Floods and PTSD

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Dr. Aizhong Liu( 刘爱忠） Prof., Chair Dept. of Epi

& Health Statistics, school of public health, CSU

lazroy@live.cn

Floods are the most common natural disaster affecting more people across the globe than all other natural or technological disasters.

A severe flood that struck China’s Hunan province in 1998 and 1999 left hundreds of thousands of residents homeless. Much of the infrastructure and many agricultural projects were damaged as well.

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Floods can lead to direct economic and property losses and result not only in physical injuries and deaths but also in psychological injuries. Posttraumatic stress disorder (PTSD) is a commonly used indicator to evaluate psychological injuries after disaster.

PTSD can cause long-term damage to an individual's social functions, family life, and health.

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PTSD? PTSD is a severe psychological reaction,

including great fear, helplessness, and averseness, caused by exposure to one or more extraordinary threats or traumatic events. The most common characteristic of PTSD is anxiety that lasts for a long time after the threat or trauma.

PTSD is a complex disorder that develops in response to severe traumatic stress, which consists of 17 symptoms.

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PTSD?

The 17 symptoms can be divided into three groups: B : the painful re-experiencing of the event C : a pattern of avoidance and emotional numbing D : fairly constant hyper-arousal

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B cluster:

1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.

2. Recurrent distressing dreams of the event.

3. Acting or feeling as if the traumatic event were recurring.

4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

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C cluster

1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma.

2. Efforts to avoid activities, places, or people that arouse recollections of the trauma.

3. Inability to recall an important aspect of the trauma.4. Markedly diminished interest or participation in significant

activities.5. Feeling of detachment or estrangement from others.6. Restricted range of affect.7. Sense of a foreshortened future.

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D cluster

1. Difficulty falling or staying asleep.

2. Irritability or outbursts of anger.

3. Difficulty concentrating

4. Hyper-vigilance

5. Exaggerated startle response

According to the DSM-IV criteria, the diagnosis of PTSD include 17 symptoms scored as 1 = none, 2 = slight, 3 = moderate,4 = severe, and 5 = extreme.

Subjects whose score is equal to or greater than 3 are defined as positive.

The 17 symptoms of PTSD are further divided into 3 groups, representing 3 diagnostic criteria: B, C, and D.

Criterion B symptoms represent the reexperiencing cluster: B1-5, Subjects are defined as positive if they show one or more positive items in the B group.

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Criterion C symptoms make up the avoidance cluster ： C1-7, Subjects are defined as positive if they show 3 or more positive items in the C group.

Criterion D symptoms make up the hyperarousal cluster: D1-5, Subjects are defined as positive if they show 2 or more positive items in the D group.

Subjects are given a diagnosis of PTSD if Criterion B, C, and D symptoms are all positive.

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MeasurementStructured interviews and self-rating scales. The Clinician-Administered PTSD scaleThe Structured Interview for DSM-IVThe Diagnostic Interview ScheduleThe Structured Interview for PTSDPTSD Checklist-Civilian version.The Davidson Trauma ScaleThe PTSD scaleOther instruments.

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Application PTSD is a commonly used indicator to evaluate the

psychological injuries after Traumatic events (natural, man-made, live stress event)

A lifetime prevalence of exposure to traumatic events ranged from 40% to 90% and a lifetime prevalence of PTSD in the community from 1% to 9%.

In flood victims ranges from 5% to 80% . Among many factors influencing the rate of PTSD, the

power of stressors connected with the catastrophe, the degree of exposure to trauma, and the amount of time elapsed since the event have emerged as critical variables.

A meta-analysis of the incidence of PTSD after floods

Both the English and Chinese literature associated with flood-related PTSD published from 1980 to 2013 were searched using the keywords PTSD and flood. The retrieval time is March 2014.

First authorYear of

publication

RegionPTSD

diagnosis standard

number of PTSD victims

Total Sample

size

Intensity of flood

Time of survey after

flood (month)

Score of literature quality

McMillen C] 2002St. Louis, US

DSM-III-R 35 162 severe 2 6

Norris FH] 2004 Mexico DSM-IV 134 561Moderate,

severe 6 6

Chae EH] 2005 South Korea DSM-IV 134 339 -- 4~6 5

Liu A] 2006 Hunan, China DSM-IV 2875 33340Mild, moderate,

severe 6~9 7

Bokszczanin A] 2007 Poland DSM-IV 94 533 severe 28 6Heo JH] 2008 South Korea DSM-IV 13 58 -- 18 5

Mason V] 2010 UK DSM-IV 124 444 severe 6 6Paranjothy S] 2011 UK DSM-IV 138 2019 mild 3~6 7

Chen Z] 2012 Gansu, China DSM-IV 125 268 severe 3 6Bei B] 2013 Australia DSM-IV 8 53 severe 1.5 5

Ishikawa M] 2013 Ladakh, India DSM-IV 2 318 -- 7 5Azuma K] 2013 Japan DSM-IV 18 297 severe 1~6 5

Alderman K] 2013 Australia DSM-IV 69 929 Mild, severe 4 7Peek-Asa C] 2012 US DSM-IV 93 1279 Mild, severe 1 7

Table1. Meta analysis of literature for PTSD after floods during 1980-2013

The weighted combined incidence of PTSD after floods was 15.74% with a 95% confidence interval of 11.25% ~ 20.82%.

