OR PROOFREADING ONLY. Psychological Consequences of the 1999 Earthquake in Turkey 1

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1 Journal of Traumatic Stress, Vol. 17, No. 6, December 2004, pp ( C 2004) Psychological Consequences of the 1999 Earthquake in Turkey 1 Ümit Tural, 2,6 Bülent Coşkun, 2,3 Emin Önder, 2,4 Aytül Çorapçıoğlu, 2 Mustafa Yıldız, 2 Coşkun Kesepara, 2 Işık Karakaya, 5 Mustafa Aydın, 2,4 Ayla Erol, 2 Fuat Torun, 2 and Gaye Aybar 2 OR PROOFREADING ONLY We explored the prevalence of posttraumatic stress disorder (PTSD) and its relation to demographic characteristics and other risk factors for developing PTSD in a large sample (N = 910) of earthquake survivors living in tent city. Twenty-five percent of the sample met DSM-IV criteria for PTSD assessed with the Posttraumatic Stress Disorder Self Test (PTSD-S). Peritraumatic factors explained the most variance when the risk factors were grouped as demographics, pretraumatic, peritraumatic, and posttraumatic. The study emphasized that PTSD among the earthquake victims was as prevalent in Turkey as after disasters in other developing countries but higher than usually found after disasters in developed countries, and there was a relation between some factors mostly peritraumatic and PTSD. KEY WORDS: posttraumatic stress disorder; natural disasters; predictor; prevalence. Natural disasters, such as earthquakes, hurricanes and cyclones, floods, and tornadoes are some of the traumatic events that may cause posttraumatic stress disorder (PTSD; American Psychiatric Association, 1994). Estimates of the prevalence of PTSD from surveys of the general adult population ranged from 1.0 to 12.3% (Fairbank, Ebert, & Costello, 2000). Studies of individuals at risk (e.g., combat veterans, victim of natural disasters or crim- 1 This study was presented in part at the 37th Turkish National Psychiatry Congress, Istanbul, Turkey, 2001 and awarded with the Turkish Psychiatric Association Research Prize. 2 Department of Psychiatry, Medical School of Kocaeli University, Derince Izmit, Turkey. 3 Community Mental Health Unit of Kocaeli University, Izmit, Turkey. 4 Psychological Trauma Centre (IREM), Kocaeli University, Izmit, Turkey. 5 Department of Child and Adolescent Psychiatry, Medical School of Kocaeli University, Derince Izmit, Kocaeli, Turkey. 6 To whom correspondence should be addressed at Kocaeli Üniversitesi Tıp Fakültesi Psikiyatri Bölümü, Derince _Izmit, Kocaeli, Turkey; turalu@kou.edu.tr. inal violence) yielded prevalence rates ranging from 3 to 58% (Fairbank et al., 2000; McNally, 1992). Some reports have suggested that PTSD is common after devastating earthquakes in developing countries. For example, after the 1988 Armenian Earthquake, the DSM-III-R rate of PTSD was found to be 87% (Goenjian et al., 1994) and 73% (Goenjian et al., 2000) after 1.5 and 4.5 years, respectively. Armenian et al. (2000) found a 50% PTSD rate in another sample of Armenian earthquake survivors, 2 years after the event. A recent study from Turkey found that the adjusted rate for PTSD was 43% 1 year after the earthquake in the survivor camps (Başoğlu, Şalcıoğlu, & Livanou, 2002). In China, the rate of earthquake-related PTSD within 9 months was 24% scored according to DSM-IV criteria (Wang et al., 2000). Despite the high rates of PTSD after earthquakes in developing countries, studies of disasters in developing countries remain few. In an extensive review, it was reported that only 14% of disaster samples have been from developing countries and, furthermore, that a greater risk for sample-level severe or very severe impairment exists /04/ /1 C 2004 Springer Science+Business Media, Inc.

