najarian2001

Journal of Traumatic Stress. Vol. 14, No. 3. 2001

The Effect of Relocation After a Natural Disaster

Louis M. Najarian,'~~ Amen K. Goenjian? David Pelcovitz,' Francine Mandel,' and Berj Najarian'

Twenty-five women remaining in a city devastated by an earthquake were compared with 24 relocated survivors and 25 comparison women. The women were administered a structured PTSD interview, the Hamilton Depression Scale, and SCL-90-R. The women in both exposedgroups showed significantly more symptoms of avoidance, arousal, and total PTSD than the comparison group. The women in the relocated city had significantly higher depression scores than the women in the earthquake city. On the SCL-90-R, relocated women were most symptomatic and comparison group women were least symptomatic. Relocarion after a disaster ap- pears to be associated more with risk for depression than with PTSD in situations where recovery is delayed following the trauma. KEY WORDS: disaster, posttraumatic stress disorder; depression.

A devastating earthquake with a magnitude of 6.9 on the Richter scale struck Armenia on December 7, 1988, killing approximately 25,000 people according to Soviet reports and 100,OOO people according to other reports (Poghosyan, 1989; Ryan, 1989). Previous reports have documented high rates of posttraumatic stress disorder (PTSD) reactions in children (Pynoos et al., 1993) and adults (Goenjian et al., 1994) in the earthquake zone in Armenia. Immediately after the earthquake, many survivors were relocated and placed in hotels, sanitariums, and government residences in distant cities that were minimally damaged.

Relocation has been noted to be a factor in coping with stress of a natural disaster. Milne (1977) noted that children relocated after a cyclone in Australia experienced more academic difficulties than those remaining at home and Maj

'Division of Child and Adolescent Psychiatry, Department of Psychiatry, North Shore University Hospital - NYU School of Medicine, Manhasset, New York.

'UCLA Trauma Psychiatry Program, Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, Los Angeles. California.

3T0 whom correspondence should be addressed at 324 Park Avenue, Manhasset, New York 11030.

511

0894-9867/01107000511519.W011 0 2001 International Society forliaumatic Stms Studies

512 Najarian, Gwnjian, Pelcovitz, Mandel, and Najarian

et al. (1 989) found victims of an earthquake, both relocated and those remaining in the devastated area, to have high prevalence of psychiatric disorders. Structured interviews or measures of PTSD were not used in either study. Steinglass and Gemty (1990) compared two communities requiring massive relocation, one due to a tornado and one due to a flood; PTSD diminished over time but the effect of relocation could not be assessed because all individuals had returned to their homes at the time of the study and there was no comparison group.

The wars and genocidal events in Southeast Asia during the last 25 years have offered further understanding of the traumatic effect of war, relocation, and life stressors on the victims. Studies of Cambodian victims traumatized during the Pol Pot regime now living in the United States several years after the trauma continue to reveal high levels of PTSD (Hubbard, Realmuto, Northwood, & Masters, 1995; Kinzie, Sack, Angell, Clarke, & Ben, 1989; Kinzie, Sack, Angell, Manson, &Ben, 1986; Sack et al., 1993; Sack, Clarke, & Seely, 1996). Epidemiological studies on Cambodian refugees identified PTSD and depression to exist across two generations of adolescents and one or both of their parents (Sack et al:, 1993, 1996; Sack, Clarke, & Seely, 1995). An early study by Beiser (1988) on refugees from many Southeast Asian countries dispersed throughout Canada demonstrated that depression declined over time but some groups were still highly depressed 2 years after resettling in Canada. A study of Bosnian adolescents several months after relocation to the United States indicate that 25% met criteria for PTSD and 17% for depression (Weine et al., 1995). The main focus in the studies of adolescents and young adults from Cambodia and Bosnia was the continued presence and severity of PTSD symptoms and depression years after the trauma. Savin, Sack, Clarke, Meas, and Richard (1996) examined PTSD and depression in Cambodian young adult trauma victims living in a Thailand refugee camp, but waiting to return to Cambodia. That study found rates of both PTSD and depression similar to a comparable group of Cambodian victims that were relocated to the United States. The sample in the refugee camp appeared more psychologically ill than traumatized victims living in the United States. This finding was similar to that of the earthquake victims in Armenia (Najarian, Goenjian, Pelcovitz, Mandel, & Najarian, 1996) where the exposed victims remaining in the disaster zone appeared to be more psychologically ill than the victims relocated to an intact city although both traumatized samples met criteria for PTSD and depression. Although these studies of Asian refugees provide important information on the effect of war trauma and subsequent resettlement, they differ in that our investigation examines a relocated population that remained in their country and did not experience the same cultural loss attending the resettled Asian refugees. The current study is investigating the psychiatric outcomes of relocation in a situation where the cultural milieu remains constant.

