Download PTSD?

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
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[email protected]
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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?
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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.
2.
3.
4.
5.
Difficulty falling or staying asleep.
Irritability or outbursts of anger.
Difficulty concentrating
Hyper-vigilance
Exaggerated startle response
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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: B15, 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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Measurement
Structured interviews and self-rating scales.
The Clinician-Administered PTSD scale
The Structured Interview for DSM-IV
The Diagnostic Interview Schedule
The Structured Interview for PTSD
PTSD Checklist-Civilian version.
The Davidson Trauma Scale
The PTSD scale
Other instruments.
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Application
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PTSD is a commonly used indicator to evaluate the
psychological injuries after Traumatic events (natural, manmade, 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.
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A meta-analysis of the incidence of PTSD
after floods
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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.
Table1. Meta analysis of literature for PTSD after floods during 1980-2013
First author
Year of
publicati
on
McMillen C]
Norris FH]
Chae EH]
2002
2004
2005
Region
PTSD
diagnosis
standard
St. Louis, US DSM-III-R
Mexico
DSM-IV
South Korea DSM-IV
number Total
of PTSD Sample
victims
size
Intensity of
flood
Time of
Score of
survey after
literature
flood
quality
(month)
35
134
134
162
561
339
severe
Moderate, severe
--
2
6
4~6
6
6
5
Liu A]
2006 Hunan, China
DSM-IV
2875
33340
Mild, moderate,
severe
6~9
7
Bokszczanin A]
Heo JH]
Mason V]
Paranjothy S]
Chen Z]
Bei B]
Ishikawa M]
Azuma K]
Alderman K]
Peek-Asa C]
2007
Poland
2008 South Korea
2010
UK
2011
UK
2012 Gansu, China
2013
Australia
2013 Ladakh, India
2013
Japan
2013
Australia
2012
US
DSM-IV
DSM-IV
DSM-IV
DSM-IV
DSM-IV
DSM-IV
DSM-IV
DSM-IV
DSM-IV
DSM-IV
94
13
124
138
125
8
2
18
69
93
533
58
444
2019
268
53
318
297
929
1279
severe
-severe
mild
severe
severe
-severe
Mild, severe
Mild, severe
28
18
6
3~6
3
1.5
7
1~6
4
1
6
5
6
7
6
5
5
5
7
7
The weighted combined incidence of PTSD after floods was 15.74% with a
95% confidence interval of 11.25% ~ 20.82%.
Application
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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
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Application
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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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1.
2.
3.
4.
5.
6.
7.
8.
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.
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
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.
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.
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.
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.
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
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.
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9.
10.
11.
12.
13.
14.
15.
16.
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
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.
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.
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.
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.
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.
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
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
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An epidemiologic study of PTSD in
flood victims in Hunan，China.
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Supported by the grant from the Chinese
Medicine Board (CMB).
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Example - Objective
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To estimate the occurrence and to assess the
determinants of PTSD in flood victims
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Example - Background
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The target population was victims who had
been directly exposed to the 1998-1999
flood in Hunan
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Example - Background
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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
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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
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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 .
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Table 1. Characteristics of the study areas and study populations
Soaked group
Collapsed group
Flashed group
total
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
Geographic areas (km2)
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Table2 the rate of PTSD and B,C,D group syndromes
chidren
# with PTSD
adults
total
% with
# with
% with
# with
% with
PTSD
PTSD
PTSD
PTSD
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
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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
Age (year)
7～
15～
25～
35～
45～
55～
65～
X2
P
PTSD
# with % with
PTSD
PTSD
245
290
895
594
408
257
186
4.3
7.5
9.9
9.6
9.4
9.8
11.2
184.29
0.000
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B
C
D
# with B % with B # with C % with C # with D
797
758
2204
1153
1127
617
407
14.1
19.7
24.4
25.1
26.0
23.4
24.4
321.78
0.000
428
463
1351
924
633
372
265
7.6
12.0
15.0
14.9
14.6
14.1
15.9
217.86
0.000
% with D
684
818
2605
1901
1440
815
568
12.1
21.3
28.8
30.7
33.2
31.0
34.1
909.77
0.000
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Table5 Risk factors of PTSD in flood victims in Hunan, China, 1998-1999
# of study
subjects
# with
PTSD
% with
PTSD
Adjusted
Odds ratio
95%CI
Male
17543
1429
8.1
Reference
Female
15797
1446
9.2
1.12
<18
6917
335
4.8
Reference
18-59
23509
2230
9.5
2.28
2.02-2.57
2914
310
10.6
2.42
2.05-2.85
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
Mild
12245
331
2.7
Reference
Moderate
8606
1111
12.9
4.05
3.55-4.62
Severe2017/4/30
12489
1433
11.5
2.98
31
2.60-3.41
Sex
1.04-1.21
Age
≥60
Flood type
Flood severity
Example - Conclusion
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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.
2.
3.
PTSD is common in flood-affected population.
It is important to provide psychological support, in
addition to physical support, for flood-affected
population.
Particular attention should be paid to females and
seniors in the flood-affected areas.
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Example - Limitations
1.
2.
3.
The study findings were based on observation in
a Chinese population in Hunan province, which
may not be applicable to other populations
Definition for the severity and type of flood were
quite arbitrary and may not necessarily reflect the
nature of flood
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)
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Thank you for your attention!