) reported on the results of a survey in England following severe flooding. Four hundred and forty four questionnaires were returned fully completed and of those 27.9% "met criteria" for symptoms that are directly linked to PTSD (Mason, et al., 2010, p. 61). As to anxiety, 24.5% responded that they indeed had serious bouts with anxiety during and after the floods, and 35.1% reported symptoms associated with depression (Mason, 61).

Not surprisingly, women in this research were more susceptible to PTSD than men, which is fairly consistent no matter what the natural disaster happens to be. Mason and colleagues admit that those that were directly affected experienced less negative psychological symptoms than victims of huge earthquakes and tsunamis albeit those that had gone through floods in previous years were more apt to have poor psychological outcomes.

Another article that delves into the psychological aftermath of those same English floods resulted in a study that was published in the Journal of Water and Health (Tunstall, et al., 2006). In this article, the authors employed the General Health Questionnaire and the results showed that some victims of the flood suffered health impacts that were long-term.

Some 983 interviews took place with adults over 18 whose homes had been directly impacted by the rising waters (above floor level) and 527 interviews were conducted with residents that were at risk for flooding but managed to duck the high waters. By the values established in the GHQ, 64% of those interviewed who had been flooded out -- and were evaluated six months later -- had a score of 4 or more, which is taken to mean there was significant psychological distress (that is juxtaposed with 25% that showed significant psychological distress at the time of the event). In addition, one-quarter of the 983 people interviewed experienced "deterioration" in their health since the flooding (Tunstall, 368).

The question posed to those that were flooded: "As the result of the flood, did you personally experience intense fear, helplessness or horror?" More than two-fifths of those who answered that question (using the GHQ) reflected that the flood was a "possible source" of PTSD (Tunstall, 370). That said, only ten respondents reported "high" stress levels (judged to be PTSD) and just 4 showed "extreme" levels of stress -- clearly cases of PTSD.

Meanwhile, a research article in the scholarly journal BMC Public Health reviews the research conducted following the 1998 floods in Hunan, China. There were a total of 25,478 study subjects in this research, and 9.2% of those 25,478 people (2,336) were diagnosed as "probable PTSD-positive" individuals (Huang, et al., 2010, p. 1). The face-to-face interviews with Chinese citizens (age 16 or older) were diagnosed using DSM-IV criteria, and the seven independent predictive factors included: age, gender, education, severity of flood, type of flood, flood experience and the mental status each participant had prior to the flood (Huang, 1). This was a monster flood, affecting more than 180 million Chinese; it destroyed 6.85 million homes, caused 4,150 deaths and displaced more than 18 million people (Huang, 2).

The response rate in this research (87%) was far better than most response rates when researchers wish to interview or have questionnaires filled out by those who have been negatively impacted by a disaster. Perhaps that is because the loss was so great and the flood so absolutely devastating.

A study was conducted on the children that became victims of the Hunan, China flood; a questionnaire was given to 7,038 children (from 13,450 households) ages 7-15 using the DSM-IV criteria. And in order to determine the association between PTSD and behavior before the flood, a questionnaire was given to the children's parents as well (Peng, 2011). Using a multivariate logistic regression, the authors determined that

Still on the subject of that terrible flood in Hunan, China, an article in the Canadian Journal of Psychiatry reports on research involving 33,340 individuals that had been impacted by the flood. Of those 33,340 people, 86% were 7 years of age or older and 8.6% showed clear symptoms that met all the diagnostic criteria for PTSD (Liu, 2006). How were the investigators certain that individuals were suffering from PTSD? In fact the diagnoses used the DSM-IV criteria, which include 17 symptoms.

The researchers scored the PTSD symptoms in three groups, B, C, and D. The B. section had to do with "re-experiencing" the flood. B1 was "intrusive recollections"; B2 involved nightmares about floods; B3 was a person acting as though a flood was occurring at that moment; B4 was when a person became miserable just being reminded about the flood; and B5 was a reaction to a reminder about floods (Liu, p. 2). The risk of PTSD was higher in females interviewed (consistent with other research reflected in this paper), and of the 33,340 citizens interviewed, 2,875 could be diagnosed as having PTSD (just 8.6% of the total). And of those 8.6% that were diagnosed with PTSD, 16.8% feared flash-flooding; and 10.4% had a terrible fear of embankments collapsing.

Literature Review -- Asian Tsunami, 2004

Another study conducted that investigated the psychological problems people suffered from after a major natural disaster is reported in the Journal of Psychosomatic Research. In this instance, over 200,000 people died but those that survived the terrible Indian Ocean tsunami that washed ashore in 2004 were evaluated fourteen months after the disaster. The authors queried 1,505 survivors of the tsunami, residents of Stockholm, who had been visiting the Indian Ocean area as tourists when the tsunami struck (Keskinen-Rosenqvist, et al., 2011, p. 180).