Most studies of the impact of relocation are hampered by a number of method- ological flaws. Failure to use comparison groups or standardized trauma-specific

Relocation After a Natural Disaster 513

measures have limited the generalizability of these findings. There are few studies that systematically assess whether relocation facilitates the process of psychological recovery from the trauma of disaster. In one of the earliest studies designed to examine the effect of relocation, Laor et al. (1996, 1997) systematically inves- tigated the effects of relocation on victims of SCUD attacks in Israel. The initial study (Laor et al., 1996) and 30-month follow-up study (Laor et al., 1997) examined three groups of preschool children and their mothers exposed to SCUD missile attacks during the Persian Gulf War. The displaced group whose homes were destroyed showed highest stress symptoms.

Present Study

During 1989 and 1990, the senior author provided crisis intervention to the traumatized victims exposed to the earthquake in Gumri (formerly Lenninakan), the major city devastated by the earthquake, and those exposed victims relocated to Yerevan, the capital of Armenia where there was minimal damage by the earthquake. Gumri is the second largest city in Armenia, with a population of 280,000 located about 20 miles from the epicenter of the earthquake. Fifty percent of Gumri was destroyed and 90% substantially damaged (Goenjian, 1993; Ryan, 1988). Al- though all exposed victims met criteria for PTSD, those individuals who relocated to the intact capital city did not appear as psychologically ill as those remaining in the earthquake city. Previous studies have suggested that victims of a natural disaster should remain in the area to maintain cohesion in the family (Galante & Foa, 1986) and in a “psychological community” to contribute to a “recovery environment” (Erikson, 1976) until reconstruction to normal predisaster conditions is completed. The design for this study was generated from the clinical observation that relocated victims of the earthquake did not appear as psychologically ill as those victims remaining in the devastated city.

The following clinical cases illustrate the basis for this study. These vignettes illustrate the difficult environment in which the survivors who remained in the earthquake city had to cope, as compared to the relocated victims. In contrast to the relocated victims, those remaining in the earthquake city were constantly reminded of the reality of the earthquake which transformed their lives. All names and identifying information were changed to ensure confidentiality.

Vignette 1: Relocated Participant

Gayane is a 40-year-old school teacher, mother of two children ages 14 and 12 who relocated to a hotel in Yerevan immediately after the earthquake because her private home was destroyed in Gumri. She lived in two rooms with her two children and 65-year-old mother. Her husband was killed in the earthquake. She

514 Najarian, Goenjian, Pelcovitz, Mandel, and Najarian

was attractive, well groomed, articulate, and met DSM-Ill-R criteria for PTSD and depression. During brief psychotherapy (six visits), she expressed survivors’ guilt for the first time. She had encouraged her husband to stay home from work because he was ill on the day of the earthquake while she and the children were at school. He was killed at home when the house was destroyed. She secured voluntary work in the school her children attended next to the hotel. She organized an arts and craft program for children in the hotel in which she resided because many relocated families lived there. As her mood and PTSD symptoms improved, she became more involved with her children and they began to attend concerts, museums, and theater in Yerevan as they had done in Gumri prior to the earthquake. During the summer 1989, she volunteered to help in a summer camp program and secured a place for her children. The PTSD and depression improved as she continued to live in the hotel indefinitely while waiting for repair of her damaged house.

