Preventive Medicine 29, 147–151 (1999)Article ID pmed.1999.0528, available online at http://www.idealibrary.com on

Posttraumatic Stress and Change in Lifestyle among theHanshin-Awaji Earthquake Victims

1 K

Sanae Fukuda, Kanehisa Morimoto,

Department of Hygiene and Preventive Medicine, Osaka University

Background. In 1995, Japan’s Hanshin-Awaji areawas severely damaged by a major earthquake. Lifestylefactors, sometimes associated with physical health andmortality, have also been known to be associated withmental health status. This report examines the rela-tionship between the subsequent change in lifestyleand the psychological stress induced by the earth-quake.

Method. An investigation was made of 108 male in-habitants of Awaji Island as to their individual lifestylebefore and after the great earthquake, any posttrau-matic stress disorder (PTSD) symptoms, and their de-mographic variables.

Results. The mean PTSD score was higher in theworse lifestyle group than in the no/better lifestylechange group. Category B or D of PTSD scores werehigher in the worse lifestyle group than in the no/betterlifestyle change group. The percentage of subjects wholived in temporary public housing was higher in theworse lifestyle group than in the no/better lifestylechange group.

Conclusions. Worse change in lifestyle might be asso-

ciated with high PTSD score in victims of Hanshin- Awaji earthquake. q 1999 American Health Foundation and Aca-

demic Press

Key Words: Hanshin-Awaji earthquake; lifestyle; post-traumatic stress disorder; stress coping.

INTRODUCTION

On January 17, 1995, the Hanshin-Awaji area in Ja-pan was severely damaged by a major earthquake,which registered 6 or 7 (M 7.2) on the Japanese seismic

scale, equivalent to 10–12 on the U.S. seismic scale.Moreover, 61 aftershocks occurred and 110 fires brokeout on the first day. The quake killed more than 6,200people (official announcement, March 1997).

1 To whom correspondence should be addressed. Fax: 181(6) 6879-3929. E-mail: morimoto@envi.med.osaka-u.ac.jp.

14

anae Mure, and Soichiro Maruyama

School of Medicine, Yamada-Oka, Suita, Osaka 565-0871, Japan

There have been many studies investigating the psy-chological states of natural disaster victims, such asearthquakes in Sierra Madre [1], Italy [2], Armenia[3,4], and India [5]; or Hurricanes Hugo [6] and Andrew[7]; or the bushfire disaster in southeastern Australia[8,9]. Numerous studies reported that exposure to di-sasters was associated with increasing psychologicaldistress, including posttraumatic stress disorder(PTSD) [5,7,8,10]. The essential feature of PTSD is thedevelopment of characteristic symptoms following ex-posure to an extreme traumatic stressor, such as wit-nessing an event that involves death and injury [11].In the wake of the Hanshin-Awaji earthquake, PTSDsymptoms were reported at an early stage [12].

There are also many studies reporting psychologicaldistress, diseases, loss of social network, and mentalcare after natural disasters. However, few studies haveinvestigated the causes of stress with the aim of thepreventing stress-related diseases after a disaster, andnone have suggested practical methods for individualsto cope with the situation.

From that preventive viewpoint, we examined notonly the psychological states of victims but also lifestylefactors triggering psychological stress induced by theearthquake. Our group showed that mental status mea-sured by general health questionnaire (GHQ) wasstrongly associated with health practices [13]. Theselifestyle evaluations were based upon the famous studyby The Human Population Laboratory in AlamedaCounty, California, and the seven practices in thatstudy were adapted for Japanese people [14–17]. Inour group’s previous report about the Hanshin-Awajiearthquake, a higher reading on the Japanese seismicscale was associated with victims’ high GHQ score andalso was associated with poor lifestyle [18]. Our grouphas clarified the association between lifestyles and

other factors: production of chromosome alterations[19–21], total Immunoglobulin E [22], natural killercell activity [23], lymphokine-activated killer cell activ-ity [24], and the urinary level of mutagens [25].

7 0091-7435/99 $30.00Copyright q 1999 by American Health Foundation and Academic Press

All rights of reproduction in any form reserved.

6. Physical exercise (exercising at least once a week)

148 FUKUDA

The Awaji Island is the closest area to the epicenterof the Hanshin-Awaji earthquake. The subjects of ourinvestigation lived in the severely exposed area. Thusthis area was suitable for collecting the base sample ofproblems following the great disasters.

In the present study to correlate between the changesin lifestyle caused by the earthquake and psychologicalstress 20 months after the Hanshin-Awaji earthquake,we administered questionnaire as to their individuallifestyle before and after the great earthquake, anyPTSD symptoms, and their demographic variables to108 male inhabitants of Awaji Island. We report thatworse change in lifestyle might be associated with highPTSD score in victims of Hanshin-Awaji earthquake.Previous studies have shown the buffer effects of a so-cial network and the protection of victim’s importance

in relieving stress. Our aim was to clarify effectivenessfor improving lifestyle as a method of coping with stressafter an earthquake. To our knowledge, this is the firstreport of the effect of lifestyle in relieving stress afteran earthquake.