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Application

PTSD is associated with increased rates of medical morbidity, poor health-related quality of life,and functional impairment.

PTSD has increased markedly over the last 2 decades. More and more scientists focused on PTSD (warfare, earthquake, traffic accident, violent crime, terrorist attack, rape, and pregnancy.). (9.11)

Hot topic

Pub Med: PTSD 2014-07-24: 25053

-------1989 1,061

1990-1999 3,919

2000-2009 11,141

2010-2014.7 8,932

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Application

1. Peng M, Liu A, Zhou J, et al. Association between posttraumatic stress disorder and preflood behavioral characteristics among children aged 7-15 years in Hunan, China. Med Princ Pract. 2011; 20(4):336-40.

2. Li X, Huang X, Tan H, Liu A, et al. . A study on the relationship between posttraumatic stress disorder in flood victim parents and children in Hunan, China. Aust N Z J Psychiatry. 2010 Jun;44(6):543-50

3. Huang P, Tan H, Liu A, et al. Prediction of posttraumatic stress disorder among adults in flood district. BMC Public Health. 2010 Apr 26; 10:207.

4. Liu A, Tan H, Zhou J, et al. A short DSM-IV screening scale to detect posttraumatic stress disorder after a natural disaster in a Chinese population. Psychiatry Res. 2008 Jun 30; 159(3):376-81. Epub 2008 May 6.

5. Feng S, Tan H, Benjamin A, Wen S, Liu A, et al. Social support and posttraumatic stress disorder among flood victims in Hunan, China. Ann Epidemiol. 2007 Oct; 17(10): 827-33. Epub 2007 Jul 2.

6. Liu A, Tan H, Zhou J, et al. Brief Screening Instrument of Posttraumatic Stress Disorder for Children and Adolescents 7–15 Years of Age. Child Psychiatry Hum Dev. 2007Oct; 38(3): 195-202. Epub 2007 Apr 3.

7. Liu A, Tan H, Zhou J, et al. An Epidemiologic Study of Posttraumatic Stress disorder in Flood Victims in Hunan China. Can J Psychiatry 2006,51(6): 350-4

8. Tan H, Ping W, Yang T, Li S, Liu A, et al. The Synthetic Evaluation Model for Analysis of Flooding Hazards. Eur J Public Health. 2007 Apr; 17(2): 206-10.23/4/19 19

9. 刘薇，谭红专，刘爱忠 ; 等 . 创伤后应激障碍与胃病发病关系的初步研究。医学临床研究 2006，（ 11）： 46-49

10. 易华云，刘爱忠，孙晓花 . 创伤后应激障碍的流行病学研究进展 . 中华创伤杂志 2006, 22(5):396-398.

11. 平卫伟，谭红专，杨土保，周价，刘爱忠，等 . 洪灾危害的卫生学综合评价指标研究 中华流行病学杂志 .2004,25(4)： 333-336.

12. 刘爱忠，谭红专，周价，等 . 洪灾区儿童创伤性应激障碍的流行病学研究 中国公共卫生 .2003,19(4)： 447-449.

13. 刘爱忠，谭红专，周价，等 . 洪灾后创伤性应激障碍及其影响因素的研究 中国医师杂志 .2003,5(12)： 1630-1632.

14. 刘爱忠，谭红专，周价，等 . 洪灾区 7-15岁儿童的行为问题及其影响因素的研究 中国学校卫生 2003， 24（ 6 ）： 591-592.

15. 伍志刚，刘爱忠，谭红专，等 . 洪灾区成人 PTSD及其危险因素的研究 中国临床心理学杂志 .2003,11(3)： 173-175

16. 平卫伟，谭红专，杨土保，周价，李硕颀，刘爱忠 . 洪灾危害程度综合评价指标体系的探讨 现代预防医学 .2003,30(4)： 475-477.

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Example

An epidemiologic study of PTSD in flood victims in Hunan ， China.

Supported by the grant from the Chinese Medicine Board (CMB).

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Example - Objective

To estimate the occurrence and to assess the determinants of PTSD in flood victims

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Example - Background

The target population was victims who had been directly exposed to the 1998-1999 flood in Hunan

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Example - Background Flood type:

soaked flood

collapsed flood

flash-flood Flood severity:

mild (affected area <50%)

intermediate (50% to 75%)

severe (>=75%)

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Example – Methods

Multistage sampling method to select study subjects. Data were collected in face-to-face interviews. Multiple logistic regression model to analyze the data.