Kgnette 2: Participant Remaining in Earthquake Cify

Aram is a 38-year-old engineer living in a tent in Gumri since the earthquake, with his 38-year-old wife, a music teacher; three children ages 12, 10,s; and both his parents ages 63. He worked in a large clothing factory where 200 people died during the earthquake because of poor construction of the building. He was outside the building at the time of the earthquake but assisted victims, including the removal of corpses. Although no one in his immediate family died, he mourned with his best friend as they both walked daily to the cemetery where his best friend’s wife and two children were buried. It was a common practice in the earthquake zone for families of victims of the earthquake to visit the cemetery daily and cry at the grave of their lost ones, even 6 months after the earthquake.

Aram spoke cautiously in a sad, suspicious manner about his life with no hope for the future. He was dressed in shabby clothes and indicated proudly with a disgusted spirit, these were his only clothes and it was difficult to keep them clean when living in a dusty tent. He was diagnosed with PTSD and reluctantly agreed to meet regularly in brief psychotherapy. When the concept of confidentiality was explained a second time after the initial consultation, there was a dramatic change in his mood and affect, as he openly attacked the government for failure to provide more adequate housing and employment. He blamed Gorbachev for the earthquake as did 30% of the residents of the city, because they suspected a bomb caused it because there was a large Soviet army post located in Gumri along the Turkish border. As his mood improved, he was encouraged to stop visiting the cemetery, which he did. On his own, he moved the tent where he lived with his family, away from the grounds of the factory where he assisted so many victims. This provided only mild help because there was no place to avoid reminders because 90% of the city was damaged. Both he and his wife were cultured, as they enjoyed attending concerts and the theater but the buildings were destroyed and this activity was


no longer available. Their recreation was limited to watching television, listening to cassettes, and visiting with friends. He changed some of his daily routine and PTSD symptoms diminished while his mood improved as he continued to express anger at the government. Aram began to attend church regularly and spoke proudly about the heritage of Armenia, it being the oldest Christian nation. At the end of treatment, his mood was improved but he still experienced mild PTSD symptoms as he and his family continued to live in a tent while waiting for repair to their damaged apartment building.

The present study focused on exploring the association between relocation and PTSD symptomatology on children and their mothers. This study was based on interviews with 25 mothers and their children. The initial study focused on the relative adjustment of children who remained in the earthquake city compared with those who were relocated (Najarian et al., 1996).

To date, there have been no studies of adults, using structured measures of PTSD and depression, which have examined the differential impact of remaining in an earthquake city where there has been no repair to the damage contrasted with relocation to an intact city. This study was designed to test the hypothesis that adults who were exposed to the earthquake and relocated to an intact city where there was no damage would show significantly lower levels of PTSD and depression than a comparison group of earthquake victims who had similar exposure and remained in the earthquake city and a comparable group who did not experience the earthquake.

Method

Participants

The families witnessing the earthquake were selected from Gumri. This study was based on interviews with 74 mothers and their children. The first group of women (n = 25) remained in Gumri after the earthquake and lived with their families, initially in tents and later trailers or reconstructed homes. The second group consisted of relocated women (n = 24) who left Gumri immediately after the earthquake because their homes were destroyed. They moved with their families to hotels and sanitariums that were emptied to receive the homeless in Yerevan. Yerevan is the capital of Armenia with a population of 1.3 million people. The damage was mild in Yerevan and there were no deaths from the earthquake. The relocated families lived in their new residences from the time immediately following the earthquake until the time of this study, 2'/2 years after the earthquake. The third group of women (n = 25) evaluated were those who lived in Yerevan at the time of the earthquake; they were the comparison group.

Table 1 shows the demographics of the sample. There were no significant differences in the distribution of ages, level of education, or the occupations of the


Table 1. Demographic Characteristics of Mothers by Location

Earthquake Relocated Comparison Variable (n = 25) (n = 24) (n = 25)

Average age Level of education

Graduate school College Trade school High school

Professional (physician, lawyer, accountant)

Teacher Trade (factory worker,

seamstress, cashier)

Employed

36 38 38

Nore. Values in parentheses are percentages.

women in the three groups. There was a significant difference in the employment of the three groups (p < .001). Sixty percent of the women in the comparison group were employed at the time of the study, whereas 36% of the mothers remaining in the ekhquake city were employed as compared with none of the relocated. There was also a significant difference in the prevalence of loss in the three groups (p c .01). Loss was measured by using a structured questionnaire that asked the adult who in their immediate family (mother, father, children. grandparents) was killed in the earthquake-for the purpose of this study, the definition of loss did not include aunts, uncles, cousins, or friends. Fifty percent of the relocated adults experienced a loss in the immediate family, whereas 20% of the adults in the earthquake city and no one in the comparison city experienced a loss.

