Relationships between posttraumatic stress disorder (PTSD), dissociation, quality of life, hopelessness, and suicidal ideation among earthquake survivors
Introduction
Epidemiological studies have shown that exposure to disasters i.e. earthquakes, floods, or hurricanes etc. are not rare among people and result in a broad range of mental and physical health consequences (Norris et al., 2002). Posttraumatic stress disorder (PTSD) is one of the most common stress reactions and presumably the most debilitating condition in case of trauma exposure, specifically disasters (Galea et al., 2005). Most individuals exposed to aversive life events experience a natural recovery process in the aftermath of the trauma and emotional regulation comes back to a level prior to the incident. Nevertheless, a substantial minority fail to extinguish eliciting various stress responses that perpetuate trauma-induced acute reactions in chronic suffering from severe symptoms, particularly PTSD (Breslau, 2002, Kessler et al., 1995).
Although defining the construct of dissociative phenomena is a matter of various debates because of its multifaceted characteristics, trauma-induced dissociation can be defined as a disruption in the usually integrated functions of mental processes including sense perceptions, thoughts, feelings, experiences, and memories (DePrince and Freyd, 2007). Significant linkages between the trauma and dissociation have also been well-established. Research has shown that dissociative symptoms have an important role in the development and maintenance of posttraumatic stress disorder (PTSD) (Galatzer-Levy et al., 2011, Stein et al., 2013, Wolf et al., 2012). Nonetheless, co-occurring dissociation is not peculiar to PTSD rather a broad range of dissociative symptomatology could be commonly observed among patients with other psychiatric disorders and even in general population (Giesbrecht et al., 2004, Maaranen et al., 2005, Mulder et al., 1998). Patients with dissociative symptoms have significantly higher rates of comorbid psychiatric conditions including depression, borderline personality disorder, and self-mutilation and suicide attempts (Ebrinc et al., 2008, Maaranen et al., 2005, Zoroglu et al., 2003). Also, it has been consistently demonstrated that dissociative experiences were associated with impaired quality of life such as physical and social functioning (Mitchell et al., 2012).
Bremner (1999) proposed a dualistic model of posttraumatic reactions is that psychological manifestations in response to traumatic events can be best understood by grouping posttraumatic syndrome into two lines: one predominantly dissociative and the other characterized by hyperarousal states. Experiencing dissociative symptoms during the adverse events strongly predicts latter onset of persistent PTSD (Friedman, 2013, Ozer et al., 2003) and dissociative symptoms such as numbing are a necessary condition for acute and posttraumatic stress disorder diagnosis in DSM-5 (American Psychiatric Association, 2013). Due to the stress–diathesis model of dissociation, dissociative mechanisms are implicated in either buffering stress-related extreme responses or disrupting affect regulation (Butler et al., 1996). Briere et al. (2005) submitted a distinction between peritraumatic and chronic pathological dissociation that, in comparison to the former, the latter was likely to represent a more pathological subtype of dissociation with worse psychological outcomes. Recent advances in PTSD research have provided supportive evidence for that dissociative symptomatology central to PTSD; whereas a sizable minority of individuals with persistent PTSD at about 30% seem to have a tendency to elicit more severe dissociative symptoms relative to the other subset of PTSD patients experiencing primarily hyperarousal states with relatively low dissociative inclination in response to reminders of trauma memory (Lanius et al., 2012). Moreover, the premise that dissociative phenomena convey both buffering and maladaptive effects among trauma exposed person was plainly demonstrated in a representative sample by Boysan (2014) that normal dissociation characterized by lower levels of dissociative experiences was negatively associated with measures of detrimental affective states; on the other extreme, greater levels of dissociative symptomatology was a significant predictor of elevations in affective symptoms. Over and above, pathological dissociation was not only a significant antecedent for persistent PTSD but also a mediator of significant associations of PTSD symptoms with other predictors as a risk factor (Kadak et al., 2013, Özdemir et al., 2015).
In the epidemiological studies of psychopathology, PTSD has exhibited an excessively discrete pattern of comorbidity relative to other psychiatric disorders and consistently detected to be co-occuring with other nosological entities to an extent to a higher of 92% (Keane et al., 2007). Significant linkages between PTSD and suicidal behaviors have long been recognized and an increase in research interest focusing on these relation has been carried on. Comorbid psychiatric conditions have been found to be conferring PTSD affected people at higher risk of suicidality across different populations, such as war veterans, survivors of disasters, victims of childhood and/or adult trauma (Krysinska and Lester, 2010, Panagioti et al., 2009, Panagioti et al., 2012). Some authors have postulated that traumatization result in disruption of basic psychobiological constructs that constitute personality (Hulette et al., 2011, Mauritz et al., 2013). These formulations suggest that traumatized individuals could exhibit behavioral problems, such as impulsivity, aggression, substance abuse, and self-injurious acts, as well as internalization problems including symptoms of depression and anxiety (Stein et al., 2013). In addition, commonly found was specifically major depression which seems to have a central role in a tendency to suicidal behaviors. Leiner et al. (2008) evidenced for mediational influence of comorbid depressive disorder in accounting the substantial relations between suicidal ideation and PSTD. A comprehensive meta-analysis put forth a series of considerable suggestions that significant correlates of PTSD were suicidal ideation and suicidal behaviors rather than completed suicides, and these relations were sustained irrespective of subtypes of traumatic experiences and of samples recruited from either psychiatric or community populations (Panagioti et al., 2012).
