Trajectories of posttraumatic stress disorders among children after the Wenchuan earthquake: a four-year longitudinal study

Recurrence of post-traumatic stress disorder: systematic review of definitions, prevalence and predictors

BACKGROUND

Many people will experience a potentially traumatic event in their lifetime and a minority will go on to develop post-traumatic stress disorder (PTSD). A wealth of literature explores different trajectories of PTSD, focusing mostly on resilient, chronic, recovered and delayed-onset trajectories. Less is known about other potential trajectories such as recurring episodes of PTSD after initial recovery, and to date there has been no estimate of what percentage of those who initially recover from PTSD later go on to experience a recurrence. This systematic review aimed to synthesise existing literature to identify (i) how 'recurrence' of PTSD is defined in the literature; (ii) the prevalence of recurrent episodes of PTSD; and (iii) factors associated with recurrence.

METHODS

A literature search of five electronic databases identified primary, quantitative studies relevant to the research aims. Reference lists of studies meeting pre-defined inclusion criteria were also hand-searched. Relevant data were extracted systematically from the included studies and results are reported narratively.

RESULTS

Searches identified 5,398 studies, and 35 were deemed relevant to the aims of the review. Results showed there is little consensus in the terminology or definitions used to refer to recurrence of PTSD. Because recurrence was defined and measured in different ways across the literature, and prevalence rates were reported in numerous different ways, it was not possible to perform meta-analysis to estimate the prevalence of recurrence. We also found no consistent evidence regarding predictors of PTSD recurrence.

CONCLUSION

A clear and consistent evidence-based definition of recurrence is urgently needed before the prevalence and predictors of recurrence can be truly understood.

Trajectories of parental posttraumatic stress disorder and children's mental health following Super Typhoon Lekima: The mediating role of feeling of safety

INTRODUCTION

Several studies have examined the impact of parents' posttraumatic stress disorder (PTSD) on their children's mental health, but few have evaluated the role of parents' specific PTSD trajectories. The aim of this study was to assess the mechanisms underlying distinct trajectories of parental PTSD that affect children's PTSD and depression through the feeling of safety.

METHODS

The final sample comprised 242 dyads of parents and their children who experienced Super Typhoon Lekima in 2019. All participants were surveyed at three time points after the typhoon: 3 months (T1), 15 months (T2), and 27 months (T3). Parental PTSD symptoms at three time points and children's PTSD, depression, and feeling of safety at T3 were analyzed.

RESULTS

Four parental PTSD trajectories were identified: recovery, resilience, delayed, and coping. Compared with the resilient group, children of parents with delayed PTSD trajectories reported higher levels of depression at T3, while children of parents in the coping group were more likely to experience severe PTSD at T3. Children of parents in the recovery group, with a reduced feeling of safety, exhibited more severe depression and PTSD at T3, whereas children of parents in the delayed group were at an increased risk of PTSD at T3.

CONCLUSIONS

These findings highlight the heterogeneity of parental PTSD trajectories following natural disasters and their distinct effects on children's PTSD and depression. Furthermore, feeling of safety emerges as a crucial mechanism in this process.

Heart rate variability in 2014 predicted delayed onset of internalizing problems in 2015 among children affected by the 2011 Great East Japan Earthquake

Experience of natural disaster was related to an increased risk of long-term child internalizing problems. Initial traumatic experiences are hypothesized to work as disaster-related stresses and sensitize neural circuitry, leading to heightened reactivity to subsequent stressful experiences, which in turn results in delayed onset of internalizing problems. However, empirical evidence is lacking. Thus, we aimed to examine the association between heart rate variability (HRV) and internalizing problems among children exposed to the disaster. The Great East Japan Earthquake Follow-up for Children (GEJE-FC) study followed children aged 4-6 years old and their siblings and parents from three affected prefectures (Miyagi, Fukushima, and Iwate) and one unaffected prefecture (Mie) in Japan over four periods: from August 2012 to June 2013 (= T1), August 2013 to April 2014 (= T2), July 2014 to December 2014 (= T3), and August 2015 to December 2015 (= T4) (n = 155). HRV was assessed at T2 and T3 as a biomarker of autonomic nervous system activity. Child internalizing problems were assessed by caregivers at T3 and T4, using the Child Behavior Checklist. HRV measurements at T2 were not associated with child internalizing problems at T3. However, HRV in low frequency domains at T3 showed an inverse association with child internalizing problems at T4 (B = -1.72, 95% CI = -3.12 to -0.31). The findings indicated that later exacerbation of internalizing problems could be predicted by dysfunction of autonomic nervous system measured by HRV.

