Deadly earthquakes: One aspect of what it's like for the survivors

A series of strong earthquakes in southwestern China in September 2012 has left at least 80 people dead, over 800 injured, and over 200,000 relocated, with the effects of the quake rippling out to at least 700,000 people within 2 days of the 2 initial quakes. (more...) A young couple after the 2010 earthquake and tsunami in Japan grapple with the enormity of re-creating both a literal and figurative sense of home.

A 2009 imaging study [1] of the brains of survivors of the deadly 2008 earthquake in China confirms what earlier psychological studies have concluded: Many of the thousands affected by the quakes will carry with them emotional scars that they will struggle with for many years afterward in the process of rebuilding their lives.

And with this study, the 'scars' are visible enough to see that the trauma of a quake has long term effects on the brain that were previously only conjectured:


Parts of the brain affected by earthquake trauma[1]

An earthquake that involves the loss of limbs, livelihood, loved ones, and/or a home produces 'assaults' on these 5 parts of the brain.

animation of the insula, caudate nucleus, hippocampus, amygdala, and cerebellum

insula

caudate nucleus

hippocampus

amygdala

cerebellum

(not shown - anterior cingulate cortex)


Most of the locations in the animation have to do with processing emotions and this provides clues to the symptoms of Post-Traumatice Stress Syndrome (PTSD) which many survivors present [1]. Careful fMRI studies, specifically hi-field fMRI , indicate that these parts have a decrease in the connections indicated by the blue lines in the figure below -- decreased 'functional connectivity'. In other words, they have a decreased ability to 'talk' to each other or to 'coordinate' with each other to do the brain's 'work'.

decreased functional connectivity between insula, caudate nucleus, hippocampus, anterior cingulate cortex, and cerebellum

This decreased ability was also seen in the 'default mode network' of the brains of many quake survivors; the default mode network is involved in monitoring internal thoughts and feelings [32], and other nebulous but typically-human behaviours. This network is often affected adversely in those with PTSD [31]:

Earthquake trauma affects the 'default mode network' as well

The brain "at rest" or in "default (no-current-task) mode" also shows decreased connectivity.[1]

default mode network

The Effects

"... [M]ost people function remarkably well in the midst of a crisis. It's only when the shaking or the shooting or the flooding stops that PTSD begins to appear. [28]" According to Haitian psychologist Dr. Guerda Nicolas:

'The psychological impact doesn't occur until several months later.... When things get quiet...you start to feel the impact and the sadness of the images you witnessed. Having come so close to death starts to set in. That "post" part of the post-traumatic reaction is what so often takes people by surprise. The brain, however, processes fear in a particularly lasting way and once lessons about danger are learned they're very hard to unlearn.' [28]

The invisible effects

Long term effects such as these have been borne out by many earthquake survivors just in the past 20 years, including after earthquakes in China [12,13], Pakistan [15], Marmara [10], Armenia [14], and other natural and man-made devastations. The effects of earthquakes specifically tend to produce hopelessness from loss of family members, home, and community, Post Traumatic Stress Disorder and Acute Stress Disorder [17,3], suicidality [14], and vertigo [8,2].

The awareness that these changes are occurring as early as 25 days after a major earthquake may help bring early treatment that "might reduce long-term psychological disability in trauma survivors" not just of earthquakes, but for all "national disasters, military conflict, and other causes of severe emotional distress." [1]

In numbers, how many quake survivors are likely to be affected by this ?

"A population that has gone through something like an earthquake of [the magnitude in Haiti] will typically have about 10 percent of people with PTSD and 10 percent with depression, based on studies of Hurricane Katrina, 9/11, and other events .... But among those who lose their homes and loved ones in an event like [that quake], the rates can be more like 40 to 50 percent [26]."

The lessons from those who lost loved ones, livelihoods, and/or homes in the Asian Tsunami are this [30]:
Approximately 21% had PTSD
Approximately 13% had severe depression.
Approximately 30% had severe anxiety
Approximately 22% had somatic symptoms (or physical symptoms without an apparent medical explanation).


Most vulnerable are the oldest and the youngest, and particularly the females in each group

Up to 95% (!) of the youngest are vulnerable

Symptoms of PTSD are much more common in children after an earthquake [33] than in their parents, and this appears to be true of most natural disasters. A study of children that were affected by Hurricane Katrina "found that about half of the children experienced high levels of depression and post-traumatic stress symptoms." In general, "currently being separated from a caregiver, living in a trailer, having to stay in a shelter, younger age, being female, having previous loss or trauma, having had family members or friends killed ... seemed to increase risk for these symptoms [22]."

"A study of children affected by the Armenian earthquake of 1988, interviewing children 18 months after the event, and published in the British Journal of Psychiatry, concluded that catastrophic natural disaster can produce PTSD in children, reaching to as high as epidemic proportions and staying high for a long time [25]." 204.13.164.45"In a study conducted by the New York Academy of Medicine, researchers found that 95% of children [my emphasis] following [and most heavily affected by] the Armenian earthquake of 1988 suffered from PTSD. The study also found that women are more prone to PTSD than men [27]."

The oldest often feel that it's just too late to rebuild a whole life

Loss of family members and/or ones home leaves them particularly vulnerable to despair, because they see themselves as too old to start building another life [12]. "Studies by psychologist Fran Norris at Dartmouth University have shown that adult disaster survivors who feel uncared for by others or who lack the capacity to manage stress are also at risk for PTSD[26]."

The study in China, after that country's 2008 quake, was particularly unique in terms of how soon after the quake the testing was done (25 days), and showed that the potential for long term effects (and thus the hope for minimizing them) shows up in a visible and quantifiable way, very soon after the quake. Not surprisingly, many quake survivors also suffer from 'compartment syndrome' [10].

