Journal of Mental Health

ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmh20

Posttraumatic stress symptoms, co-morbid

psychiatric symptoms and distorted cognitions
among flood victims of different ages

Man Cheung Chung, Sabeena Jalal & Najib Ullah Khan

To cite this article: Man Cheung Chung, Sabeena Jalal & Najib Ullah Khan (2016): Posttraumatic
stress symptoms, co-morbid psychiatric symptoms and distorted cognitions among flood
victims of different ages, Journal of Mental Health, DOI: 10.3109/09638237.2016.1149803

To link to this article: http://dx.doi.org/10.3109/09638237.2016.1149803

Published online: 03 Mar 2016.

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ISSN: 0963-8237 (print), 1360-0567 (electronic)

J Ment Health, Early Online: 1–8

! 2015 Taylor & Francis. DOI: 10.3109/09638237.2016.1149803

ORIGINAL ARTICLE

Posttraumatic stress symptoms, co-morbid psychiatric symptoms and

distorted cognitions among flood victims of different ages
Man Cheung Chung1, Sabeena Jalal2, and Najib Ullah Khan3
1
Department of Educational Psychology, The Chinese University of Hong Kong, Shatin NT, Hong Kong, 2Medical and Dental College, Bahria
University, Karachi, Pakistan, and 3Abbasi Shaheed Hospital, Karachi, Pakistan
Downloaded by [University of California, San Diego] at 23:58 08 March 2016

Abstract Keywords
Background: In literature, the effect of age on posttraumatic stress disorder (PTSD) is Age differences, distorted cognitions, flood
inconclusive; the effect on flood-related PTSD is particularly unclear. Little is known on disaster, posttraumatic stress disorder
distorted cognitions among flood victims, although cognition distortions and PTSD have been
linked among victims of other traumas. History
Aims: To investigate: (1) whether flood-related PTSD, psychiatric co-morbidity and cognitive
distortions would differ according to age and (2) distinctive patterns of association between the Received 24 February 2015
preceding variables for different age groups. Revised 5 January 2016
Methods: One hundred and fifty-four flood victims of different ages completed standardized Accepted 25 January 2016
questionnaires measuring PTSD, psychiatric co-morbidity and cognitive distortions. Published online 1 March 2016
Results: Adolescents and young adults reported significantly fewer PTSD, psychiatric co-
morbidity and distorted cognition symptoms than people who were older. Preoccupation with
danger and hopelessness were associated with both outcomes for adolescents, people in their
thirties and middle-aged/older people. For young adults, helplessness was associated with
PTSD; hopelessness and preoccupation with danger with psychiatric co-morbidity.
Conclusions: Adolescents and young adults buffered against flood-related psychological distress
better than older people. Distorted cognitions related to distress outcomes differently
depending on age.