The degree of trauma exposure in this sample was extreme. Exposure to hor- rifying sights continued for days following the earthquake in Gumri. Throughout the city, people heard screams from those who had been injured, burned, or trapped under collapsed buildings, or they saw mutilated corpses exposed on the sidewalks and bodies hanging from buildings.

Procedure

The principal of each school selected the children. They were asked to select 25 children from the same grade, ages 11 through’ 13 years, to participate in the study. The principals were told to chose the students randomly without any bias. Because we were concerned that they may have viewed the research interview as a chance to get help for their more troubled students, they were specifically instructed not to choose students based on psychological need. They were also asked not to bias their selection by choosing problem-free students. At the time


of the study, in May 1991, Armenia was a republic in the Soviet Union. In the communist system, school principals were extremely powerful, therefore, when a student was identified to participate in the study, all mothers complied without any challenge to the principals’ authority. However, when the mothers convened at the school to begin the study, the principal investigator made it clear to all the women that if they were not comfortable participating in the study, they were free to refuse without any consequences. In keeping with research standards in Armenia at the time of the study (10 years ago) verbal consent was obtained from all subjects. The children and their mothers were interviewed in the school in May 1991,2’/2 years after the earthquake. No one in the sample had received prior treatment.

All self-report measures were administered to the women in a classroom adja- cent the child’s classroom while the children were examined. Four local Armenian psychologists who had extensive mental health experience, including test administration, supervised the administration of .the measures. All instruments were translated into the Armenian version following previously published guidelines, including the use of independent back-translation and administration to bilingual participants (Brislin, 1976). Ten bilingual participants in Armenia were interviewed with both the English and Armenian versions. The correlation between scores for the two versions was .95.

Measures

The PTSD section of the third revised edition of the Diagnostic and Statistical Manual (DSM-111-R: American Psychiatric Association, 1987) was administered to each woman. Because there were no available interviews in the Armenian language to measure PTSD in adults, the DSM-111-R PTSD section was translated into the Armenian language and administered in a structured interview format that systematically asked participants about each of the 17 DSM-111-R symptoms.

The Hamilton Depression Scale (HDS: Hamilton, 1960), a widely used measure of adult depression, was administered to all participants. The HDS is a21-item self-report questionnaire, which measures depression in adults.

The Symptom Checklist-90-R (SCL-90-R: Derogatis, 1983) was also administered to all participants. The SCL-90-R is a 90-item self-report symptom inventory developed to reflect primarily symptom patterns of psychiatric patients. Each of the 90 items of the inventory is rated on a 5-point scale of distress (W), ranging from not at all to extremely. The 90 items are scored and interpreted in terms of nine primary symptom dimensions and three global indices of distress.

Statistical Analysis

Comparisons of the three groups on response to items or endorsement of PTSD symptoms were made using chi-square tests for proportions followed by


Boneferroni adjusted pairwise comparisons. An analysis of variance was used to determine whether the proportion of items endorsed is equal for each subscale in each location. Student-Newman-Keuls tests were used to determine which location differed within each subscale if there was a significant difference in the three locations on that subscale.

Comparisons of the mean scores of the three groups on the Hamilton De- pression score and the SCL-90-R scores were made using analysis of variance followed by post hoc comparisons using Student-Newman-Keuls tests. The level of depression of those who lost family in the earthquake was compared with the level of depression of those who did not lose family in the earthquake using an independent samples t test. Additionally, an analysis of variance was used in order to compare the locations and presence of loss as an indicator of level of depression in the women.