These tourists (after having been back in Sweden for 14 months) were given the General Health Questionnaire and the Impact of Events Scale, to determine the proportion of those individuals impacted psychologically by the tsunami. The results showed that 300 of the 1,505 people had physical symptoms only; and 123 people only had psychological symptoms (Keskinen-Rosenqvist, 182). The four physical symptoms that were found to have been associated with the tsunami were: threat to life only; threat to life and presence in the water or beach; threat to life and loss of a loved one. Those physical symptoms were linked by the authors to "psychological distress and post traumatic stress" thanks to the GHQ-12 and IES-R evaluative surveys (Keskinen-Rosenqvist, 183).

Interestingly, there were people that completed the surveys who were not injured in the tsunami but who complained of physical symptoms but did not report any psychological symptoms, which suggest that indeed these individuals suffered from psychological issues.

An article in the International Journal of Social Psychiatry shows that of 643 survivors of the 2004 tsunami (in five Indian villages), 15.1% suffered what researchers called post traumatic stress symptoms (PTSS). That is, these individuals suffered from "traumatic grief" because of the loss of children, because of financial losses, and due to physical injuries as well. But to elevate the 15.1% from "symptoms" to actual "disorder" was "questionable" (Rajkumar, et al., 2011). The scales used by the researchers -- the IES-R and the Complicated Grief Assessment scale (CGA) -- and the data was collected by a 10-member team (including two psychiatrists, a professor of psychiatry, social workers, psychiatric nurses and an occupational therapist) (Rajkumar, 3).

Interviews were conducted in the homes of the survivors -- or in the temporary shelters many were living in -- nine months after the Asian tsunami. Each interview lasted between an hour and 90 minutes, and if the person being interviewed showed fatigue or had trouble staying in good concentration, another interview was scheduled for later. The statistics that were accumulated show that 65% of those that showed PTSS were female and that 68% of the participants experienced fear, helplessness and horror while 87% were afraid they were going to die when the tsunami hit. The authors believe that too often researchers believe they are recording instances of PTSD when in fact the individuals were only showing symptoms (Rajkumar, 5). So great care was taken in this research not to over-report a symptom that cannot be wholly validated; in other words, the authors avoided "false positives" and moreover, they believe that the validity of existing screening instruments when verifying PTSD is still "questionable" (Rajkumar, 6).

Additional research on survivors of the Asian tsunami (Heir, et al., 2011) indicates that predictably, some tourists from Norway, Denmark and Sweden that were in the region when the tsunami roared ashore suffered symptoms of PTSD. Those individuals that were "danger exposed" (either caught in the waves or chased inland by waves), not surprisingly, reported to have suffered more post-traumatic stress than those tourists in the "non-danger exposed" (not directly affected by the giant waves but in the region and hence psychologically impacted) (Heir, 9). The scale that was used was the IES-R, which revealed that the lower the level of education and the fact that the individual was female determined the degree to which PTSD was detected.

The Norwegian survey using IES-R was conducted 6 months after the tsunami; the Danish survey was done 10 months after the tsunami and the survey in Sweden took place 14 months following the disastrous tsunami. In summation, Heir and colleagues determined that the tourists that returned home from the Asian experience showed "long-term" post traumatic stress disorder "symptoms" based upon the severity of their exposure to the deadly waves (9).

Meanwhile, that December tsunami in the Indian Ocean in 2004 -- the day after Christmas, when millions of people were on the long sandy beaches, including tourists from all over the world -- had a profound impact on adolescents, according to a peer-reviewed article in the Journal of Loss and Trauma (Bhushan, et al., 2007, p. 245). In this research paper 130 adolescents (61 girls and 69 boys between the ages of 10 to 16 years) were studied in order to determine the prevalence of PTSD; as has been noted in previous research, female adolescents exhibited more likelihood of trauma than males did. The adolescents surveyed were from the Nagapatinan district of Tamilnadu, India, which was powerfully impacted by the tsunami. The IES scale was used, along with the Children's Revised Impact of Event Scale (CRIES) -- which has been used in many instances as a valid screening tool for PTSD -- and also the Pediatric Emotional Distress Scale (PEDS) was employed for this research, Bhushan writes (248).