2 452 Tural et al. in developing countries than in U.S. samples (78% vs. 25%; Norris et al., 2002). The need for more studies focused on earthquakes in developing countries is evident considering that 91 of the 108 major earthquakes (with a death toll over 1,000 from 1900) in the twentieth century occurred in the developing countries, accounting for 83% of 1.8 million deaths worldwide (National Earthquake Information Center, 2000). We know relatively little about the psychological consequences of earthquakes in developing countries even though they are prone to large-scale destruction because of their geographical location, poor structural quality of buildings, insufficient machinery and equipment, and unpreparedness for earthquakes. Because PTSD and other disaster-related psychological problems are prevalent after natural disasters, it is important to determine the people who develop disaster-related psychological problems especially for planning appropriate interventions both in the shortand long-term after disaster (Coşkun & Coşkun, 2000). Previous psychiatric disorders, female gender, and severity of earthquake experience have consistently been found to relate to worse psychological outcomes after earthquakes (Armenian et al., 2000; Başoğlu et al., 2002; Kılıç & Ulusoy, 2003; Lewin, Carr, & Webster, 1998; Webster, McDonald, Lewin, & Carr, 1995; Wang et al., 2000). Other reported predictors of post-earthquake psychological problems are loss of close ones (Armenian et al., 2000; Başoğlu et al., 2002), older age at trauma (Lewin et al., 1998), lower education (Armenian et al., 2000; Başoğlu et al., 2002; Webster et al., 1995), previous trauma (Goenjian et al., 1994), neuroticism (Lewin et al., 1998), family history of psychiatric disorders (Başoğlu et al., 2002), ethnicity (Webster et al., 1995), being single or widowed (Lima et al., 1989), property or resource loss (Armenian et al., 2000; Bland et al., 1997), being alone during earthquake (Armenian et al., 2000), avoidance-type coping (Webster et al., 1995), lower social support (Armenian et al., 2000; Bland et al., 1997), and stressful life events (Lewin et al., 1998). The present study has two main objectives: (1) to find the prevalence of PTSD in a selected population exposed to the earthquake that demolished Kocaeli, north-western Turkey, in August 1999; and (2) to identify risk factors for PTSD. In the light of previous evidence, we organized risk factors into four groups: demographic characteristics, pretraumatic, peritraumatic, and posttraumatic period. The Earthquake in the Marmara Region, Turkey At 03:01 a.m. on August 17, 1999, an earthquake that measured 7.4 on the Richter scale awakened residents of the big provinces of Kocaeli, Sakarya, Bursa, and, Istanbul. The earthquake s epicenter was located in Gölcük, which is a county in Kocaeli. The earthquake resulted in 15,226 fatalities, 23,983 wounded, and caused approximately US $9 13 billion of property damage. Altogether, 27,634 households were totally destroyed or heavily damaged, and 27,428 households were moderately damaged. It was estimated that 14,444,298 inhabitants living in the Marmara region were affected by the event (Government Planning Organization of Primeministery, 1999). After the Marmara earthquake, the Turkish Government and Military Forces established and ran a number of tent cities (survivor camps) in the Marmara region, including the Mehmetçik tent city that was located in Kocaeli about 20 km from Gölcük. At approximately the same time, the Kocaeli University Psychiatry Department began providing counseling and other social services to the Mehmetçik camp as well as the other camps. The main base of the social support service was located on the Mehmetçik camp. Method Participants and the Study Design This study was conducted after the Marmara Earthquake (between December 1999 and August 2000) at the Mehmetçik tent city. A thousand persons were selected randomly from approximately 5,000 inhabitants. Research teams visited every tent in the Mehmetçik tent city one by one and explained the aims of the study. A potential participant between the ages of 16 and 65 within the residents of tent (household), who were present at the time of visit by research team, was selected on the basis of birth date. The one whose birthday was closest to the date of interview was selected as potential participant. After a presentation of the study, oral consent was obtained. If, for some reason, that person was unable to be interviewed or she/he refused to participate, the person with the next closest birthday was selected and invited to participate in the study. All steps of participation were voluntary and participants were free to stop the interview at any time. Interviewers were the authors (CK, IK, MA, AE, FT, GA) who were assistant Doctors of Psychiatry and known by residents of the tent city. Participants filled in the forms in a single session. Participants who had difficulty in understanding the written material or had low educational levels were helped to complete the survey by staff. Ninety households refused to participate. The response rate was 91%, and totally 910 persons between the ages 16 and 65 participated in the study and filled in the earthquake inquiry form.