Results

Table 2 shows the rate of endorsement for each of the 17 items, three PTSD clusters and PTSD. The women in the three cities were significantly different in

Table 2. Comparison of PTSD Symptoms by Location

Eanhquake Relocated Comparison

Criterion n % n % n 9% xz(df=2)

PTSD Summary Criterion B: Reexperiencing

Intrusive thoughts Bad dreams Fears recurrence Distress at reminders

Criterion C: Avoidance Avoid thoughts Avoid activities Memory loss Diminished interests Detached Restricted affect Foreshonened future

Criterion D: Arousal Sleep disturbance Irritable Concentration Hypervigilance Startle Physiologic reactivity

23 24 22 9

21 21 25 22 20 21 20 14 18 18 24 17 11 17 12 8

19

92 96 88 69 88 84

100 88 83 84 87 58 82 75 96 71 50 78 50 32 76

16 89 18 100 17 94 12 80 16 89 17 94 17 94 16 89 17 94 10 56 10 56 14 78 9 50

14 78 16 89 15 83 7 41

11 61 12 67 11 65 15 83

3 12 42.7"'

5 19 36.0.'. 1 8 16.5"'

17 65 5. I 12 48 13.8"' 6 23 42.7***

10 40 17.8*** 9 36 20.4*" 1 4 33.8"' 2 8 30.4"' 3 12 2 I .2*** 4 15 21.2*** 3 12 25.9*** 5 19 39. I *** 4 16 23.5*'* 2 8 1 1.2" 0 0 3 1.8*" 1 4 20.9*** 1 4 18.5"' 3 12 29.9***

22 85 4.4

~

Nore. Both the earthquake and relocated groups differed from the comparison group except for Criterion B (fears recurrence), on which there were no differences, and for restricted affect, on which only the earthquake group differed from the comparison group. **p c .01. ***p < .001.


Table 3. Average Number and Percentage of PTSD Items Endorsed by Location

Earthquake (n = 25) Relocated (n = 24) Comparison (n = 25)

Subscale M S D % M S D % M S D %

Reexperiencing 2.92 0.95 0.73 3.44 0.78 0.86 1.35 0.98 0.34 Avoidance 5.40 1.26 0.77 5.00 1.75 0.71 1.42 1.47 0.20 Arousal 4.20 1.53 0.70 4.61 1.75 0.77 0.69 1.01 0.12

their meeting criteria for the PTSD of arousal and avoidance symptoms clusters, as well as for PTSD. Pairwise comparisons showed that the women in the earthquake and relocated cities did not differ in experiencing PTSD. There was a significant difference in the rate of PTSD for the avoidance and arousal cluster between the earthquake and comparison cities. Similarly, there were the same differences between the women in the relocated and comparison cities. However, there was no significant difference in their scores on the reexperiencing criterion.

Table 3 shows the average number of symptoms and percentage of items endorsed by each group of the three PTSD symptom clusters. There was a significant location effect on the PTSD symptom categories ( p < .001). Pairwise comparisons showed the earthquake and relocated groups having significantly higher scores on each of the symptom clusters.

The three groups had significantly different average Hamilton Depression scores, F( 1,64) = 26.63 ,~ < .OO1. This result was significantly different between each of the cities. Those participants in the relocation city had a mean score of 3 1.7 (SD = 7.0). women in the earthquake city had a mean score 24.8 (SD = 8.9). and women in the comparison city had a mean score of 17.1 (SD = 5.7).

There were significant differences among groups in responses to the question about diurnal mood, x2(4, N = 64) = 39.9, p < .001. Pairwise comparisons showed that each of the three groups was significantly different from the other two groups. Almost three quarters of those in the earthquake city (7 1.4%) answered that their mood was a little worse in the morning or night or at both times. In contrast, the women in the relocated city were more evenly distributed between those who answered little worse in the morning or night or at both times (55.6%) and those who indicated diurnal mood variation occurred very much (44.4%). Conversely, 80% of the women in the comparison city said that they experienced no diurnal mood variation.

There were also significant differences among groups on Hamilton items relating to experiences of derealizatioddepersonalization, x2(8, N = 65) = 46.9, p c .OO 1. pairwise comparisons showed that each of the groups was significantly different from the other two groups. Over 90% of the women in the earthquake city reported that they did not experience significant derealizatioddepersonalization (39% did not experience, and 52.2% experienced this symptom only a little). In contrast, 44% of the women in the relocated city reported difficulties with


derealizatioddepersonalization (33.3% much; 11.1% very much); 16.7% did nor experience depersonalizatiodderealization; 16.7% experienced this symptom a lirrle, and 22.2% rated themselves in the middle range on derealizatiod depersonalization. The women in the comparison city almost exclusively answered that they had no experience of derealizatioddepersonalization.