According to the PEDS scale, one year after the tsunami, 94.2% of males and females scored "high" on the aspect of "anxiety withdrawal" and all the adolescents scored high (98.55%) on the aspect of "fearfulness" (Bhushan, 251). Young people are known to "act out" bad or abnormal behaviors after a frightful event, and in this case 20.29% of the male adolescents were acting out a year after the event, and 24.59% of the females were acting out as well, indicating that they were still impacted by the trauma of the tsunami (Bhushan, 251). And while only a small number of adolescents actually developed full-blown PTSD (just 13%), 48% reported "numbing symptoms" and they indicated they continued to re-experience the traumatic event which they could not avoid (even when they weren't thinking about it) (Bhushan, 253).

In the Journal of Psychiatric and Mental Health Nursing (Agustini, et al., 2011, p. 543) the authors investigated another incidence of post traumatic stress disorder symptoms in adolescents (482 youthful survivors of the terrible tsunami in Asia in 2004, ages 11 to 19 years of age). The research was conducted four and a half years after the event. Child Post-Traumatic Stress Reaction Index was used in this research to determine how much psychological suffering the young victims endured following the tsunami. As was true in all previous research presented, those that suffered most often were females; that said, a total of 63.1% of all 482 participants reflected "severe" to "moderate" symptoms of PTSD (again, just showing symptoms of PTSD doesn't necessarily assure that the full impact of PTSD was experienced).

Factors that influenced the level of intensity vis-a-vis PTSD included: gender, low support level previous to the tsunami, loss of parents, heavy "somatic response" (Agustini, 543). The authors reported that 54 of the adolescents suffered "none" of the symptoms of PTSD (11.2%); 124 of the adolescents (25.7%) reported "mild" PTSD symptoms 4.5 years after the tsunami experience. One hundred ninety-six adolescents reported "moderate" psychological impacts (40.7% of the group of 482); 103 adolescents (21.4%) had "severe" PTSD symptoms 4.5 years after the disaster, and only 5 (1%) responded to the survey by saying they suffered "very severe" symptoms (Agustini, 543).

The authors point out (544) that with younger people the symptoms of PTSD don't always show up immediately, but in fact the symptoms may arrive six months after the traumatic event and continue longer than is typically expected for adults. Still, to have 21.4% of 482 adolescents still experiencing PTSD four and a half years after the tsunami is a reminder to those in the psychological and medical field that these horrific events perhaps take a greater toll on young people than they do on adults. And the fact that 63.1% of those 482 adolescents showing at least moderate to very severe PTSD symptoms is an eye-opening revelation.

Coping with PTSD after the tsunami in Asia has been a problem for many people, and in the journal Acta Psychiatrica Scandinavica, the authors suggest a trauma reduction exposure technique -- a yoga breathing intervention. The authors used 183 survivors of the 2004 tsunami who had scored 50 or more on the Post-traumatic Checklist 17 (PCL-17); those 183 were assigned to camps where they would undergo yoga breath interventions (Vedamurtachar, et al., 2010, p. 289). Those who didn't get into the first group were on a waiting list that was for 6 weeks. The camps were near to the refugee camps that had been set up after the devastating tsunami.

Eight months after the tsunami, the 183 survivors were administered a yoga breath program that was followed by "an exposure therapy" and the result was a 60% lessening of stress and trauma from what the individuals were going through prior to the yoga (Vedamurtachar, 289). The yoga interventions were intended to reduce symptoms of PTSD, which included: sadness, worry, insomnia and depression. More women than men volunteered to participate in this study -- likely because women know they are more likely to develop PTSD than men and women are also more willing than men to report symptoms of PTSD. One positive result from the yoga intervention was that about twenty percent of participants continued to be actively involved in breath control activities -- some bringing friends and getting the training necessary to provide yoga instructions for others (Vedamurtachar, 298). This could be a practice that future healthcare providers should consider when there are major natural disasters in the future.

Still on the subject of the Asian tsunami in 2004, Michael Hollifield and colleagues presented a research project in The British Journal of Psychiatry that delved into the prevalence of psychiatric and somatic symptoms 20 and 21 months following the disaster. Randomly Hollifield and colleagues selected adults in the area where the tsunami hit hardest, and assessed the psychological conditions there using the Kish method -- administered in Sinhala (Hollifield, 2008, p. 39).

The findings are stark: the researchers assessed the survivors for PTSD, for depression, anxiety, somatic distress and impairment, and for "culturally-relevant coping activities" (Hollifield, 39). The results of their research 20 and 21 months after the horrifying waves that washed ashore and killed thousands: 21% of the citizens they evaluated had clinically significant PTSD; 16% were diagnosed with depression; and 30% were found to have anxiety (Hollifield, 39). The respondents reported "a mean" of 8 "persistent and bothersome somatic complaints" -- all of which were linked to negative symptoms they experienced nearly two years after the fact.