3 Psychological Consequences of the 1999 Earthquake in Turkey 453 Assessment Instruments The assessment included a 1-hr paper and pencil survey that measured survivors background characteristics, certain risk factors and DSM-IV criteria for PTSD. The earthquake inquiry form was designed by the investigators and consisted of items including: demographic variables; psychological and psychosocial consequences of the trauma; and PTSD-Self Test (PTSD-S). Demographic Characteristics Form This was a self-reported form specifically developed by the investigators for the study, which recorded the demographic characteristics of participants such as age, sex, marital status (unmarried, married, divorced, widowed), educational level (illiterate, literate, primary school, middle school, high school and university), family type (traditional or core), current employment status (yes, no), and occupation. The Form of Psychological and Psychosocial Consequences of the Trauma This self-report questionnaire developed by the investigators gathered information about risk factors and the psychological and psychosocial consequences of the Marmara Earthquake. Questions were anchored to the effects of the Marmara Earthquake and, except where noted, the information was coded 0 for a no response and 1 for a yes response. In particular, this section contained items on known risk factors in the development of the PTSD as reported in the previous studies. The known risk factors were categorized into three main groups as pretraumatic, peritraumatic, and posttraumatic. The risk factors explored by investigators at pretraumatic (last 6 months to trauma) period were as follows: general features of the person s life; moral support (by family, friends, relatives, public institutions or volunteer associations); the length (in months) of residency in the earthquake area; income (in local currency, monthly), personal and family history of physical and psychiatric disorders (the type, duration of physical or psychiatric disorder, and need for hospitalizations), previous traumatic experiences, such as rape, assault, fire, accident, combat and natural disasters; psychological distress induced by stressful life events in the last month prior to trauma, such as divorce, immigration, financial problems, unemployment, loss of job, being robbed, being arrested, disrupted relationships with friend, husband or wife, broken relationships with acquaintances, serious illness, moved, serious illness to a family member, or death of a family member; and nicotine alcohol drug usage habits and amount (recoded into two categories yes or no for each one of the substances). Peritraumatic factors (the trauma and next 2 weeks) included the following: physical injuries due to the earthquake (presence of bone fractures, renal failure, hospitalization, wounded skin, bruises); damage to one s house at the moment of earthquake (5-point scale); being alone in the earthquake; deaths of family members (each one of the loss such as suppose, child, parents, brother or sister were recorded and recoded into two categories yes or no); relatives or significant others being trapped under collapsed buildings (the time passed under rubble recorded and recoded into two categories yes or no); fears, emotions, perceptions, and cognitions related to the earthquake (unusual visual, auditory, smelling or tactile perceptions, such as hearing the crashes, screams or booming, seeing the bright light, smelling of putrid corpses, burns, chemicals or cement, the level of perceived threat to life (4-point scale); sense of helplessness; working with volunteer rescue teams; and witnessing a dead body or body parts. The posttraumatic period (between 2 weeks after the trauma and assessment time) factors included material damages and financial problems including homelessness, increase of expenses, debts; level of lost possessions (4- level scale); family and work problems, such as loss or change of job, variation of income, hard work conditions, loss of family privacy due to crowded living places; variation in consumption or abuse of alcohol nicotine drug (decreased, unaltered, increased); variation in monthly income (reduced, unaltered, increased); material or moral support by family, friends, relatives, public institutions, or volunteer associations; their satisfaction with material and mental health support; scientific information about the traumatic event. Posttraumatic Stress Disorder Self Test (PTSD-S) Diagnosis of current PTSD was made by using the PTSD-S (Anxiety Disorders Association of America, 1999) at the assessment time. This questionnaire was selfrated, and derived from the PTSD criteria for DSM-IV. The scale has one item for category A, three items for category B, seven items for category C, and five items for category D. It also measures the category E (symptom duration more than a month) and F (symptoms interfere with the daily life and the occupation). In this screening test, participants answered the questions in the form of yes or no. Patients who met PTSD criteria according to

