Armen K. Goenjian

Psychiatric Comorbidity in Children after the 1988: Earthquake in Armenia

OBJECTIVE To determine current rates of posttraumatic stress disorder (PTSD), depressive disorder, and separation anxiety disorder (SAD) among children 1 1/2 years after the 1988 earthquake in Armenia; to determine current rates of comorbid PTSD and depressive disorder; and to assess the contribution of exposure, gender, loss of family members, and loss of residence. METHOD Two hundred eighteen school-age children from three cities at increasing distances from the epicenter were evaluated using the Child Posttraumatic Stress Disorder Reaction Index, the Depression Self-Rating Scale, and the section on SAD from the Diagnostic Interview for Children and Adolescents. RESULTS On the basis of these evaluations, high rates of current PTSD, depressive disorder, and their co-occurrence were found among victims residing in the two heavily impacted cities. SAD was comparatively less frequent, although symptoms of SAD had been pervasive throughout the region. Severity of posttraumatic stress and depressive reactions were highly correlated. Extent of loss of family members was independently correlated with each. CONCLUSION After a catastrophic natural disaster, children are at risk for comorbid PTSD and secondary depression. Based on the findings, an interactive model is proposed of postdisaster psychopathology. Early clinical intervention is recommended to prevent chronic posttraumatic stress reactions and secondary depression.

A behavioral animal model of posttraumatic stress disorder featuring repeated exposure to situational reminders

The purpose of this study was to evaluate an animal model of posttraumatic stress disorder (PTSD) in mice. The model featured repeated exposures to situational reminders of a traumatic stress, which consisted of a brief electric shock, and included assessment of two behavioral parameters and the startle reflex. The findings indicated an initial, but unsustained, increase in locomotor activity in a neutral environment due to traumatic stress. Exposure to situational reminders was associated with a persistent bidirectional abnormal behavioral pattern in a fear-provoking environment and a progressive increase over time in the magnitude of the startle reflex. Exposure to situational reminders also produced an increase in aggressive behavior. This animal model appears to produce behavioral changes analogous to those seen in patients with PTSD.

Relocation after a disaster: posttraumatic stress disorder in Armenia after the earthquake

OBJECTIVE To explore the relationship between exposure to the earthquake in Armenia on December 7, 1988, and relocation from the disaster zone, and the subsequent development of posttraumatic stress disorder (PTSD), depression, and behavioral difficulties in children. METHOD The PTSD module of the Diagnostic Interview for Children and Adolescents-Revised and the Depression Self-Rating Scale were administered to 25 children, aged 11 through 13 years, who had high exposure to the earthquake and remained in the earthquake city. They were compared with a demographically similar group of 24 children exposed to the earthquake who were relocated to another city after the earthquake and 25 nonexposed children. For each child the mothers responded to the Child Behavior Checklist and the teachers responded to the Teachers Report Form. RESULTS The hypothesis that relocated children would present with less PTSD, depression, and behavioral problems was not confirmed. Both groups of children with high exposure to the earthquake, one remaining in the earthquake city and one relocating, demonstrated significantly higher rates of PTSD, depression, and behavioral difficulties than the comparison group. There were no differences between the relocated children and those who remained in the earthquake zone. CONCLUSION Children who were relocated after a natural disaster did no worse than children who remained in the disaster zone. Relocation should be considered as an alternative after catastrophic natural disasters in situations where resources are so limited that rebuilding cannot take place for an indefinite period of time.

The effect of relocation after a natural disaster

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 exposed groups 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. Relocation after a disaster appears to be associated more with risk for depression than with PTSD in situations where recovery is delayed following the trauma.

Issues in the Developmental Neurobiology of Traumatic Stress

Over the last decade, significant advances have been made in characterizing the neurobiology of traumatic stress reactions among adults. Increasing evidence for a similar phenomenology of posttraumatic stress disorder (PTSD) symptoms in adults and school-age children and adolescents’-’ provides a compelling rationale for the possibility of common neurobiological alterations. If present, such alterations in children and adolescents would be of special concern in view of the potential adverse impact on a wide range of developmental processes. We recently presented a developmental psychopathology model of traumatic stress in ~hildhood.~ Such a model emphasizes the complex interrelationship of trauma and developmental progression and the essential linkage between disrupted and normal development. Analogously, investigation of the neurobiology of PTSD among children and adolescents will need to be embedded in a neurodevelopmental framework. This paper provides an overview of selected areas of neurodevelopment and recent findings relevant to this research enterprise. A key feature of our developmental model of childhood traumatic stress is the prominent role assigned to the trauma-related formation of expectations, as these are expressed in the thought, emotion, behavior, and biology of the developing child. Such traumatic expectations dramatically alter the sense of safety and security of the environment and interpersonal life and the child’s sense of personal integrity. Ultimately, a comprehensive neurodevelopmental approach to traumatic stress among children and adolescents will place such investigation within the broader context of the child’s evolving capacity for appraising, processing, and responding to danger, trauma, and posttrauma reminders.