MATERIALS AND METHODS

Subjects

Some 108 healthy male residents of the town closestto the epicenter on Awaji Island were randomly chosenfrom the participants in a regular public healthcheckup. Before participating in this study, informedconsent was obtained by the medical staff. At the sametime, we also collected blood from subjects for measur-ing cortisol (data not shown). Thus subjects were lim-ited to males. The town was the area closest to theepicenter and its population was about 10,000. Thirty-nine residents were killed and more than 90% of thedwellings were damaged in the town. About 40% of thepopulation is older than 60 years of age.

The present study was performed 20 months afterthe Hanshin-Awaji earthquake. The average age of theparticipants was 62 years old. They completed the ques-tionnaire covering demographic variables (age, maritalstatus, occupation, loose family members, and dwellingstyle), as well as lifestyle and posttraumatic stresssymptoms.

Total Lifestyle Evaluation

The total lifestyle evaluation was performed 20months after the earthquake, so subjects recalled theirlifestyle before the earthquake. To evaluate personalhealth practice and overall lifestyle before and after

the earthquake, we used the eight health practices de-veloped by Morimoto et al. [19–21], while taking ac-count of the differences between Japanese and Ameri-can culture (Table 1). Each item had multiple answers(two to six each), and the answers were classified into

7. Nutritional balance (eating nutritionally)8. Perceived mental stress (keeping mental stress levels moderate)

Note. The health practices recommended by Morimoto et al. aregiven in parentheses.

the category of good practices including not smokingcigarettes, not consuming alcohol every day, eatingbreakfast every morning, sleeping 7 to 8 h per day,working less than 9 h per day, physically exercising atleast once a week, maintaining a nutritionally balanceddiet, and keeping mental stress at manageable levels.Good practices were scored as 1, and other practices,0. The total score of the eight criteria was regarded asthe Health Practice Index (HPI).

Subjects were classified into two groups by their cur-rent HPI compared with their former HPI: the no/betterlifestyle change group and the worse lifestyle changegroup. We combined the no change lifestyle group withthe better lifestyle group, because a poor lifestyle mayinduce a number of diseases.

Psychological Aspects

To investigate psychological aspects related to theearthquake, the PTSD symptom score was employed.This questionnaire was based on PTSD diagnostics ofDSM-IV [11]. It consisted of 19 items: 2 items fromcategory A (experience threat of life, shudder response),5 items from category B (repetitive images, bad dreams,repetitive thoughts, upset at reminders, somatic com-plaints), 7 items from category C (emotional avoidance,behavioral avoidance, psychogenic amnesia, dimin-ished interest in activities, emotional numbing, fore-shortened future), and 5 items from category D (sleepdifficulties, irritability, disability of concentration, hyp-ervigilance, easily startled) of the PTSD criteria. Ques-tions answered in the affirmative were given one point,and in the negative, no points. The total score was usedfor the PTSD score. Sub-scoring was used for each cate-gory (B, C, D).

Statistical Analysis

ET AL.

TABLE 1

Eight Health Practice Index

1. Cigarette smoking (not smoking cigarettes)2. Consuming alcohol (not consuming alcohol every day)3. Eating breakfast (eating breakfast every day)4. Sleeping hours (sleeping 7 to 8 h per night)5. Working hours per day (working less than 9 h per day)

Differences in individual demographic variables(marriage status, death of family, dwelling style) be-tween the no/better lifestyle change and the worse life-style change groups were analyzed by x2 test. Differ-ences in the mean PTSD scores and age between two

Other 77.78 (21) 92.00 (75)Death of family members (%)

None 74.07One or more 25.93

a t test; other, x2 test.

groups were analyzed by two-tailed t-test. The appear-ance rate of each PTSD symptom category was deter-mined and compared between the two groups. If replies

LIFESTYLE CHANGE AND POSTTRAUMATIC STRESS INDUCED BY EARTHQUAKE 149

TABLE 2

Differences in Demographic Variables between Worse and No/Better Lifestyle Change

Lifestyle change

Worse (n) No/better (n) P

Age, years (mean 6 SD)a 60.38 6 12.86 (26) 62.04 6 12.34 (81)Marital status (%)

Married 92.00 (23) 85.00 (68)Single 0.00 (0) 7.50 (6)Widowed 8.00 (2) 7.50 (6)

Dwelling style (%)Temporary public housing 22.22 (6) 8.00 (6) ,0.05

to one or more of the questions in each category were

differences in categories B and D. The risk of category

affirmative, this category’s symptom was considered tohave appeared. These analyses were conducted withthe use of the Statistical Package for Social Sciencescomputer program [26].