4 454 Tural et al. DSM-IV on the self-reported PTSD-S questionnaire (positive category A, at least one symptom from category B, at least three symptoms from category C, at least two symptoms from category D, positive category E and positive category F) were classified as PTSD positive. Questions answered in the affirmative were given 1 point, and negative responses were assigned zero points. The total score of PTSD-S was calculated by summing up the values for each symptom. Therefore, higher total scores indicated higher frequency of PTSD symptoms. Although PTSD-S appears face-valid in matching DSM criteria, the authors established the Turkish reliability and validity of the scale in 90 of the earthquake survivors. The scale was internally consistent, α =.89. For subscales the Cronbach s α values were.76 for the reexperiencing subscale,.79 for the avoidance/emotional numbness subscale, and.79 for the arousal subscale. The construct validity was assessed with the Clinician-Administered PTSD Scale for DSM-IV (CAPS). The concordance between the two scales was 86.6%, while false-positive and false-negative diagnoses were observed in 8.6 and 21.9% of the cases, respectively. Cohen s Kappa value as a measure of agreement between CAPS and PTSD-S was.71, p<.001. With these figures, the scale was shown to be as reliable and valid for screening the PTSD. Statistical Analyses We calculated both the overall prevalence of current PTSD and the prevalence according to covariates of interest. Chi-square tests (with continuity correction for 2 2 tables) were used to examine for possible differences in the categorical variables, and t tests for independent groups were used to evaluate differences in the continuous variables. A hierarchical multiple logistic regression, which allows obtaining the relative contribution of each set of predictors to variance explained (R 2 ), was used to examine predictors for PTSD and multivariate associations. The covariates were classified into groups (blocks) as demographics, pre-, peri-, and posttraumatic factors, and then these blocks were entered hierarchically to regression analysis with stepwise selection only within each new block. Differences in log likelihood (p <.05) were used to determine whether variables would be retained or removed in subsequent models. In that multiple regression analysis with simple contrast model, each category of the predictor variable (except the reference category) is compared to the reference category and it gives the predicted change in odds for a unit increase in the predictor. Statistical analyses were performed with SPSS for windows statistical analysis software, version All tests were two-tailed. Significance was defined as p<.05 with a two-tailed test. Results Sample and Prevalence of PTSD The mean age of the 910 participants was 36.1 years (SD = 13.3) on the day of interview, mean duration of habitation in the earthquake area was 21.2 (SD = 14.0) years. The majority (63.7%, n = 580) of participants were women, and 36.3% (n = 330) were men. Overall, 67.7% of the respondents were married, and 41.5% were primary school educated. Of these participants 25.4% (n = 231) met study criteria for PTSD as assessed with the PTSD-S. PTSD-S score averaged 9.95 (SD =5.11). Bivariate Associations Demographic Charactersitics and PTSD (Table 1) Women have a significantly higher PTSD frequency than men do as shown in Table 1. The mean ages of participants with PTSD (37.6, SD = 12.6) and without PTSD (35.6, SD = 13.5) were not significantly different, t(908) = 1.88, ns. A significant association was observed between marital status and developing PTSD. Frequency of PTSD was significantly less prevalent in unmarried persons than in married, widowed, or divorced persons. A significant negative association between educational level and rate of PTSD was observed. In the higher degree of education (university) group, the rate of PTSD was the lowest. Pretraumatic Factors and PTSD (Table 1) A history of psychiatric treatment, mostly at outpatient clinics, was reported by 20.4% of the participants. Participants who had a psychiatric history prior to the disaster had a significantly higher prevalence of current PTSD that did those who had no psychiatric history. It was also found that PTSD frequency was significantly higher in those who had a family history of psychiatric disorders, a personal history of traumatic experience, or psychological distress prior to the earthquake. PTSD-S scores decreased significantly as participant s length of residence in the earthquake area increased, r = 0.09, p<.05 controlling for age.