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Example - Results A total of 8 counties, 40 towns, 310 villages,

13,450 families, and 38,760 individuals, 7 years of age or older were selected into this study.

33,340 (86.0% of the selected subjects in the study villages) were interviewed .

Table 1. Characteristics of the study areas and study populations

Soaked group Collapsed group Flashed group total

Geographic areas (km2) 1390(50.5%) 850(30.9%) 510(18.6%) 2750

population size 491153(54.4%) 329344(36.5%) 82312(9.1%) 902809

Flood-affected population

229331(42.4%) 265004(49.0%) 46881(8.6%) 541216

GDP in Yuan (per capital) 3102 2997 1856 2905

Medical staff (per 1000) 2.0 1.8 2.9 2.0

Hospital bed (per 1000) 0.92 0.79 2.19 0.99

study towns 23(57.5%) 12(30.0%) 5(12.5%) 40

study villages 169(54.7%) 135(43.7%) 5(1.6%) 309

study families 6229(47.1) 5598(42.3%) 1395(10.6%) 13222

study subjects 14394(43.1%) 13893(41.7%) 5053(15.2%) 33340

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chidren adults total

# with PTSD % with

PTSD

# with

PTSD

% with

PTSD

# with

PTSD

% with

PTSD

PTSD 280 4.6 2595 9.5 2875 8.6**

B 884 14.6 6579 24.1 7463 22.4**

C 488 8.0 3948 14.5 4436 13.3**

D 773 12.7 8058 29.6 8831 26.5**

**p<0.01

Table2 the rate of PTSD and B,C,D group syndromes

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Table3 the rate of PTSD and B,C, and D group syndromes by gender

Male Female X2 p

# with PTSD % with PTSD # with PTSD % with PTSD

PTSD 1429 8.1 1446 9.2 22.94 0.000

B 3654 20.8 3809 24.1 49.18 0.000

C 2330 13.3 2106 13.3 1.29 0.256

D 4415 25.2 4416 28.0 32.04 0.000

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Table4 the rate of PTSD and B, C, and D group syndromes by different age groups PTSD B C D

Age (year) # with PTSD

% with PTSD

# with B % with B # with C % with C # with D % with D

7～ 245 4.3 797 14.1 428 7.6 684 12.1

15～ 290 7.5 758 19.7 463 12.0 818 21.3

25～ 895 9.9 2204 24.4 1351 15.0 2605 28.8

35～ 594 9.6 1153 25.1 924 14.9 1901 30.7

45～ 408 9.4 1127 26.0 633 14.6 1440 33.2

55～ 257 9.8 617 23.4 372 14.1 815 31.0

65～ 186 11.2 407 24.4 265 15.9 568 34.1

X2 184.29 321. 78 217.86 909.77

P 0.000 0.000 0.000 0.000

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# of study subjects

# with PTSD

% with PTSD

Adjusted Odds ratio

95%CI

Sex          

Male 17543 1429 8.1 Reference  

Female 15797 1446 9.2 1.12 1.04-1.21

Age          

<18 6917 335 4.8 Reference  

18-59 23509 2230 9.5 2.28 2.02-2.57

≥60 2914 310 10.6 2.42 2.05-2.85

Flood type          

Soaked 14394 588 4.1 Reference  

Collapsed 13893 1440 10.4 1.84 1.64-2.05

Flashed 5053 847 16.8 3.12 2.76-3.52

Flood severity          

Mild 12245 331 2.7 Reference  

Moderate 8606 1111 12.9 4.05 3.55-4.62

Severe 12489 1433 11.5 2.98 2.60-3.41

Table5 Risk factors of PTSD in flood victims in Hunan, China, 1998-1999

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Example - Conclusion

PTSD occurs in about 8 to 9% of the flood victims, and the risk of PTSD increases in female and older victims and varies by type and severity of flood

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Example - Implications

1. PTSD is common in flood-affected population.

2. It is important to provide psychological support, in addition to physical support, for flood-affected population.

3. Particular attention should be paid to females and seniors in the flood-affected areas.

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Example - Limitations

1. The study findings were based on observation in a Chinese population in Hunan province, which may not be applicable to other populations

2. Definition for the severity and type of flood were quite arbitrary and may not necessarily reflect the nature of flood

3. We have not been able to study modifiable risk factors (family or social support) .

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To estimate the long-term prognosis and identify the prognostic factors.

"PTSD chronic risk prediction model": Specialized Research Fund for the Doctoral Program of Higher Education （ 20130162110054 ）

Other events: disease(cancer, MI, HIV/AIDS)

Thank you for your attention!