1. Floods and PTSD 1 Dr. Aizhong Liu( 刘爱忠） Prof., Chair Dept. of Epi & Health Statistics, school of public health, CSU lazroy@live.cn

2. 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. 2015-10-32

3. 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. 2015-10-33

4. 4 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.

5. 2015-10-35 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

6. 2015-10-36 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.

7. 2015-10-37 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.

8. 2015-10-38 D cluster 1. Difficulty falling or staying asleep. 2. Irritability or outbursts of anger. 3. Difficulty concentrating 4. Hyper-vigilance 5. Exaggerated startle response

9. 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. 2015-10-39

10. 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. 2015-10-310

11. 2015-10-311 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.

12. 2015-10-312 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.

13. 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.

15. First author Year of publicati on Region PTSD 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, USDSM-III-R35162severe26 Norris FH]2004MexicoDSM-IV134561Moderate, severe66 Chae EH]2005South KoreaDSM-IV134339--4~65 Liu A]2006Hunan, ChinaDSM-IV287533340 Mild, moderate, severe 6~97 Bokszczanin A]2007PolandDSM-IV94533severe286 Heo JH]2008South KoreaDSM-IV1358--185 Mason V]2010UKDSM-IV124444severe66 Paranjothy S]2011UKDSM-IV1382019mild3~67 Chen Z]2012Gansu, ChinaDSM-IV125268severe36 Bei B]2013AustraliaDSM-IV853severe1.55 Ishikawa M]2013Ladakh, IndiaDSM-IV2318--75 Azuma K]2013JapanDSM-IV18297severe1~65 Alderman K]2013AustraliaDSM-IV69929Mild, severe47 Peek-Asa C]2012USDSM-IV931279Mild, severe17 Table1. Meta analysis of literature for PTSD after floods during 1980-2013

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

17. 2015-10-317 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

18. Pub Med: PTSD 2014-07-24: 25053 -------1989 1,061 1990-1999 3,919 2000-200911,141 2010-2014.78,932 2015-10-318 Application

19. 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.Tan H 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. 2015-10-319

20.  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. 2015-10-320

21. 2015-10-321 Example An epidemiologic study of PTSD in flood victims in Hunan ， China. Supported by the grant from the Chinese Medicine Board (CMB).

22. 2015-10-322 Example - Objective To estimate the occurrence and to assess the determinants of PTSD in flood victims

23. 2015-10-323 Example - Background The target population was victims who had been directly exposed to the 1998-1999 flood in Hunan

24. 2015-10-324 Example - Background Flood type: soaked flood collapsed flood flash-flood Flood severity: mild (affected area <50%) intermediate (50% to 75%) severe (>=75%)

25. 2015-10-325 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.

26. 2015-10-326 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.

27. Table 1. Characteristics of the study areas and study populations Soaked groupCollapsed groupFlashed grouptotal Geographic areas (km 2 )1390(50.5%)850(30.9%)510(18.6%)2750 population size491153(54.4%)329344(36.5%)82312(9.1%)902809 Flood-affected population229331(42.4%)265004(49.0%)46881(8.6%)541216 GDP in Yuan (per capital)3102299718562905 Medical staff (per 1000)2.01.82.92.0 Hospital bed (per 1000)0.920.792.190.99 study towns23(57.5%)12(30.0%)5(12.5%)40 study villages169(54.7%)135(43.7%)5(1.6%)309 study families6229(47.1)5598(42.3%)1395(10.6%)13222 study subjects14394(43.1%)13893(41.7%)5053(15.2%)33340 2015-10-327

28. **p<0.01 Table2 the rate of PTSD and B,C,D group syndromes 2015-10-328

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31. # of study subjects # with PTSD % with PTSD Adjusted Odds ratio 95%CI Sex Male1754314298.1Reference Female1579714469.21.121.04-1.21 Age <1869173354.8Reference 18-592350922309.52.282.02-2.57 ≥ 60291431010.62.422.05-2.85 Flood type Soaked143945884.1Reference Collapsed13893144010.41.841.64-2.05 Flashed505384716.83.122.76-3.52 Flood severity Mild122453312.7Reference Moderate8606111112.94.053.55-4.62 Severe12489143311.52.982.60-3.41 Table5 Risk factors of PTSD in flood victims in Hunan, China, 1998-1999 2015-10-331

32. 2015-10-332 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

33. 2015-10-333 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.

34. 2015-10-334 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).

35. 2015-10-335 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)

36. Thank you for your attention!