5 Psychological Consequences of the 1999 Earthquake in Turkey 455 Table 1. Comparison of Participants With and Without PTSD on Demographic Characteristics and Pretraumatic Factors Variable Without PTSD PTSD df χ 2 Gender, n (%) Femal 413 (71.2) 167 (28.8) Male 266 (80.6) 64 (19.4) Education,n(%) Illiterate 35 (64.8) 19 (35.2) Literate 33 (75.0) 11 (25.0) Primary school 272 (72.0) 106 (28.0) Middle school 113 (74.8) 38 (25.2) High school or equivalent 183 (77.9) 52 (22.1) University 43 (89.6) 5 (10.4) Marital status, n (%) a Unmarried 177 (87.2) 26 (12.8) Married 445 (72.2) 171 (27.8) Divorced 14 (66.7) 7 (33.3) Widowed 36 (60.0) 24 (40.0) Previous traumatic experience, n (%) 111 (66.9) 55 (33.1) Previous psychiatric treatment, n (%) 76 (61.3) 48 (38.7) Psychiatric disorders in family, n (%) 65 (61.3) 41 (38.7) Previous earthquake exposure, n (%) 64 (70.3) 27 (29.7) Distress prior to earthquake, n (%) 215 (65.2) 115 (34.8) a Ten cases are missing. p<.05. p<.01. p<.001. Peritraumatic Factors and PTSD (Table 2) Level of perceived threat to life, being injured, level of damage to buildings where one was exposed to the earthquake, being trapped under rubble, death of a close friend or a family member, being faced with a corpse were all significantly associated with PTSD, whereas being alone during the earthquake and participating in rescue work were not. The rate of PTSD was significantly higher in participants who had had unusual perceptions such as a bright light, a smell, or a sound during the earthquake than in participants who did not report such a perception. Table 2. Comparison of Participants With and Without PTSD on Peritraumatic Factors Variable Without PTSD PTSD df χ 2 Perceived life threat, n (%) Notatall 49(90.7) 5 (9.3) A little bit 83 (84.7) 15 (15.3) Moderately 180 (84.1) 34 (15.9) Extremely 367 (67.5) 177 (32.5) Damage of building where ones exposed to the earthquake, n (%) Notatall 122(81.3) 28 (18.7) Yes, a little bit 122 (78.2) 34 (21.8) Yes, moderately 176 (73.9) 62 (26.1) Yes, quite a bit 175 (72.6) 66 (27.4) Yes, collapsed totally 84 (67.2) 41 (32.8) Being alone in the earthquake, n (%) 23 (79.3) 6 (20.7) 1.35 Trapped under rubble, n (%) 36 (60.0) 24 (40.0) Physical injuries, n (%) 61 (61.6) 38 (38.4) Witnessing a dead body or body parts, n (%) 203 (69.3) 90 (30.7) Involved in rescue effort, n (%) 195 (73.3) 71 (26.7) 1.40 Death of a close friend or family member, n (%) 262 (67.9) 124 (32.1) Unusual visual perceptions, n (%) 243 (70.8) 100 (29.2) Unusual auditory perceptions, n (%) 438 (70.5) 183 (29.5) Unusual smelling perceptions, n (%) 187 (67.3) 91 (32.7) Other unusual perceptions, n (%) 110 (60.8) 71 (39.2) p <.05. p<.01. p<.001.

6 456 Tural et al. Table 3. Comparison of Participants With and Without PTSD on Posttraumatic Factors Variable Without PTSD PTSD df χ 2 Consumption of cigarettes (daily), n (%) Decreased 20 (76.9) 6 (23.1) Unchanged 458 (79.7) 117 (20.3) Increased 201 (65.0) 108 (35.0) Consumption of alcohol (weekly), n (%) Decreased 30 (75.0) 10 (25.0) Unchanged 635 (74.9) 213 (25.1) Increased 14 (63.6) 8 (36.4) Satisfied with social support, n (%) 333 (78.7) 90 (21.3) Level of possessions loss, n (%) Notatall 81(83.8) 35 (16.2) Yes, a little bit 135 (77.6) 39 (22.4) Yes, moderately 166 (72.2) 64 (27.8) Yes, quite a bit 197 (67.9) 93 (32.1) Alteration of income (monthly), n (%) Decrease 359 (70.8) 148 (29.2) No change 313 (79.4) 81 (20.6) Increase 7 (77.8) 2 (22.2) p <.05. p <.01. p <.001. Posttraumatic Factors and PTSD (Table 3) Persons who reported that they had been supported sufficiently by milieu had significantly lower rates of PTSD than those who reported that they had not received such help. The level of destruction of possessions had an influence on developing PTSD; the fewer possessions lost, the less PTSD. Similarly, the rate of PTSD was significantly lower in persons who reported an unaltered income than a reduced income during the posttraumatic period. A significant relation was found between PTSD and increased cigarette consumption; however, there was no such relation between PTSD and alcohol use. Multivariate Associations In the hierarchical multiple logistic regression analysis demographic variables were entered first and explained 5.4% of the variance in PTSD likelihood. Pretraumatic factors explained an additional 5.1% of the variance; peritraumatic factors explained an additional 9.1%, and posttraumatic factors explained an additional 2.3% of the variance. Taken together, these blocks accounted for 21.9% of the variance. The significant predictors of PTSD are shown in Table 4. Discussion Marmara Earthquake s negative impact on the general psychological health was as significant as its impact on the physical environment Following the 1999 earthquake in Turkey the rate of PTSD