RESULTS

The results of comparing individual demographicvariables between the worse and the no/better lifestylechange groups are shown in Table 2. The mean age,marital status, and death of family members showedno differences between the two groups. One subjectfailed to complete the question regarding age and threedid not answer the question as to marital status. Inthe worse lifestyle change group, about 22% of subjects

were living in temporary public housing after the earth-

FIG. 1. The relationship between lifestyle change and PTSDscore. Error bars, SE. The differences between the two groups wereanalyzed by two-tailed t-test (t 5 4.11, df 5 98). ****P , 0.001.

(20) 76.54 (62)(7) 23.46 (19)

the two lifestyle groups. Eight subjects are missing be-cause of incomplete answers. The total PTSD score wassignificantly higher in the worse lifestyle change groupthan in the no/better lifestyle change group (P , 0.001).

Each PTSD symptom category was also examinedbetween the worse lifestyle change and the no/betterlifestyle change group (Table 3). It showed significant

quake, whereas only 8% lived in such housing in theno/better lifestyle change group. This was a statisticallysignificant difference (P , 0.05).

Figure 1 shows the difference in PTSD score between

B in the worse lifestyle change group was 2.6 times ashigh as that in the no change/better lifestyle group. Thehighest risk of three category is category D. The oddsratio was 4.40 (CI 1.81–10.72).

DISCUSSION

In the present study, the psychological stress as-sessed subsequent to the Hanshin-Awaji earthquakewas significantly associated with changes in lifestyle.Subjects in the worse lifestyle change group showed asignificantly higher PTSD score than in the no/betterlifestyle change group.

Awaji Island is the area closest to the epicenter of theHanshin-Awaji earthquake. And the town investigatedwas exposed to the most severe damage. Indeed, 50%of the subjects experienced direct threats to their lives.Adolescents who lived near the epicenter in the Arme-nia earthquake, for example, showed higher PTSDsymptom scores than those who lived 20 miles from theepicenter 5 years after the earthquake [27,28]. Thesereports suggested that the more severe the psychiatricsymptoms were, the closer the victims were to the epi-center. McFarlane et al. reported that 12.5% of thebushfire’s victims in southeastern Australia were de-

fined as having PTSD after 42 months [8]. Thirty-sixpercent of the Hurricane Andrew evacuees met PTSDcriteria at 6–12 months post-hurricane [7].

The relationships between lifestyle and mentalhealth are widely acknowledged [29,30]. In particular,

D 81.48 (22) 38.67 (29) 4.40** 1.81–10.72

no

Note. x2 test: *P , 0.05; **P , 0.001.a Percentages of subjects at PTSD score: B, 1–5; C, 1–7; D, 1–5.b Relative risk estimate in worse lifestyle compared with better orc Confidence intervals.

depressive symptom rates were strongly associatedwith poor health habits [31,32]. Good lifestyle has beenreported to be associated with better mental healthstatus in Japanese factory workers [13]. In particular,the percentages of affirmative answers in the questionsrelated to categories B and D in PTSD diagnosis weresignificantly higher in the worse lifestyle change group.Thus, the rates of main symptom of PTSD, intrusivememory, and arousal symptoms were high in this group.

Demographic variables show that the number of sub-jects who lived in the temporary pubic housing in theworse lifestyle change group were nearly three timesthose in the no/better lifestyle change group. Nearly 2years had passed since the earthquake when we beganthe present investigation and 9% of all subjects stilllived in the temporary public housing. Twenty-two per-cent of the worse lifestyle change group still lived in thehousing. No subjects lived in temporary public housingbefore the earthquake.

In 1995, Japan’s Hanshin-Awaji area was severelydamaged by a major earthquake. Lifestyle factors,sometimes associated with physical health and mortal-ity, have also been known to be associated with mentalhealth status. The mean PTSD score was higher inthe worse lifestyle group than in the no/better lifestylechange group. Category B or D of PTSD scores washigher in the worse lifestyle group than in the no/betterlifestyle change group. Worse change in lifestyle mightbe associated with high PTSD score in victims of Hans-hin-Awaji earthquake. Our data suggest that improvinglifestyle might be effective as a method of coping withstress after an earthquake. Thus, we recommend regu-lar lifestyle evaluation and instruction about suitablehealth habits, such as methods simply to cope with

150 FUKUDA ET AL.

TABLE 3

Relationship of Each PTSD Category and Lifestyle Change

Lifestyle change

PTSD categorya Worse (%) (n) Better/no (%) (n) Rb 95% CIc

B 85.19 (23) 62.67 (47) 2.63* 0.99–6.98C 73.91 (17) 57.75 (41) 1.76 0.77–4.04

stress after earthquake. Previous studies have shownthe buffer effects of a social network and the protectionof victim’s importance in relieving stress. Thus, thepresent study has important new implications for disas-

ter relief programs and the prevention of PTSD.

ACKNOWLEDGMENT

This study was performed through Special Coordination Funds ofthe Science and Technology Agency of the Japanese Government.

change lifestyle group.

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