At the very least, the psychological trauma hinders healing from the shorterm visible injuries. People suffering from psychological trauma tend not to attend to the self-care that is necessary for their physical injuries to heal [14], tending to have persistent 'avoidance' symptoms and irritableness [9], and this is especially true if they've lost a limb [14], have been rendered paraplegic or have other spinal cord injuries [15].

This underlies how important it is for the survivor to get psychological treatment as soon as possible, and this benefits the surrounding community as well. The neurological effects start early and last a long time [3,6]. The more time, energy, and money spent now to identify and treat these problems will avoid a greater expenditure later [3,1].

Mental vs. physical effects

As the 2 top-most brain images show, the trauma of a natural disaster can have as physical an effect on the brains of the survivors as can objects which crush limbs and destroy homes, and treating a broken psyche is as essential to rebuilding a life as treating a broken limb.

I suspect many agencies receiving donations are wondering how they will make the money stretch over the many many months that the survivors will be battling with these less-visible, but still debilitating and long-term effects of living through an earthquake or tsunami or both.
Here are some agencies giving long-term support:

Huffington Post's page http://news.yahoo.com/s/huffpost/20100113/cm_huffpost/421014" target="_blank" Raj Patel's page: http://rajpatel.org/2010/01/14/haiti-how-you-can-help/
Partners in Health: http://www.standwithhaiti.org/haiti

References

[1] Su Lui et al. (2009) High-field MRI reveals an acute impact on brain function in survivors of the magnitude 8.0 earthquake in China PNAS 2009 106 (36) 15412-15417. This was an fMRI study of survivors of the 2008 earthquake in Wenchuan China, 8.0 on the Richter scale of intensity (The 2011 quake with tsunami in Japan was 9.0, Christchurch New Zealand was 6.3, and the 2010 quake in Haiti was 7.0)

[2 ] Gordon CR et al. (2004) Is posttraumatic benign paroxysmal positional vertigo different from the idiopathic form? Arch Neurol. 2004 Oct;61(10):1590-3.

[3] King's College London (2009). Acute Impact On Brain Function In Earthquake Survivors. ScienceDaily, 2009, September 24. Last retrieved May 1, 2010.

[4] Associated Press (2010) Haiti raises earthquake toll to 230,000. The Washington Post. AP. 10 February 2010. . Retrieved 30 April 2010.

[5] BBC News (2010) Haiti will not die, President Rene Preval insists, 12 February 2010. Retrieved 12 February 2010.

[6] People's Daily Online (2009) Acute impact on brain function in earthquake survivors. September 01, 2009 . Last retrieved May 4, 2010.

[7] (2010) China to mourn quake dead, public entertainment to be suspended. Xinhuanet (Xinhua News Agency). 2010-04-20. Retrieved 2010-04-20.

[8] Tevzadze N et al. (2007) Vertigo syndromes associated with earthquake in Georgia, Georgian Med News. 2007 Jul-Aug;(148-149):36-9.

[9] Guo Y et al. (2008) Psychological stress in the earthquake survivors: the psychological aftermath of the Wenchuan earthquake 2008 Jul;28(7):1114-6. [Abstract in English, article in Chinese].

[10] Uzun N et al. (2005) Electrophysiologic evaluation of peripheral nerve injuries in children following the Marmara earthquake. J Child Neurol. 2005 Mar;20(3):207-12.

[12] Zhu Zhe (2008) Elderly try hard to deal with trauma (China Daily) 2008-05-23.

[13] (Agencies, to China Daily) 2008 Treating mental trauma a daunting task2008-05-28

[14] Jing Chen et al., (2009) Administration of Nursing Services in a Newly Built Traumatic Infection Ward After an 8.0-magnitude Earthquake in Wenchuan, Journal of Emergency Nursing, Volume 35, Issue 6, November 2009, Pages 532-535

[15] Arsalan Ahmad MD. (2008) Earthquake 2005 - Spinal Cord Injury Rehabilitation in Pakistan (PDF). ACNR, VOLUME 8 NUMBER 4, SEPTEMBER/OCTOBER 2008. 74,000 people died in the earthquake.

[22] Tull M (2009) The Effect of Hurricane Katrina on ChildrenNovember 04, 2009, citing Osofsky et al. (2009) Posttraumatic stress symptoms in children after Hurricane Katrina: Predicting the need for mental health services. American Journal of Orthopsychiatry, 79, 212-220.

[25] Trappler, B. (2010) The risk of PTSD following the earthquake in Haiti, Psychology Today, January 21, 2010, citing the British Journal of Psychiatry 163: 1993

[26] Landau E (2010) In Haiti, mental aftershocks could be far-reaching (CNN), January 19 2010, quoting an Assistant Professor of Psychiatry at Yale, and quoting the chair of the Department of Epidemiology at Columbia University's Mailman School of Public Health.

[28] Kluger J (2010) Haiti: After the Devastation, the Emotional Wreckage Time magazine, Sunday, Jan. 17, 2010, quoting, in part, a Haitian psychologist interviewed here.

[30] Tull M (2009) The Psychological Impact of the 2004 Tsunami July 20, 2009

[31] Lanius RA, et al. (2010) Default mode network connectivity as a predictor of post-traumatic stress disorder symptom severity in acutely traumatized subjects. Acta Psychiatr Scand. 2010 Jan;121(1):33-40.

[32] Mason MF, et al. (2007) Wandering minds: The default network and stimulus-independent thought. Science 315:393–395. 2007

[33] Salcioğlu E et al. (2008) Psychological effects of earthquakes in children: prospects for brief behavioral treatment. World J Pediatr. 2008 Aug;4(3):165-72.

 
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