was found to be 25.4% in the survivors living in a tent city 1 year postdisaster. This rate for PTSD was higher than found among earthquake survivors in the United States (McMillen, North, & Smith, 2000) but lower than that found in an Armenian study (Goenjian et al., 1994). The rate of PTSD in the present study is concordant with those found after an earthquake in China (Wang et al., 2000). The differences in the findings of studies might be due to the usage of different diagnostically criteria (Schwartz & Kowalski, 1991), differences in the samples such as educational level (Armenian et al., 2000; Webster et al., 1995), or differences in the extent of devastation and casualties the earthquakes caused. There is also inconsistency in PTSD rates between the developed and developing countries after earthquakes. It is possible that earthquakes in developed countries with higher resources can cause less psychological distress in survivors compared with other countries. In addition, it is possible that developed countries may have better social support systems than developing countries. Many of the well-known risk factors belonging to the personal background and pretraumatic period characteristics also predicted PTSD in the present study. As a set, demographics and pretraumatic factors contributed with nearly equal explained variances to PTSD likelihood, respectively 5.4 and 5.1%. The block of peritraumatic factors explained the most variance in PTSD likelihood (9.1%). It is noteworthy that demographic variables and pretraumatic factors together better accounted for the variance in PTSD likelihood than the peritraumatic block. Moreover, the block of posttraumatic factors had less of

7 Psychological Consequences of the 1999 Earthquake in Turkey 457 Table 4. Predictors and Relative Risks for Obtaining PTSD Variable Relative risks for PTSD (odds ratio) 95% confidence interval Gender Male Female Marital status Unmarried Married Divorced Widowed Psychiatric disorder in family No Yes Distress prior to the earthquake No Yes Perceived life threat Notatall A little bit Moderately Extremely Death of a close friend or family member No Yes Unusual smelling perception No Yes Other unusual perception No Yes Satisfied with social support Yes No Note. Binary logistic regression, demographics, pre-, peri-, and posttraumatic factors as blocks entered hierarchically with stepwise selection method and simple contrast model only within each new block. Ten cases are missing (N = 900). p <.05. p <.01. p <.001. an effect than expected. This finding is in accordance with the DSM-IV (American Psychiatric Association, 1994), which stresses the importance of peritraumatic factors and considers these as a diagnostic criteria for the diagnosis of PTSD. The results of our study, however, suggest that predisposing factors may be at least as important as peritraumatic ones. The present study revealed that the rate of PTSD was bivariately associated with both perceived severity of life threat and actual physical effects of trauma. We found higher rates of PTSD in persons who had higher levels of perceived life threat, who had been injured, or who had been trapped under rubble in the earthquake. Nevertheless, in the multivariate analysis of risk factors, the strength of the subjective perceived level of life threat had stronger effects than did objective features (such as injury, trapped under rubble) of the traumatic event. This finding emphasizes the significance of individual attributions about the traumatic event. However, it should be noted that ideal measures of perceived life threat should be collected as soon as possible after the trauma, since cognitive and memory distortions may give rise to a bias in the course of time. In that area of trauma, researches have been indicating the conflicting results as characteristics and objective or subjective severity of stressors could influence the risk for developing PTSD. Previous studies showed that a high level of severity attributed to an event increases the probability of PTSD (Başoğlu & Paker, 1995; Ehlers, Mayou, & Bryant, 1998), as well as severity, physical danger, and the type of the traumatic event (Curran et al., 1990; Wolfe, Ericson, Sharkansky, King, & King, 1999). It might be interpreted that perceived life threat is a core factor or an outline of both objective and subjective aspects of the traumatic event. From a neuropsychological point of view, PTSD might be conceptualized as a disorder derived from emotional memory. Therefore, strong perceptual experiences during the trauma, such as voices and images, might contribute to the occurrence of PTSD symptoms. Not surprisingly, we found both bivariate and multivariate associations between unusual perceptional experiences during the earthquake and PTSD.