The Contributing Factors of Delayed-Onset Post-traumatic Stress Disorder Symptoms: A Nested Case-Control Study Conducted After the 2008 Wenchuan Earthquake

Background: Delayed-onset post-traumatic stress disorder after catastrophes is a major public health issue. However, good designs for identifying post-traumatic stress disorder (PTSD) among earthquake survivors are rare. This is the first nested case-control study to explore the possible factors associated with delayed-onset PTSD symptoms. Methods: A nested case-control study was conducted. The baseline (2011) and follow-up (2018) surveys were utilized to collect data. A total of 361 survivors of the Wenchuan earthquake were investigated and 340 survivors underwent follow-up. The survivors, from the hardest-hit areas, who met the criteria for PTSD were included in the case group, and PTSD-free survivors from the same area, matched for age, were included in the control group, with a ratio of one to four. Conditional logistic regression was used to evaluate the variables' odds ratio (OR). Results: The overall prevalence of delayed-onset PTSD symptoms in survivors of the Wenchuan earthquake was 9.7% (33/340). The unemployed earthquake survivors had a higher risk of developing delayed-onset PTSD symptoms (OR = 4.731, 95% CI = 1.408-15.901), while higher perceived social support was a protective factor against delayed-onset PTSD symptoms (OR = 0.172, 95% CI = 0.052-0.568). Conclusion: Delayed-onset PTSD symptoms, after a disaster, should not be ignored. Active social support and the provision of stable jobs can contribute to the earthquake survivors' mental health.

Consistencies and differences in posttraumatic stress disorder and depression trajectories from the Wenchuan earthquake among children over a 4-year period

BACKGROUND

Posttraumatic stress disorder (PTSD) and depression are the most prevalent mental disorders following disasters, and they often co-occur. The current study investigated trajectories of PTSD and depression among children after exposure to the Wenchuan earthquake and identified factors associated with PTSD or depression trajectories.

METHODS

Three hundred children who were exposed to the Wenchuan earthquake reported PTSD and depression symptoms 4, 16, 29, 40 and 52 months after the disaster, and potential predictors (age, earthquake exposure, prequake trauma and parental relationship) were identified. The PTSD and depression trajectories were identified with latent growth mixture modeling (LGMM), and the predictors were explored with multinomial logistic regression.

RESULTS

Two depression trajectories emerged: resilient (66.2%) and chronic (33.8%). Three PTSD trajectories emerged: resilient (74.9%), recovery (7.5%) and relapsing (17.7%). Overall, 57.3% of the children had low depression and PTSD symptoms over four years. Depression trajectories were significantly predicted by age and parental relationship, while PTSD trajectories were significantly predicted by trauma exposure and prequake trauma experience.

LIMITATIONS

The children's prequake mental health statuses were unknown, and all assessments relied on self-report questionnaires.

CONCLUSION

The postdisaster developmental course of depression was more stable than that of PTSD, and PTSD and depression had different risk factors. Previous studies that focus only on PTSD or depression trajectories may overestimate children's resilient responses. Longer-term postdisaster intervention should pay more attention to depression than to PTSD.

Evolution of the network pattern of posttraumatic stress symptoms among children and adolescents exposed to a disaster

Growing network approach analyses of posttraumatic stress disorder (PTSD) have enhanced the knowledge of PTSD symptomatology. This study aims to explore changes in network patterns of PTSD symptoms among youth survivors following the Zhouqu debris flow through a network approach. A two-year longitudinal study was conducted to follow 1460 children and adolescents at 3, 15, and 27 months after the disaster. Symptoms with high centrality varied at different time points. Sleep problems and nightmares exhibited high centrality at 3 months, and their centrality decreased over time, while the centrality of physiological cue reactivity and flashbacks increased over time and reached a high level at 27 months. The global connectivity of the network was stronger at 27 months than at 3 and 15 months. These findings provide novel insights into youths' PTSD symptom evolution. Temporal differences in PTSD symptoms merit more attention from researchers. Different core symptoms in acute and chronic PTSD structures should be treated as targets at different stages following trauma in clinical practice.