The participants answered the paranoid scale significantly differently in the three cities, x2(6, N = 67) = 18.7, p < .01. Pairwise comparisons determined that the women in the earthquake city were significantly different from the women in the comparison city. The response of women in the earthquake city was as follows: none (44%). paranoid (32%). and thinks people talk about them (24%). The women in the relocated city replied none (55.6%), paranoid (16.7%), rhinks people ralk about them (26.7%). and thinks people follow them (1 1.1 %); and the women in the comparison city replied almost exclusively none (91.7%).

The participants answered the obsessivekompulsive question significantly differently in the three cities, x2(4, N = 63) = 1 3 . 8 , ~ < .01. Pairwise comparisons showed that each of the groups was significantly different from the other two groups. The response of the women in the earthquake city was as follows: none (52.4%), little (33.3%), and much (14.3%); the women in the relocated city replied none (55.6%), little (22.2%), and much (22.2%); and the women in the comparison city replied almost exclusively none (95.9%).

The women’s answer regarding whether they have more fights after the earthquake was significantly different in the three cities, x2(8 , N = 66) = 30.3, p < ,001. Pairwise comparisons showed that the women differed significantly between the comparison and the other two cities. The response of the women in the earthquake city was as follows: none (29.2%), lirtle (16.7%). and occasionally (25%), a lot (20.8%), and always (8.3%); the women in the relocated city replied none (27.8%), a lirtle (17.8%), occasionally (1 1.1 %), and a lor (33.3%); and the women in the comparison city replied almost exclusively none (9 1.7%).

There was no significant difference in the levels of depression expressed by those women who had lost members of their immediate families as compared with those who did not lose members of their immediate families. Further, when the location of the participants was controlled for, there was no relationship between location and loss in relation to depression, F(2,38) = 2.22, ns.

Table 4 shows the SCL-90-R scores for the participants in the three cities. There were significant differences between groups on the following scales: somatization, obsessivekompulsive, depression, anxiety, phobia, paranoid, and the global seventy index. In each case, those in the relocated city were most symptomatic and those in the comparison city were least symptomatic. For all scales on which there were group differences, the relocated women were significantly different than comparison women. The earthquake city mothers exhibited significantly greater symptoms than the comparison mothers on the following scales: somatization, obsessivekompulsive, depression, anxiety, and the global severity


Table 4. SCL-90-R Scores by Location ~~ ~

Earthquake Relocated Comparison

M SD M SD M SD F(2.66)

Sornatization Obsessive/compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobia Paranoid Psychoticism Global seventy index

58.9 9.0 63.5 12.0 48.9 16.6 7.1" 55.2 9.7 56.1 11.7 45.8 12.0 5.8** 50.9 9.3 49.2 10.0 45.7 11.3 1.6 54.9 7.8 59.2 8.1 46.7 9.4 11.9.'. 59.5 7.3 63.1 11.2 49.7 14.9 7.8*** 47.1 8.8 45.2 9.0 44.3 11.3 0.5 61.6 8.8 62.3 8.3 54.2 12.2 4.4' 50.2 10.4 53.2 8.2 44.3 11.0 4.2' 52.0 11.7 54.8 10.0 49.5 11.8 1.1 55.5 10.0 58.3 9.4 45.5 15.3 6.8'

' p c .05. '*p c .01. '"p < .001.

index. There was no significant differences between the symptoms of the women in the relocated and earthquake cities.

