Journal of Affective Disorders 146 (2013) 174180

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research report

Age, gender and epicenter proximity effects on post-traumatic stress

symptoms in LAquila 2009 earthquake survivors
DellOsso L.a, Carmassi C.a,n, Massimetti G.a, Stratta P.b, Riccardi I.b, Capanna C.b,
Akiskal K.K.c, Akiskal H.S.c, Rossi A.b
a

Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, University of Pisa, Pisa, Italy
Section of Psychiatry, Department of Experimental Medicine, University of LAquila, LAquila, Italy
c
International Mood Center, University of California at San Diego, La Jolla, CA, USA.
b

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 10 April 2012
Accepted 29 August 2012
Available online 23 October 2012

Background: Earthquakes are among the most frequently occurring natural disasters affecting the
general population and inducing Post-Traumatic Stress Disorder (PTSD). Thus, increasing effort has
been devoted to explore risk factors for PTSD onset after exposure. The aim of the present study was to
investigate the impact of gender, degree of exposure and age on PTSD and post-traumatic stress
symptoms in the general population exposed to the LAquila 2009 earthquake (Richter Magnitude 6.3).
Methods: A total sample of 1488 subjects (721 women and 767 men) was assessed by means of the
Trauma and Loss Spectrum Self Report (TALS-SR): 939 subjects have been directly and 549 not-directly
exposed to the earthquake. We performed a random extraction of units from the population in order to
have 8 homogenous comparable subgroups.
Results: A main signicant effect of exposure (exposed 4 non exposed subjects) and gender (women 4
men) emerged on the TALS-SR domain scores. Further signicant interaction effects of exposurenage
and gendernage emerged with signicantly more TALS-SR symptoms being reported in younger with
respect to older non-exposed subjects and in younger with respect to older women.
Limitations: Social support was not examined systematically as well as major depression. Further
limitations are the relatively small sample size and the use of lifetime instruments.
Conclusions: Our results corroborate literature on female gender and proximity to the epicenter being
correlated to PTSD after earthquake exposure and suggest a possible secondary effect of age.
& 2012 Elsevier B.V. All rights reserved.

Keywords:
PTSD
Gender
Age
Earthquake
Degree of exposure

1. Introduction
Post-Traumatic Stress Disorder (PTSD) is the most frequently
reported psychiatric sequelae of traumatic exposure and is
often characterized by a chronic course and associated with high
risk for suicide (McMillen et al., 2000; Lai et al., 2004; Bal and
Jensen, 2007; Goenjian et al., 2009; Cairo et al., 2010; Hussain et
al., 2010; DellOsso et al., 2011a). Increasing attention has been
devoted to PTSD occurrence, even in its partial or subthreshold
forms, in populations exposed to natural disaster such as earthquakes (Lai et al., 2004; Chang et al., 2005; DellOsso et al.,
2011b,c) and many studies have been focused on potential risk
factors.
There is agreement across studies that women are more
vulnerable to the impact of these events usually reporting higher
n
Correspondence to: Department of Psychiatry, Neurobiology, Pharmacology
and Biotechnology, University of Pisa, Via Roma 67, 56126 Pisa, Italy.
Tel.: 39 050 2219766; fax: 39 050 2219787.
E-mail address: ccarmassi@gmail.com (C. Carmassi).

0165-0327/$ - see front matter & 2012 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.jad.2012.08.048

rates of PTSD than men (Green, 2003; Lai et al., 2004; Bal and
Jensen, 2007; Cohen, 2008; Goenjian et al., 2009; Pratchett et al.,
2010; Ali et al., 2012; DellOsso et al., 2011b; Xu and Liao, 2011;
Xu and Song, 2011; Zhang et al., 2011). Gender differences have
also been reported in the frequency of PTSD symptoms in
earthquake survivors with women being more symptomatic than
men (Karanci and Rustemli, 1995; Carr et al. 1997; Livanou et al.,
2002; Aksaray et al., 2006; Bal and Jensen, 2007; DellOsso et al.,
2011b,c).
Along with gender, several other risk factors for PTSD onset
among earthquake survivors have been investigated, such as
family deaths, personal injury and house damage (Basoglu et al.,
2004; Ahmad et al., 2010; DellOsso et al., 2011c), but increased
attention has also been devoted to the degree of earthquake
exposure, dened as the distance from the epicenter, suggesting a
relationship between the proximity to the epicenter and the
increasing levels of psychopatology (Armenian et al., 2000; Cao
et al., 2003; Chan et al., 2011; Wang et al., 2010). Armenian et al.
(2000) in fact, in a sample of 1785 adult participants of an
epidemiological study initiated in the immediate aftermath of