8 458 Tural et al. There is some evidence that certain features of the posttraumatic period have a significant influence on improving or worsening of PTSD symptoms. We found that the rate of PTSD was significantly lower in participants who declared that they had social support after the traumatic event. Likewise, some other researchers have reported that lack of social support (Armenian et al., 2000), failure to perceive positive responses from others (Dunmore, Clark, & Ehlers, 1999), and the amount of possessions lost (Bland et al., 1997) after the trauma might increase the rate of PTSD. In spite of the presence of significant associations between posttraumatic factors and PTSD bivariately, the posttraumatic factors as a set explained only a small amount of variance in PTSD likelihood. However, it is difficult to generalize this result because all the people living in the tent city had the same standardized support. Thus, it may be concluded that the meaning attributed to the provided support might be more important than the actual support that was available for everyone in the area. On the other hand, despite the high prevalence of PTSD and although they had been through a traumatic event, 44% of the earthquake survivors in the same region indicated that what they need most is still financial support rather than a psychological/emotional support (Kasapoğlu, Ecevit, & Ecevit, 2003). This may be indicative of the fact that their immediate and unsatisfied real needs at the time were primarily material rather than psychological, or alternatively they were not aware of psychological needs. The severity of PTSD was less in people who had been living in the earthquake area for a longer period. One explanation may be the knowledge of the existence and the use of a social network in the area. Therefore the persons who had been living in the earthquake area for a longer period can reach the social network easier than others can, and in that way they might be protecting themselves from the psychological effects of the trauma. These results are consistent with the results of research where following a disaster, higher levels of PTSD symptoms were found among immigrants when compared to those already living in the region (Webster et al., 1995). Limitations of the study should be noted in the interpretation of results. The main limitation of the present study is the lack of a clinical interview assessment of PTSD, because self-reported measures may not always provide an accurate representation of PTSD symptomatology. In addition, use of participants who accept entry into the study is a limitation that may have lead to under- or overestimation of the rate of PTSD. The higher proportion of female participants in the present study may lead also to an overestimation of PTSD rate since female gender is a well-known high risk factor for PTSD. The low proportion of male participants in our study might have resulted from both the fact that many men worked long hours and the fact that many young men were away from the tent city as temporary workers when the study took place. From the point of view of cognitive processing, the data could have been collected immediately after the trauma to prevent memory faults and cognitive distortions. It would also be useful to have data from an unaffected population as a control group to indicate the rate of increased incidence. Furthermore, life in a tent city over an extended period will probably represent a stressor in itself; this confounding variable has not been controlled. Another limitation is that no measure was used for personality, especially neuroticism. It has been estimated that, on average, a person with PTSD will endure 20 years of active symptoms and will experience almost 1 day a week of work impairment, perhaps resulting in a loss of US $3 billion annual productivity (Kessler, 2000). This information tells the clinicians they should not forget about PTSD. Therefore, it is important to be able to identify the persons under high risk for developing PTSD after trauma and to offer them preventive interventions, such as psychosocial support. References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Anxiety Disorders Association of America. (1999). Post-traumatic stress disorder self-test. Retrieved December 20, 1999, from the World Wide Web: PTSD.htm Armenian, H. K., Morikawa, M., Melkonian, A. K., Hovanesian, A. P., Haroutunian, N., Saigh, P. A., et al. (2000). Loss as a determinant of PTSD in a cohort of adult survivors of the 1988 earthquake in Armenia: implications for policy. Acta Psychiatrica Scandinavica, 102, Başoğlu, M., & Paker, M. (1995). Severity of trauma as predictor of long term psychological status in survivors of torture. Journal of Anxiety Disorders, 9, Başoğlu, M., Şalcıoğlu, E., & Livanou, M. (2002). Traumatic stress responses in earthquake survivors in Turkey. Journal of Traumatic Stress, 15, Bland, S., O Leary, E. S., Farinaro, E., Jossa, F., Krogh, V., Violanti, J. M., et al. (1997). Social network disturbances and psychological distress following earthquake evacuation. Journal of Nervous and Mental Disease, 186, Coşkun, B., & Coşkun, A. (2000). Evaluation of community mental health services programs after the Marmara earthquake. Psikiyatri Psikoloji Psikofarmakoloji Dergisi, 8 (Suppl. 