Depression and PTSD symptoms among bereaved adolescents 6½ years after the 1988 spitak earthquake

OBJECTIVE To compare depression and PTSD symptoms of parentally bereaved adolescents and a comparison group after a catastrophic natural disaster. METHOD Six and a half years after the Spitak earthquake, 48 parentally bereaved adolescents and a comparison group of 44 subjects with no parental loss were evaluated using the Depression Self - Rating Scale (DSRS) and Child Posttraumatic Stress Disorder Reaction Index (CPTSD-RI). RESULTS Orphans scored significantly higher on depression than those who lost a father (Mean DSRS scores: 20.2+/-3.3 vs. 16.6+/-5.2; p<0.001), who in turn scored significantly higher than those who lost a mother (Mean DSRS scores: 16.6+/-5.2 vs. 12.7+/-4.1; p<0.002). Depression scores for orphans fell above the cut-off for clinical depression, while those who lost a father scored slightly below. PTSD scores within each group fell in the moderate range of severity, with girls scoring higher than boys (Mean CPTSD-RI scores: 35.9+/-11.3 vs. 29.3+/-10.1; p<0.04). LIMITATION As self-report instruments were used, responses may have been over- or under- reported. Participants belonged to the same ethnic group and therefore the results may not be generalizable to other populations. CONCLUSION Loss of both parents and, to a lesser degree, loss of a father is a significant risk factor for depression, but not for PTSD. This study extends prior findings documenting post-disaster chronicity of depression and PTSD among bereaved adolescents, and underscores the need for post-disaster mental health and social programs, especially for those who suffer the loss of both parents.

Posttraumatic stress reactions after single and double trauma

This study evaluated the severity and symptom profile of posttraumatic stress reactions of 202 adults exposed in 1988 to political violence in Azerbaijan and/or the earthquake in Armenia. High rates of severe posttraumatic stress reactions were found among the most highly exposed individuals, irrespective of the type of trauma. There was no difference in symptom profile for subjects exposed to earthquake versus violence. These similarities in severity and symptom profile may be attributable to common features of the exposures, which included experiencing life‐threat and witnessing injury, mutilation and death. Recent prior exposure to violence contributed to the severity of reaction to the earthquake. The high rates of chronic and severe posttraumatic stress reactions in Armenia constitute a major public mental health problem.

Hypothalamic-pituitary-adrenal activity among Armenian adolescents with PTSD symptoms.

This study evaluated basal levels and responsiveness to exercise of plasma adrenocorticotropic hormone (ACTH), and serum thyroid stimulating hormone (TSH), growth hormone (GH) and cortisol among adolescents from two differentially exposed groups 61/2 years after the 1988 earthquake in Armenia. Severity of total PTSD and Category C and D symptoms were negatively correlated with baseline cortisol. Preexercise ACTH was significantly lower, and preexercise TSH higher, among adolescents with more exposure. Depressive symptoms were negatively correlated with baseline cortisol and positively with TSH. Mean GH, TSH, and cortisol levels in both groups fell within normal limits. The pre- to postexercise increase in GH, TSH, and cortisol suggests that exercise challenge may be useful in the field investigation of neurohormonal activity among traumatized individuals.

Moral development and psychopathological interference in conscience functioning among adolescents after trauma

OBJECTIVES To compare moral development and psychopathological interference with conscience functioning (PI) among adolescents exposed to different degrees of earthquake-related trauma and to investigate the relationship of moral development and PI to exposure to trauma, severity of posttraumatic stress disorder (PTSD) symptoms, postearthquake adversities, and extent of loss of nuclear family members. METHOD Adolescents (N = 193) from 2 cities at different distances from the epicenter were evaluated. The Stilwell Structured Conscience Interview was used to assess moral development and PI. Structured self-report instruments were used to obtain ratings of severity of earthquake-related trauma, posttraumatic stress symptoms, and postearthquake adversities. RESULTS Adolescents in the city near the epicenter manifested advanced moral development as compared with their counterparts in the less affected city. Concomitantly, they endorsed responses indicating PI. Levels of PI were significantly correlated with severity of PTSD symptoms. CONCLUSION In the aftermath of a catastrophic natural disaster, children assume greater responsibilities and confront a multitude of morally challenging interpersonal situations which may result in an advancement of their moral development. Yet, at the same time, PTSD symptoms and negative schematizations of self and others may give rise to disturbances in conscience functioning. The findings suggest that therapeutic consideration should be given to assisting children in integrating the horror of their traumatic experiences and the harshness of posttrauma adversities into an adaptive schema of good and evil in themselves and the world.

Strategies of Disaster Intervention for Children and Adolescents

Children are frequently victims of disasters and, until recently, little attention has been paid to their plight. This chapter presents recommendations for the design and implementation of school-based disaster-related mental health interventions for children and adolescents, their families, schools and communities. It proposes that three levels of organization are required for the implementation of such a public mental health disaster program, and recommends the use of a developmental model of traumatic stress to guide intervention strategies in addressing risks of psychological, interpersonal and developmental disturbances. Recommendations are made regarding strategies for the evaluation of primary and secondary preventive interventions and clinical mental health services. Public policy should make provision for the allocation of resources for disaster safety at schools and post-disaster services for children and adolescents.