L. DellOsso et al. / Journal of Affective Disorders 146 (2013) 174180

the 1988 earthquake in Armenia, reported higher PTSD rates

among survivors from areas with the worst destruction. More
recently, Chan et al. (2011) recruited a sample of earthquake
survivors from 2 areas at different distances from the epicenter of
the Sichuan earthquake, nding signicantly higher PTSD symptom rates (55.6% versus 26.4%) among people from the closest
area to the epicenter.
Conversely, conicting results have been reported in the
literature on the role of age on PTSD after earthquake exposure.
Although most studies seem to show higher levels of PTSD
symptoms after an earthquake among middle-aged and older
people with respect to younger ones (Goenjian et al., 1994;Carr
et al., 1997; Lewin et al., 1998; Salcioglu et al., 2003; Toyabe et al.,
2006; Wu et al., 2006; Chen et al., 2007, Ali et al., 2012), other
authors (Kato et al., 1996) reported a signicant decrease in posttraumatic stress symptoms in subjects older than 60 years. Priebe
et al. (2009), in a sample of 2.148 subjects exposed to an earthquake in a rural region of Italy in 2002, reported female gender,
lower school education and age over 55 years to be predictors of
higher PTSD rates. More recently, Xu and Liao (2011) observed
that psychological interventions and care for survivors of
Sichuan earthquake disaster should focus on females and older
people as these two categories resulted to be more affected by the
disaster.
To the best of our knowledge, no study explored the possible
interactions between gender, degree of exposure and age on PTSD
and post-traumatic stress symptoms among earthquake survivors, and these data could help a better understanding of psychopathological traumatic sequelae.
Italy is one of the most seismically active countries in Europe
but it is unusual for the Country to experience deadly earthquakes. On April 6th 2009, at 3:32 a.m., an earthquake (Richter
Magnitude 6.3) struck LAquila, Italy, a town with a population of
72,000 inhabitants. Because of the earthquake many buildings
collapsed and large parts of the town were destroyed, 309 people
died and more than 1600 individuals were injured and 66,000
displaced. In two previous studies we reported PTSD rates as high
as 37.5% after 10 months (DellOsso et al., 2011b) and 30.7% after
21 months (DellOsso et al., 2011c), among adolescents survived
to this event, with higher rates among women and bereaved
subjects (DellOsso et al., 2011c).
The aim of the present study was to explore the interactions
between gender, degree of exposure (direct versus indirect
exposure) and age on post-traumatic stress symptoms among
subjects exposed to the LAquila 2009 earthquake 10 months
earlier.

2. Method
2.1. Study participants
The target population were residents of the town of LAquila,
who had experienced the April 6th 2009 earthquake 10 months
earlier, and a comparison population of subjects not directly
exposed to this same earthquake (non-exposed group) as they
were recruited among subjects living more than 150 Km far from
the town of LAquila and had not been affected by the earthquake.
The exposed population included people living in the town of
LAquila who had received assistance in the emergency conditions
that prevailed. All residents of the town of LAquila were directly
exposed to the disaster and were displaced in locations within a
150 km area from the town or in tents located in the urban area.
Even 10 months after the earthquake, only 25% of the inhabitants
were able to return to their homes.

175

The Ethics Committee of the University of LAquila approved

all recruitment and assessment procedures. Eligible subjects
provided written informed consent after receiving a complete
description of the study and having an opportunity to ask
questions.
Symptoms of post-traumatic stress related to the earthquake
were self-rated on the Trauma and Loss Spectrum-Self Report
(TALS-SR) (DellOsso et al., 2009) for assessing post-traumatic
stress symptoms related to the April 2009 earthquake.
On the basis of the assumption that younger and older subjects
might report different levels of symptomatology, we dichotomized
the sample on the bases of two age categories: r40 and 440 years,
both for exposed and not exposed subjects. This age threshold
was determined accordingly to the sample distribution.
The instruments were administered to an initial sample of
1497 subjects (946 exposed and 551 not exposed), but complete
data were available for 1488 subjects (99.4%), due to partial nonresponse. The total sample of 1488 subjects, 721 women and 767
men, included: 939 exposed (468 women and 471 men) and 549
not-exposed (253 women and 296 men) subjects. In the total
sample the mean age7SD was 30.1714.9 years, with a signicant difference between exposed (24.4 712.1 years) and notexposed (40.0714.1 years) subjects (t 21.74, po.001). As the
aim of the present study was to investigate the eventual effects of
age, gender and direct/indirect exposure to the earthquake on
post-traumatic stress symptoms, we had to stratify the sample on
the basis of the former three independent values. In order to have
8 homogenous comparable subgroups we performed a random
extraction of units from the original sample. As in the original
sample, the smallest subgroup was that of the older ( 440 years)
exposed women (N 75), we generated 8 random samples of 75
subjects each: [A] young ( r40 years) men not exposed; [B] old
( 440 years) men not exposed; [C] young ( r40 years) women
not exposed; [D] old (449 years) women not exposed; [E] young
( r40 years) men exposed; [F] old (440 years) men exposed; [G]
young ( r40 years) women exposed; [H] old (4 40 years) women
exposed.