1), (Turkish) Curran, P. S., Bell, P., Murray, A., Loughrey, G., Roddy, R., Rocke, L. G., et al. (1990). Psychological consequences of the Enniskillen Bombing. British Journal of Psychiatry, 156, Dunmore, E., Clark, D. M., & Ehlers, A. (1999). Cognitive factors involved in the onset and maintenance of PTSD after physical or sexual assault. Behaviour Research and Therapy, 37, Ehlers, A., Mayou, R. A., & Bryant, B. (1998). Psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents. Journal of Abnormal Psychology, 107,

9 Psychological Consequences of the 1999 Earthquake in Turkey 459 Fairbank, J. A., Ebert, L., & Costello, J. (2000). Epidemiology of traumatic events and post-traumatic stress disorder. In D. Nutt, J. R. T Davidson, & J. Zohar (Eds.), Posttraumatic stress disorder: Diagnosis, management and treatment (pp ). London: Martin Dunitz. Goenjian, A. K., Najarian, L. M., Pynoos, R. S., Steinberg, A. M., Manoukian, G., Tavosian, A., et al. (1994). Posttraumatic stress disorder in elderly and younger adults after the 1988 earthquake in Armenia. American Journal of Psychiatry, 151, Goenjian, A. K., Steinberg, A. M., Najarian, L. M., Fairbanks, L. A., Tashjian, M., Pynoos, R. S., et al. (2000). Prospective study of posttraumatic stress, anxiety, and depressive reactions after earthquake and political violence. American Journal of Psychiatry, 157, Government Planning Organization of Primeministery Press Release. (1999). Retrieved December 20, 1999, from the World Wide Web: Kasapoğlu, A., Ecevit, Y., & Ecevit, M. (2003). Support needs of the survivors of the August 17, 1999 earthquake in Turkey. Social Indicators Research, 66, Kessler, R. C. (2000). Posttraumatic stress disorder: The burden to the individual and to society. Journal of Clinical Psychiatry, 61(Suppl. 5), Kılıç, C., & Ulusoy, M. (2003). Psychological effects of the November 1999 earthquake in Turkey: An epidemiological study. Acta Psychiatrica Scandinavica, 108, Lewin, T. J., Carr, V. J., & Webster, R. A. (1998). Recovery from post earthquake psychological morbidity: Who suffers and who recovers? Australian and New Zealand Journal of Psychiatry, 32, Lima, B. R., Chavez, H., Samaniego, N., Pompei, M. S., Pai, S., Santacruz, H., et al. (1989). Disaster severity and emotional disturbance: Implications for primary mental health care developing countries. Acta Psychiatrica Scandinavica, 79, McMillen, J. C., North, C. S., & Smith, E. M. (2000). What parts of PTSD are normal: Intrusion, avoidance, or arousal? Data from the Northridge, California, Earthquake. Journal of Traumatic Stress, 13, McNally, R. J. (1992). Psychopathology of PTSD: Boundaries of the syndrome. In M. Başoğlu (Ed.),Torture and its consequences (pp ). Glasgow: Cambridge University Press. National Earthquake Information Center. (2000). Earthquakes with 1,000 or more deaths from Retrieved February 14, 2000, from World Data Center Web site: eqlists/eqsmajr.html Norris, F. H., Friedman, M. J., Watson, P. J., Byrne, C. M., Diaz, E., Kaniasty, K., et al. (2002). 60,000 disaster victims speak: Part I. An empirical review of the empirical literature, Psychiatry, 65, Schwarz, E. D., & Kowalski, J. M. (1991). Posttraumatic stress disorder after a school shooting: Effects of symptom threshold selection and diagnosis by DSM-III, DSM-III-R, or proposed DSM-IV. American Journal of Psychiatry, 148, Wang, X., Gao, L., Shinfuku, N., Zhang, H., Zhao, C., Shen, Y., et al. (2000). Longitudinal study of earthquake-related PTSD in a randomly selected community sample in North China. American Journal of Psychiatry, 157, Webster, R. A., Mc Donald, R., Lewin, T. J., & Carr, V. J. (1995). Effects of natural disaster on immigrants and host populations. Journal of Nervous and Mental Disease, 183, Wolfe, J., Ericson, D. J., Sharkansky, E. J., King, D. W., & King, L. A. (1999). Course and predictors of posttraumatic stress disorder among Gulf War veterans: A prospective analysis. Journal of Consulting and Clinical Psychology, 67,