Despite suicide has long being a matter of intense interest and the extensive clinical and epidemiological literature, there are still huge gaps in our understanding of factors associated with suicidality and suicidal thought (Silverman, 2011). To the best of our knowledge, suicidality may be a relatively stable vulnerability for some individuals and unlike suicidal behaviors, suicidal ideation by its own may be a specific cognitive susceptibility factor for development of psychopathology rather than co-occuring with psychopathology, such as depression or PTSD. Poor problem solving capabilities, greater impulsivity (Windfuhr and Kapur, 2011), and deficiencies in interpersonal skills, conceptualized as burdensomeness and thwarted relatedness (Ribeiro and Joiner, 2011), have been suggested to be the hallmark features of suicidal individuals. Suicidal behavior is one of pathological manifestations which represents incapability in dealing with stressful situations coupled with emotional regulation deficits. General coping deficiencies in conjunction with emotional dysregulation may lead to both a failure in extinguishing acute stress responses and suicidal behaviors along with the psychopathology in the face of traumatic events. Turning to higher order cognitive information processing in suicide, the perception of defeat and entrapment are speculated to be significant correlates of suicidal behaviors (Johnson et al., 2008) which seem reminiscent of the conceptualization of mental defeat in the cognitive model of PTSD proposed by Ehlers and Clark (2000). Overlapping cognitive mechanisms in suicide and PTSD still remain elusive and need further investigations.
To date, several models have been proposed to explain the relationship between dissociation, and self-destructive behaviors that are important in suicide attempts. First, self mutilation might be related to regulate overwhelming discomfort of dissociative experiences, sensations, emotions or feelings resulting from immature and maladaptive coping strategies (Chang et al., 2010). Second, dissociative mechanisms may be upholding the pain threshold and pain tolerance during the self-injury behaviors (Orbach, 1994). Third, dissociative symptoms often accompany to psychiatric disorders, particularly major depression, and borderline personality disorder in which higher rates of suicidal behaviors are observed (Chang et al., 2010, Grabe et al., 1999, Klonsky and Moyer, 2008). Although, suicidal thoughts and proneness to suicidal behaviors generally suggested to be a function of mood regulation problems and psychopathology, to the best of our knowledge, these relations are likely to be reciprocally determined that suicidality may also be an important antecedent of mood symptoms and self-regulation problems. In a preliminary study, Selvi et al. (2010) demonstrated that, by using multi-sample path modeling, suicidal ideation was not predicted by depressive symptomatology but rather depressive symptoms were a product of suicidal ideation. In this vein, suicidality may be the antecedent of PTSD as a function of mediational effect of pathological dissociation.
In a recent study conducted amongst a representative community sample, Sareen et al. (2007) plainly provided convincing evidence for that PTSD remains a significant predictor of physical health problems after controlling for socio-demographic features and other mental disorders. PTSD was also predictive of suicide attempts, poor quality of life, and short- and long-term disability after adjusting for socio-demographic factors, mental disorders, and severity of physical disorders. Previous studies have consistently reported poor health status and functional impairment among disaster survivors. Lai et al. (2004) examined the differences in a set of demographic and clinical features between full, partial and non-PTSD groups after 10 months of a severe earthquake in Taiwan and found that individuals with either full or partial PTSD reported significantly greater levels of suicidality, general psychopathology, disability; and impaired well-being relative to individuals with non-PTSD. Injured victims of earthquake reported higher levels of PTSD symptoms compared to individuals with no injury due to the disaster (Kuo et al., 2007). Six months after the devastating floods and mudslides in Mexico, acute PTSD reactions were found to mediate the relations between disaster exposure and physical health problems in a sample of adults. Regardless of whether physical health was medically verifiable, subjective health was inversely associated with PTSD symptom severity (Norris et al., 2006).
In October 2011, an earthquake with a magnitude of 7.2 struck to Van Province in the eastern part of Turkey and caused severe damage. A great many aftershocks occurred after the earthquake and many people sought help in mental health services. In the present study conducted 2 years after the earthquake, our utmost aim was to examine the relations of PTSD symptom clusters with demographic characteristics, dissociation, quality of life, hopelessness, and suicidal ideation among a community sample, most of which experienced the disaster. The current study differentiates from prior investigations in several ways that in the literature, to date, various strands of research has partially focused on such relations in PTSD and moderately addressed these issues among individuals who experienced severe disasters. Given the variables of suicidality and dimensions of health status, previous surveillance has often been designed with such a formation of investigating co-occurrence of suicidality and health problems with PTSD or possible influence of posttraumatic syndromes on these conditions as outcomes. Moreover, as mentioned above, it appears that specifically the role of depression in PTSD symptom severity in response to traumatic experiences in disasters has been widely examined. However, potential influence of dissociation central to PTSD pathology has been increasingly recognized in recent advances but received less attention specifically in the epidemiology of disasters. In the present work, we put forth several hypothesis: (i) as the perceived symptom severity and meta-worry such as anxiety sensitivity is a risk factor for persistent PTSD (Kadak et al., 2013, Taylor, 2009), co-occurring mental and physical health problems such as depression, poor quality of life, and disability would significantly contribute to persistence of PTSD; (ii) individuals who were more prone to pathological dissociation would report more deteriorations in physical and mental health; and (iii) pathological dissociation would be not only predictive in PTSD symptom severity but also would mediate the relations between risk factors and PTSD.
