A 13-year follow-up study of posttraumatic stress disorder in flood victims in Huarong China

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A 13-year follow-up study of posttraumatic stress
disorder in flood victims in Huarong China

• Shimin Hu, PhD candidate
• School of Public Health, Central South University
• 2014.8.19

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Contents

• 1. Introduction
• 2. Methods
• 3. Results and Discussion
• 4. Acknowledgments

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Introductionconception of PTSD

• Posttraumatic stress disorder(PTSD)is a severe
  and complex disorder precipitated by exposure to
  a psychologically distressing event and is
  characterized by persistent intrusive memories
  about the traumatic event, persistent avoidance
  of stimuli associated with the trauma, and
  persistent symptoms of increased arousal.

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Introductionrates of PTSD
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Introductionchronicity of PTSD

• Oil platform disasters
• World Trade Center Disaster
• Oklahoma city bombing
• Buffalo Creek dam collapse

chronicity rate of PTSD within the range of
6.3-68.9.
Oil platform disasters revealed chronic PTSD can
persist for over 27 years.
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Introductionharm of chronic PTSD

• A long disease course leads to huge burdens on
  the society, patients' families, and patients
  themselves. Importantly, patients with chronic
  PTSD experience significantly impaired quality of
  life. Doctor et al study demonstrated that
  chronic PTSD patients are willing to give up 34
  of their life span to live the rest of their life
  without PTSD.

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Introductionaim of this study
No study to our knowledge has focused on the
prognosis of PTSD for more than 10 years after a
flood.
Chinas Hunan province in 1998 and
1999 PTSD---8.6 Natural progression of
PTSD---unknown
Aim In this study, we analyzed the chronicity
rate of PTSD and associated prognostic factors in
part of these victims 13 years after the flood.
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Methods--Participants

• This study was a subsequent follow-up study of a
  large community-based survey.
• Previous study
• Covered 8 counties (Yueyang, Lingxiang, Huarong,
  Qianlianghu, Ziyang, Anxiang, Datonghu, Longshan)
  that had been directly exposed to the 19981999
  flood in Hunan province, China.
• 7 years of age or over-- enrolled
• A total of 2875 (8.6) subjects were diagnosed as
  PTSD according to the DSM-IV criteria.
• Current study
• Huarong540 PTSD patients,
• 16 years of age or over, 439 victims enrolled

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MethodsPTSD outcome

• The interviewers were trained in using PTSD
  Checklist-Civilian version (PCL-C) questionnaire
  developed from DSM-IV, which was also used in our
  former survey in 2000.
• 17 symptoms scored as 0 none, 1 slight, 2
  moderate, 3 severe, and 4 extreme (2 symptom
  positive)
• 3 sets of diagnostic criteria B(5), C(7), and
  D(5)
• the re-experiencing cluster B 1 positive
  symptoms
• the avoidance cluster C 3 positive symptoms
• the hyperarousal cluster D 2 positive symptoms

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MethodsIndividual characteristics
demographic characteristics
Flood-related stressors
After 2000, have you experienced or witnessed an
incident, which almost caused death or serious
injury and caused you to be frightened?
life-threatening experiences, death of a loved
one, victimization after the flood physical
illness/injury caused or exacerbated by the
flood, extreme physical adversity ,extreme
psychological adversity, major property loss,
income loss, and housing adversity
gender, age, and education level
frequency of general collective action
Post-flood severe stressors
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MethodsIndividual characteristics
frequency of general collective action
General collective action means participating in
the activities organized by the following groups
political party, trade union, environmental
group, parents / school association, tenants /
residents group or neighbourhood watch, church
organization, voluntary service group, pensioners
group /organization, social club / working mens
club, sports club and the Womens Institute
Situation in 2000 date of previous
study Situation around 2006 according to the
memory, collected currently Situation in 2012
collected currently
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MethodsStatistical methods
1. Post-flood severe stressors---- if positive,
exclude 2. two new indicators fluctuation of
frequency and total score of frequency,
according to the direction of change of frequency
of three periods 2000, around 2006, and
2012 total score of frequency integration of
frequency of three periods 3. grouped victims
with constant score of frequency into a group to
analyze the date separately
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Results and Discussion

• Baseline data

439 individuals were selected for this study

151 were visited at their home
30 died of old age

173 temporarily left to find work in other cities
85 migrated to other villages or counties


151 were visited at their home
9 subjects with positive answer of Post-flood
severe stressors
144 victims included
--