Discussion

Relocation did not diminish the prevalence of PTSD in the adults who wit- nessed the earthquake and were displaced to Yerevan. Presumably, the severity of the trauma outweighed the benefit of living in an intact city. Contrary to those who suggest remaining in the disaster area minimizes PTSD symptomatology, the women who relocated were no worse than those who remained in the disaster city. Our hypothesis that the adults who relocated would be less symptomatic than those who remained in the earthquake city was not substantiated. The finding that 92% of the women remaining in the earthquake city and 89% of the relocated women met criteria for PTSD 2'/2 years after the disaster is not surprising in light of the trauma suffered in the earthquake. It is now well known that natural disasters that involve threat to one's life, and the lives of family members, are associated with very high risk for PTSD (Pynoos et al., 1987; Vogel & Vernberg, 1993). The finding that in both cities only approximately 10% of the women were not diagnosed with PTSD testifies to the extremely high risk women face for experiencing this disorder when they do not receive treatment after a disaster of such magnitude. Galante suggests that remaining at the site of the disaster is associated with quicker recovery and healing (Galante & Foa, 1986), but our finding that 92% of the women who remained in Gumri continued to have PTSD, highlights the difficulty of recovering from the effects of a trauma when a city remains in disrepair, and no psychiatric treatment for the effects of the trauma is available.

The high rate of women endorsing avoidance (100% in earthquake city, 94% in relocated city) was in contrast to their children (Najarian et al., 1996)

522 Najarian, Goenjian, Pelcovik, Mandel, and Najarian

who were less likely to avoid reminders of the earthquake (32% in earthquake city, 28% relocated city). This is similar to the findings of Laor et al. (1997) who also reported that in response to SCUD attacks in Israel, mothers were more likely to endorse avoidance symptoms than were their children. A possible explanation of higher avoidance rates in the mothers in our study is that, unlike their children, who attended school, most of the mothers in both cities remained unemployed after the earthquake. The conditions in Armenia, at the time of this study made it virtually impossible for most of the parents to find employment outside of the home. Remaining in their home may have perpetuated PTSD related avoidance, because they were not “forced” to extinguish their fears by venturing outside. In contrast, their children attended school on a regular basis, in effect forcing them to overcome avoidant behaviors.

A surprising finding was that 85% of the participants in the comparison group reported reexperiencing. This finding is consistent with the report in children who lived in the capital city. All 25 (100%) of the children in our previous report endorsed reexperiencing symptoms (Najarian et al., 1996). This may be explained by the fact that television coverage of the earthquake continued on a daily basis in the entire country for several months and there is only one television station in Armenia. The entire population was overwhelmed with a daily visual stimulation of the devastation. Television coverage of a traumatic event has proven to contribute to mass reaction to the trauma (Kiser et al., 1993). Also, many adults in the comparison city had relatives in the earthquake city or traveled to the earthquake city to offer aid. Finally, the severity of the earthquake and related experiences may have fostered development of memories that recurred with a multiplicity of cues.

The SCL-90-R results suggest that the women in the earthquake samples had general distress in addition to their PTSD symptoms. Specifically, both groups of exposed adults had significantly higher scores on the global severity index, as well as in the specific areas reflecting difficulties with somatization, obsessive- compulsive symptoms, depression, and anxiety. Somatization is a common cluster of symptoms seen in survivors of trauma (Van der Kolk et al., 1996). In the presence of total environmental chaos, an increase in obsessive-compulsive symptomatology might be seen as an adaptive manner of organizing one’s life. In a large community survey of traumatized victims, Saunders found a higher incidence of obsessive-compulsive disorder in traumatized individuals than nontraumatized persons (Saunders, Villeponteaux, Lipovsky, Kilpatrick, & Veronen, 1992).

The strikingly high number of responses to questions relating to paranoia on both the HDS and the SCL-90-R warrants elaboration. Although the relocated women clearly showed more evidence of global depression and mood instability, a different clinical picture emerges in the two exposed groups when paranoid symptoms and aggression are examined. Although paranoid symptoms were statistically greater in women who remained in the earthquake city as compared with the comparison group, no such significant differences were found when relocated women


were compared with the comparison group. These findings raise the intriguing pos- sibility that women who remained in the earthquake city, when confronted with extreme hardships had to worry about how to meet basic needs for themselves and their families. This pressure might have contributed to increased suspiciousness of the government for not allocating them housing and resources. Also, individuals often were perceived as opportunist taking advantage of others. In comparison, although the relocated women had to struggle with a sense of loss of community, they were living in an environment that was physically more comfortable and basic needs such as heat, water, and electricity were more readily available.