Section snippets
Participants
Participants were 611 subjects recruited from Van, Turkey where was hit by a 7.2 magnitude earthquake on October 23rd, 2011. Due to missing data, 28 subjects were excluded from the analysis that the final sample consisted of 583 participants (428 male; 73.4%). Their mean age was 24.9 years (S.D.=6.5) and age of the sample ranged between 17 and 67 years. 261 participants (44.8%) experienced the earthquake. 71 participants had a psychiatric disorder (12.2%), 40 participants (6.9%) reported family
Results
To explore the differences in posttraumatic symptoms, depression, hopelessness and suicidal ideation as well as physical, social and emotional functioning in terms of the SF-36 sub-scales between individuals with a high tendency of pathological dissociation and without such an inclination, mean scale scores of participants in the DES-taxon group were compared with the scale scores of participants with no pathological dissociation by running one-way analysis of variance models. Individuals who
Discussion
In the current study, we examined the associations between PTSD, dissociation, quality of life, hopelessness, and suicidal ideation among earthquake survivors. The results of this study demonstrated that individuals with pathological dissociation have elevated depression, more severe PTSD symptoms, greater levels of suicidal ideation and hopelessness as well as lower quality of life compared to low dissociation group. Our findings suggested that there were significant linkages between
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2023, European Journal of Trauma and DissociationSuicide ideation and a post-disaster assessment of risk and protective factors among Hurricane Harvey survivors: Suicide Ideation Among Hurricane Harvey Survivors
2020, Journal of Affective DisordersCitation Excerpt :Despite the fact that suicidality has long been an interest in both clinical and epidemiological literatures, there continues to be significant gaps in our understanding of precisely what risk and protective factors are associated with these specific behaviors. While a number of studies have documented factors associated with suicidality in disaster zones, (Goldman and Galea, 2014; Kolves et al., 2013; Ozdemir et al., 2015) the current study, to the best of our knowledge, is the first to examine the correlates of suicide ideation among Hurricane Harvey survivors. A cross-sectional study of Hurricane Harvey adult survivors was conducted from October to December 2017.
Risk factors of post-traumatic stress among survivors of the 2017 Iran earthquake: The importance of peritraumatic dissociation
2019, Psychiatry ResearchCitation Excerpt :As shown in the Table 2, being female, having more education, history of recent trauma, trait dissociation, peritraumatic dissociation and being in need / damage to home and goods after the earthquake are the significant predictors of post-traumatic stress. The finding that being female is a risk factor in developing PTSD is in line with findings from recent studies (Cofini et al., 2015; Dell'Osso et al., 2011; Henderson and Elsass, 2015; Naeem et al., 2011; Ozdemir et al., 2015; Priebe et al., 2009; Salcioglu et al., 2007; Su et al., 2010; Wang et al., 2009; Xu and Song, 2011) and meta-analyses (Dai et al., 2016; Tang et al., 2017) but contradicts findings of one study on tsunami victims (Rosendal et al., 2011). The finding that more education is a risk factor in developing PTSD contradicts findings from earlier studies (Naeem et al., 2011; Priebe et al., 2009; Yuan et al., 2012; Wang et al., 2009; Xu and Song, 2011) and meta-analyses (Dai et al., 2016; Tang et al., 2017) but is in line with a study on Sri Lankan and Danish adults exposed to tsunami (Henderson and Elsass, 2015; Rosendal et al., 2011).
A senior high school-based survey on the long-term impact of the Wenchuan earthquake on survivors’ quality of life: PTSD as a mediator
2018, Psychiatry ResearchCitation Excerpt :Ozdemir et al. (2015) have similarly put forward that general health was inversely associated with PTSD symptom severity, while the earthquake-related trauma has no direct impact on GHQ and QOL. On the one hand, according to the research of Ozdemir et al. (2015), earthquake exposure is one of the significant predictors of PTSD symptom severity. Similarly, Chang et al. (2005) reported that bereaved students reported significantly higher PTSD rates and post-traumatic symptom levels with respect to those who were not bereaved.
The relationship between the frequency of suicidal ideation and sleep disturbance factors among adolescent earthquake victims in China
2018, General Hospital PsychiatryCitation Excerpt :Unfortunately, SI after disasters is poorly understood. Study of suicidal risk following natural disasters has focused more on adults [5–8] and less on teenagers [9,10]. In addition, SI has proven to be strongly associated with clinical and functional impairment and is a significant predictor of future suicide attempts [11,12], so it warrants public concern.