2.2. Instruments and assessments

The TALS-SR (DellOsso et al., 2008 and 2009) is an instrument
developed and validated by an international collaborative group
of clinicians and researchers under the name of the Spectrum
Project, which is aimed at assessing lifetime mood spectrum
symptoms (Frank et al., 1998; Cassano et al., 1999). The TALSSR includes 116 items exploring the lifetime experience of a range
of loss and/or traumatic events and lifetime symptoms, behaviors
and personal characteristics that might represent manifestations
and/or risk factors for the development of a stress response
syndrome. Items responses are coded in a dichotomous way
(yes/no). The instrument is organized into 9 domains and domain
scores are obtained by counting the number of positive answers.
According to the aims of the present study subjects were asked to
fulll domains IV and over, referring symptoms occurred after the
earthquake exposure. Domain IV (Reactions to losses or upsetting events) includes a range of emotional, physical and cognitive symptoms occurring as acute response to the event. Domain
V (Re-experiencing), domain VI (Avoidance and numbing) and
domain VIII (Arousal) include re-experiencing, avoidance and
numbing, and arousal symptoms respectively. Domain VII (Maladaptive copying) targets maladaptive coping and behaviors. Each
item explores whether these occurred since the loss or the trauma
exposure. A last domain (IX; Personal characteristics/risk factors)
includes an experimental list of 6 personality traits. In the present
study, the scores of domains IV, V, VI, VIII were analyzed.

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L. DellOsso et al. / Journal of Affective Disorders 146 (2013) 174180

2.3. Statistical analyses

4. Discussion

The effects of age, gender and exposure on post-traumatic

stress symptoms (assessed by TALS-SR domain scores), and of
their possible interactions, were analyzed by a model of multivariate
analysis of variance (MANOVA), followed by four separated univariate three-way ANOVA analyses. The MANOVA model included the
three dichotomous variables (age, gender, exposure) as independent
ones and the four TALS-SR domains as dependent ones.
All statistical analyses were carried out using the Statistical
Package for Social Science, version 18.0 (SPSS Inc., Chicago 2010).

The results of the present study showed high rates of posttraumatic stress symptoms among survivors to the LAquila 2009
earthquake in Italy, 10 months after exposure. In line with
previous studies on earthquake-exposed populations investigated
at different distances from the epicenter, we found signicantly
higher symptom levels among individuals located in the closest

areas to the epicenter (Cao et al., 2003; Bodvarsdottir

and Elklit,
2004; Toyabe et al., 2006; Chan et al., 2011; Naeem et al., 2011;
Wang et al., 2010). Further, accordingly to the literature we found
signicantly higher TALS-SR domain scores in women with
respect to men. In two previous studies on the general population
exposed to the same event we found similar results at different
time frames from exposure (DellOsso et al., 2011b,c). Lazaratou
et al. (2008), in a retrospective study 50 years after a catastrophic
earthquake, found women had considerably more often recurrent
dreams of the earthquake and distress than did men. Our results
show signicantly higher post-traumatic stress symptoms in all
the TALS-SR domains with respect to men. Unlike these authors,
we did not nd young adults as a whole to be the most vulnerable
groups regarding the psychological effects of the event but age
differences emerged only among women with younger ones being
the most affected. Younger men did not differ from older one on
post-traumatic stress symptoms reported. Moreover, a further
interaction between age and exposure was found as younger
subjects reported signicantly higher symptoms levels than older
one only among non-exposed subjects. Recently, Priebe et al.
(2009), in another earthquake exposed Italian population, reported
higher PTSD rates among older subjects. Conversely, our data
showed no signicant age difference in the proximity of the

3. Results
The MANOVA analysis showed a signicant main effect of
exposure [Pillais trace 0.146, F(4,531) 22.663, po0.001] and
gender [Pillais trace .212, F(4,531)35.609, po0.001]. Further, a
signicant interaction effect emerged for exposurenage [Pillais
trace 0.021, F(4,531) 2.848, p 0.023] and gender*age [Pillais
trace 0.030, F(4,531) 4.161, p 0.003]. These three-way ANOVA
analyses showed similar effects on each of the four outcome
variables (see Table 1 for details).
Figs. 1 and 2 show the main effect of exposure, with exposed
subject being the most affected, and gender, with women showing signicantly higher symptoms than men. Fig. 3 conrms the
signicant interaction effect of exposurenage on TALS-SR domain
scores, showing signicant effects among non-exposed subjects
only. Similarly, Fig. 4 conrms the signicant interaction effect of
gendernage on TALS-SR domain scores, showing signicant effects
among women only.