Adults with a paranoid disorder have a higher incidence of childhood trauma such as abuse or a chronic illness (Blum, 1968, 1974). Rangell, in an essay on the course of psychic trauma, stresses the importance of “attachment to ground” as a prerequisite for the maintenance of psychic equilibrium (Rangell. 1976). He elaborates further on how the loss of confidence in this attachment results in basic anxiety with the threat of total annihilation of the self and this relationship extends from the ground beneath one to the space around one’s self, including people, institutions, and culture. When the devastation is so severe as it was in Armenia with delay in the reconstruction, one can appreciate how a primitive anxiety may evolve to a lack of faith and mistrust of others. The presence of a high degree of paranoia in the women also supports Colby’s homeostatic theory of paranoia in which the phenomenon results from attempts of the organism to pursue internal equilibrium (Colby, 1977). Any threat, whether internal or external, to restoring this equilibrium may be transformed into the belief that “others threaten me.”

Our results regarding the differential levels of depression in the three cities consistently indicate that the relocated women were experiencing significantly higher levels of depression. This was the case in terms of total depression scores. Although almost three quarters of the women who remained in the earthquake city reported only relatively minor symptoms of depression, almost half of the women who were relocated, reported significant difficulty with depression. Similarly, 44% of the relocated women reported serious difficulty with feelings of unre- ality as compared with 10% of the mothers who remained in the earthquake city. One can speculate that relocated women had particular difficulties with their sense of connectedness to their environment, that is they felt “unreal” in relation to the outside world, or experienced unstable moods as their day progressed. Although they lived in neighborhoods, which were physically intact, their internal mood did not reflect a sense of stability and reality. Perhaps their primary sense of connec- tion and sense of community was so compromised by the move that they were not able to regain a sense of equilibrium and integration, even 2’/2 years after the earthquake. Another possible contribution to this lack of connectedness is unem- ployment. As noted in Table 1, in contrast to the earthquake city group where 36% of the women were employed, none of the women in the relocated group were employed. This may also have played a role in their higher levels of depression. Our


findings that depression was still significant relative to the comparison groups in both exposed groups is consistent with the research of others in which depression is a persistent problem in survivors of trauma (Beiser, 1988; Goenjian et al., 1995; Sack et al., 1994, 1996; Westermeyer, Nerder, & Callies, 1989).

There is much information about the effect of relocation of war refugees to different countries that necessitate acculturation and learning a new language (Beiser, 1988; Westermyer et al., 1989). This study examined the effect of relocation within the same country, which avoids the need for cultural and language adaptation. It allows for a more precise examination of the effect of relocation. In light of our finding that the relocated women were more symptomatic, our results suggest that policy should direct all humanitarian aid to maintaining victims in the disaster area. Considering the amount of financial and material aid donated to Armenia from the entire world, more effort should have been directed to the reconstruction of the earthquake zone and this would have avoided victims remaining in relocated areas 2'/2 year after the earthquake.

There are some limitations in the design of this study. We did not measure severity of exposure, nor did we assess perceived life-threat or percentage of participants who lost extended family members. The relatively small number of participants points to the need for replication of our findings with a much larger sample. Another limitation was the nature of participant selection. As noted earlier, the principals were asked not to choose students on the basis of who they felt needed help. This limits the generalizability of our results in that we could not control any bias, which may have subtly affected the principals' choice of participants. Future research should also be conducted assessing these variables, using a longitudinal design.

Our study is consistent with previous research that finds a high risk for PTSD and depression for survivors of a natural disaster. Because of the extensive damage by recent natural disasters, such as earthquakes, floods, avalanches, and tornadoes, many victims are relocated to intact communities. Relocated adults are at particu- larly high risk for depression in addition to PTSD and a variety of other psychiatric symptoms. This study was generated by the clinical observation that relocated victims appeared less psychologically ill than those victims remaining in the disaster zone. When studied statistically, this fact was not substantiated. More research is needed before definitive conclusions informing public policy are drawn. However, our results suggest the need to direct aid, including medical, psychological, food, and shelter, to maintain victims in their natural environment and to expedite the reconstruction process.

Acknowledgments

The authors wish to thank the Psychiatric Outreach Program of the Armenian Relief Society, Western Region, in Glendale California for their support of the


clinical work, which made this study possible and Dr. Victor Labruna for his editorial assistance.

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