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Table 1. Comparison of Individual characteristics
between subjects interviewed (n 144) and
unreachable (n 288)
Individual characteristics Interviewed Interviewed Unreachable Unreachable ?2 P
Individual characteristics Number Number ?2 P
Gender            
Male 79 54.9 146 50.7 0.668 0. 414
Female 65 45.1 142 49.3 0.668 0. 414
Age            
29-57 97 67.4 234 81.3 10.338 0.001
58-81 47 32.6 54 18.8 10.338 0.001
Education Level            
Elementary school or below 56 38.9 91 31.6 2.274 0.132
Middle school or above 88 61.1 197 68.4 2.274 0.132
Flood-related stressors            
0 55 38.2 106 36.8 0.297 0.862
1 35 24.3 77 26.7 0.297 0.862
2 54 37.5 105 36.5 0.297 0.862
Frequency of General Collective Action at 2000            
Never 25 17.4 61 21.2 1.998 0.368
Occasionally 60 41.7 101 35.1 1.998 0.368
Actively 59 41.0 126 43.8 1.998 0.368
more young subjects among the unreachable victims
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Table 2. DSM-IV criterion symptoms of PTSD
reported by 144 subjects with PTSD 13-year after
first exposure to flood
PTSD symptoms N
PTSD 21 14.6
B. Re-experiencing 111 77.1
B1. Intrusive recollections 91 63.2
B2. Repeated nightmares about floods 46 31.9
B3. Acting as if the flood is occurring 42 29.2
B4. Feeling worse mentally when reminded of the flood 74 51.4
B5. Feeling worse physically when reminded of the flood 40 27.8
C. Avoidance/Numbing 23 16.0
C1. Efforts to avoid thoughts or feelings associated with the flood 31 21.5
C2. Efforts to avoid activities that arouse recollections of the flood 29 20.1
C3. Amnesia in regards to the flood 8 5.6
C4. Diminished interest 21 14.6
C5. Detachment or estrangement 18 12.5
C6. Restricted range of emotion 17 11.8
C7. Sense of foreshortened future 19 13.2
D. Hyper-arousal 70 48.6
D1. Difficulty falling or staying asleep 43 29.9
D2. Irritability or anger 57 39.6
D3. Difficulty concentrating 19 13.2
D4. Hyper-vigilance 71 49.3
D5. Exaggerated startle response 48 33.3
The positive rate of Group C was much lower than
group B and D. Although the dates were not
list, the positive rate of 3 symptom group were
undoubtedly all 100 in 2000. Group C had
biggest drops in positive rate (Plt0.000, by ?2
test, have not shown in table).
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Table 3. Independent prognosis factors for
current PTSD, expressed in OR and adjusted ORs of
6 models
Individual Characteristics Univariate Analysis Univariate Analysis Univariate Analysis 2000 model Around 2006 model 2012 model Fluctuation model Total Scores model Constant Scores model
Individual Characteristics Number prevalence OR Adjusted OR Adjusted OR Adjusted OR Adjusted OR Adjusted OR Adjusted OR
Gender                  
Male 79 12.7 Reference            
Female 65 16.9 1.406 1.428 1.412 1.390 1.373 1.373 0.978
Age                  
29-57 97 15.5 Reference            
58-81 47 12.8 0.800 0.559 0.624 0.846 0.836 0.583 1.248
Education Level                  
Elementary school or below 56 14.3 Reference            
Middle school or above 88 14.8 1.040 0.859 0.862 0.985 0.907 0.772 0.439
Flood-related stressors                  
0 55 3.6 Reference            
1 35 17.1 5.483 7.892 8.479 8.290 6.213 8.038 8.655
2 54 24.1 8.402 12.486 12.712 9.670 9.067 12.657 21.882
FGCA at 2000                  
Never 25 40.0 Reference            
Occasionally 60 11.7 0.198 0.136          
Actively 59 6.8 0.109 0.075          
FGCA at around 2006                  
Never 22 54.5 Reference            
Occasionally 60 8.3 0.076   0.057        
Actively 62 6.5 0.057   0.045        
FGCA at 2012                  
Never 28 42.9 Reference            
Occasionally 46 13.0 0.200     0.222      
Actively 70 4.3 0.060     0.052      
Fluctuation of FGCA                  
No Change 87 16.1 Reference            
Getting Frequent 29 6.9 0.386       0.335    
Getting Less Frequent 19 21.1 1.390       1.172    
Fluctuation 9 11.1 0.652       0.523    
Total Scores of FGCA                  
3 18 50.0 Reference            
4-6 45 17.8 0.216         0.187  
7-9 81 4.9 0.052         0.037  
Victims with constant score of FGCA                  
Never 18 50.0 Reference            
Occasionally 28 10.7 0.120           0.099
Actively 41 4.9 0.051           0.034
Note FGCA Frequency of General Collective
Action Constant Score model only have 87 victims
involved p lt .05 p lt .01 p lt .001.
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interpretation of table 3

• Flood-related stressors in our study included
  some factors reflecting the quality and privacy
  of life during post-disaster temporary
  resettlement. These may suggest that keeping
  victims safe with adequate food and clothing is
  very important but not enough post disaster.
  Government should take the privacy of living and
  calming nerves into consideration.
• Participating in general collective action can
  strengthen victims contact with society, and may
  have a positive impact on prognosis of PTSD
  through individual appraisal processes (i.e.
  primary and secondary appraisal), social support,
  and coping behavior. Our study therefore suggests
  that more social participation is beneficial to
  the recovery of PTSD.

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Conclusion

• This study suggests the existence of chronicity
  in PTSD victims of flood. Remission of the
  avoidance/numbing symptoms plays an important
  role in the recovery from PTSD. More social
  participation is beneficial to the recovery of
  PTSD and re-building a high quality life after a
  disaster with help from society or the government
  could reduce the development of chronic PTSD in
  flood victims.

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limitations

• sample size is small
• PTSD symptoms often fluctuate. Observations on
  relapsing-remitting and late-onset symptoms'
  trajectories may add more information to the
  current one level measurement.

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Acknowledgments

• This study was supported by the Fundamental
  Research Funds for the Central Universities of
  Central South University (2013zzts289) and
  Specialized Research Fund for the Doctoral
  Program of Higher Education(20130162110054).
• Aizhong Liu, Hongzhuan Tan, Reuben Cofie, Jia
  Zhou, Tubao Yang, Xuemin Tang contribute a lot to
  this study.

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The end Thank you!