Table 1
Three-way ANOVA analyses on TAL-SR domain scores.
Indipendent variables

Reaction to losses
F(1,534), P

Re-experiencing
F(1,534), P

Avoidance
F(1,534), P

Arousal
F(1,534), P

Exposure
Gender
Exposurenage
Gendernage

56.941, o0.001
88.549, o0.001
6.078, 0.014
2.974, 0.085

49.553, o 0.001
129.264, o 0.001
9.607, 0.002
11.349, 0.001

63.713, o 0.001
54.173, o 0.001
3.742, 0.053
12.050, 0.001

69.849, o0.001
86.149, o0.001
8.107, 0.015
6.056, 0.014

Fig. 1

L. DellOsso et al. / Journal of Affective Disorders 146 (2013) 174180

Fig. 2

Fig. 3

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L. DellOsso et al. / Journal of Affective Disorders 146 (2013) 174180

Fig. 4

epicenter with older subjects reporting slightly higher levels than

younger ones only. These data are in line with authors suggesting
that women and younger subjects are more vulnerable to traumatic
events and more prone to develop post-traumatic stress symptoms
when exposed to trauma, despite we found an impact of age only
among less affected ones and within women (Chan et al., 2011; Xu
and Liao, 2011; Xu and Song, 2011).
Interpretation of our results should keep in mind some
important limitations of the study. First, there is agreement that
social support is usually a very important buffering mechanism,
which protects the severity of post-traumatic mental reactions to
either natural or human made disasters (Weiss et al., 2003;
van Ommeren et al., 2008; Perlman et al., 2011; Tol et al., 2011;
Ali et al., 2012). In the present investigation we did not assess
social support, though such support is generally believed to be
high in Italy due to the closely knit family structure; however,
from a strictly methodological standpoint we have listed it as a
limitation in our abstract. Further limitation is the lack of
information on mood disorder prevalence, particularly that of
major depression. Loss induced depression has in fact being found
as relevant as PTSD among survivors to the 1988 Spitak earthquake in Armenia (Armenian et al., 2000 and 2002; Goenjian

et al., 2009). In this regard, we are now conducting another study

on mood and post-traumatic stress reactions to the LAquila
earthquake. Another important limitation is the limited number
of subjects in each subgroup. This was related to the signicant
mean age difference between exposed and non-exposed subjects,
as the design of the study did not allow us to match cases.
Another limitation of the present study is the use of self-report
instruments, instead of the rating of the clinician, in order to
detect PTSD symptoms and even diagnosis. A self-report of PTSD
symptoms may be, in fact, considered less accurate. A further
limitation is represented by the lack of information on the
presence of Axis I psychiatric comorbidities.
Despite these limitations, our results conrm the pervasive
effects of a disaster, such as an earthquake, for mental health in
the general population exposed and demonstrate the relevance of
mental health as a key component of public health response to
mass traumas. Further studies are also needed in order to assess
the emerging evidence of an impact of such trauma not only in
the populations exposed but also on the physicians, psychiatrists
and other disaster relief workers involved, who can also develop
PTSD (Guo et al., 2004; Ehring et al., 2011; Varley et al., 2012). Our
results also highlight the relevance of gender differences and the

L. DellOsso et al. / Journal of Affective Disorders 146 (2013) 174180

proximity to the earthquake in the response to earthquake

exposure, which should be taken into account when facing such
events, and suggest possible differences in such reactions among
younger and older victims. In order to corroborate our results,
further studies on a randomly matched subsample that would
avoid signicant differences in age and gender distribution
between exposed and non-exposed subjects should be performed.

Role of funding source

No pharmaceutical company supported the present study, all support derived
from the funding of the Department of Experimental Medicine (Section of
Psychiatry) of the University of LAquila (LAquila, Italy), and of the Department
of Psychiatry, Neurobiology, Pharmacology and Biotechnology of the University of
Pisa (Pisa, Italy), for observational and clinical studies.

Conict of interest
The authors declare that they have no grant and pharmaceutical support,
afliations, and honoraria received for past and present material.

Acknowledgments
None.

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