Mental Health in Frontline Medical Workers during the 2019 Novel Coronavirus Disease Epidemic in China: A Comparison with the General Population

BACKGROUND

Since December 2019, China has been affected by a severe outbreak of coronavirus disease 2019 (COVID-19). Frontline medical workers experienced difficulty due to the high risk of being infected and long and distressing work shifts. The current study aims to evaluate psychological symptoms in frontline medical workers during the COVID-19 epidemic in China and to perform a comparison with the general population.

METHODS

An online survey was conducted from 14 February 2020 to 29 March 2020. A total of 899 frontline medical workers and 1104 respondents in the general population participated. Depression, anxiety, insomnia, and resilience were assessed via the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7), Insomnia Severity Index (ISI), and abbreviated Connor-Davidson Resilience Scale (CD-RISC-10), respectively.

RESULTS

Overall, 30.43%, 20.29%, and 14.49% of frontline medical workers in Hubei Province and 23.13%, 13.14%, and 10.64% of frontline medical workers in other regions reported symptoms of depression, anxiety, and insomnia, respectively. In addition, 23.33%, 16.67%, and 6.67% of the general population in Hubei Province and 18.25%, 9.22%, and 7.17% of the general population in other regions reported symptoms of depression, anxiety, and insomnia, respectively. The resilience of frontline medical staff outside Hubei Province was higher than that of the general population outside Hubei Province.

CONCLUSION

A large proportion of frontline medical workers and the general public experienced psychological symptoms during the COVID-19 outbreak. Psychological services for frontline medical workers and the general public are needed.

Rumination mediates the relationships of fear and guilt to posttraumatic stress disorder and posttraumatic growth among adolescents after the Ya'an earthquake

Background: Although previous research has demonstrated that fear and guilt have an effect on posttraumatic stress disorder (PTSD), it is still unclear how these two emotions affect posttraumatic growth (PTG). Moreover, few studies have examined the mechanisms by which fear and guilt affect PTSD and PTG. Guided by Lee et al.'s theory of PTSD generation mechanisms and Calhoun and Tedeschi's PTG theory, the current study proposes that intrusive rumination (IR) and deliberate rumination (DR) may play a mediating role in the effects of guilt and fear on PTSD and PTG. Objective: This study aimed to simultaneously examine the mediating roles of IR and DR in the relationship between fear, guilt, PTSD, and PTG. Method: This study employed a two-wave longitudinal design. A total of 408 adolescent survivors were assessed using self-report questionnaires after the Ya'an earthquake in China. Measures were obtained for trauma exposure, subjective fear, survivor guilt, IR, and DR at three and a half years after the Ya'an earthquake (Time 1), while PTSD and PTG were assessed at time point four and a half years after the Ya'an earthquake (Time 2). Results: The results showed that both fear and guilt had a direct and positive effect on PTSD and PTG. Fear and guilt were positive predictors of PTSD and negative predictors of PTG through the mediating variable of IR. DR mediated the relationship between guilt and PTG but not PTSD, and also mediated the relationship between IR and PTG. Conclusions: Study findings indicate that fear, guilt, and intrusive rumination may contribute to PTSD symptoms in adolescent trauma survivors. Results also suggest that adolescent survivors can grow emotionally and psychologically following traumatic events, and that directed rumination may contribute to such growth. Interventions that reduce fear, guilt, and intrusive rumination while increasing directed rumination may assist adolescent trauma survivors in recovery and growth.

A mixed-methods investigation of parent-child posttrauma discussion and the effects of encouraging engagement

Recent developments in the child trauma field include preventative interventions that focus on augmenting parental support. However, we have limited knowledge of how parents experience trauma conversations with children. We examined how parents and children experienced both spontaneous trauma conversations and a structured task in which they generated a joint trauma narrative, following the child's experience of an acute trauma. Parent and child ratings of distress during the structured narrative were low for all 127 families that took part, with child ratings of distress being lower overall than parent ratings. Task-related distress was positively associated with parent and child PTSD symptoms. Thematic analysis of semi-structured interviews conducted with a subset of twenty parents identified both facilitators of (e.g. open and honest relationship with child) and barriers to (e.g. parent/child avoidance of discussion) spontaneous trauma-related conversations with their child. Additionally, parents described the structured trauma narrative task as an opportunity to start the conversation with their child, to understand their child's feelings, and for the child to process the trauma. However, the task was also uncomfortable or upsetting for some parents/children, and resulted in parents becoming more overprotective. The findings can inform development of low-dose interventions that encourage families to engage in trauma-related conversations following child experiences of trauma.