Introduction cause the meaning of the trauma to be interpreted differently,

in turn influencing emotional response to trauma (Baltes &
Floods are the most common natural disaster, affecting more
Nesselroade, 1984; Baltes et al., 1980). Also, age differences
people globally than any other natural disaster (IFRC, 2006).
can impact how people cope with trauma. Getting older may
Their sudden and destructive nature can cause death/
increase vulnerability (Fillenbaum, 1977–1978), affect adap-
threatened death and physical/psychological injury to those
tive and coping capacities (Elwell & Maltbie-Crannel, 1981)
involved (Liu et al., 2006). Victims can experience extreme
or increase resistance to subsequent stress and adaptability to
aversive details (like seeing people drown) which fit well with
the trauma (Eysenck, 1983; Norris & Murrell, 1988; Phifer &
DSM-V trauma criteria. Posttraumatic stress disorder (PTSD)
Norris, 1989).
is prevalent among these victims (Norris et al., 2002a, 2002b;
The relationship of age to flood-related PTSD is unclear,
Sharan et al., 1996; Wang, 2000). Despite changes in DSM-V,
although one study suggested that older flood victims
natural disasters including flood are still considered traumatic
reported more severe PTSD symptoms than younger victims
events. The prevalence rate for flood-related PTSD can range
(Liu et al., 2006). Based on other disaster types, younger
from 5% to 71% (Li, 2010; Liu, 2006; Mason et al., 2010;
victims reported less PTSD symptoms and psychiatric co-
North et al., 2004; Tobin & Ollenburger, 1996) and is
morbidity than older victims (Cheung, 1994; Kim-Goh et al.,
associated with depression and anxiety (Keane et al., 2007;
1995; Lahad & Leykin, 2010; Ticehurst et al., 1996; Weine
Mason et al., 2010; McMillen et al., 2002; Sajid, 2007).
et al., 1998). However, some studies suggest that older people
This study addressed two issues: the effects of age and
are more resilient than younger people regardless of trauma
distorted cognitions. Age can affect emotional response to a
type (e.g. Böttche et al., 2012; Mosher & Danoff-Burg, 2005).
trauma (Charles et al., 2003; Urry & Gross, 2010), largely due
They report fewer PTSD or psychiatric co-morbid symptoms
to different life experiences throughout the lifespan which
than younger people (Kato et al., 1996; Scott et al., 2013) and
middle-aged people over time (Cook et al., 2011; Frueh et al.,
Correspondence: Professor M. C. Chung, The Chinese University of
2007; Reppesgaard, 1997).
Hong Kong, Department of Educational Psychology, Ho Tim Building,
Faculty of Education, Shatin NT, Hong Kong. E-mail: Little is known on distorted cognitions among flood
man.chung@cuhk.edu.hk victims (Owens & Chard, 2006). Following traumatic events,
 2 M. C. Chung et al.
distorted cognitions can lead to dysfunctional thinking
patterns or maladaptive views of oneself and others,
characterized by a tendency to criticize oneself, feel helpless
about what happened and hopeless about the future. Victims
also exaggerate the degree of danger in the world (Briere &
Spinazzola, 2005; Owens & Chard, 2006). Distorted cogni-
tions often maintain traumatic reactions (e.g. Cieslak et al.,
2008; Dunmore et al., 1999; Foa et al., 1999; Mayou et al.,
2002; Owens et al., 2008; Wenninger & Ehlers, 1998) and are
incompatible with basic self-schemas used by victims to
understand the meaning of the trauma. However, in activating
distorted cognitions, they also activate the response element
leading them to re-experience the intensive emotion asso-
ciated with the trauma. They therefore try to avoid thinking
about it. This tension between needing to find meaning and
avoid thinking about it leaves them in a state of chronic
hyperarousal (Foa & Riggs, 1993; Foa et al., 1989, 1995).
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In this study, we focused on victims exposed to a
devastating flood in Pakistan in 2010. Monsoon rainfall
submerged villages killing approximately 2000 people and
injuring over 3000. More than 20 million people were affected
in different provinces. Over 1.9 million households were
destroyed (Congressional Research Service, 2010). We
investigated whether: (1) flood-related PTSD, co-morbid
psychiatric symptoms and cognitive distortions would differ
according to age, (2) there were distinctive patterns of
association between distorted cognitions, flood-related PTSD
and psychiatric co-morbidity for different age groups. We
hypothesized that (1) flood-related PTSD, psychiatric co-
morbidity and distorted cognitions would differ between age
groups with older victims reporting fewer distress symptoms
than younger victims. Given recent research suggesting that
there are different patterns of traumatic response (e.g.
Gudmundsdottir & Beck, 2004; Kelley et al., 2009; Runyon
et al., 2002), we also hypothesized that (2) there would be
distinctive patterns of association between distorted cogni-
tions, flood-related PTSD and psychiatric co-morbidity for
different age groups. We were unable to hypothesize specif-
ically what these distinctive patterns were, due to a lack of
research in this area.
Methods
Procedure
One hundred and fifty-four flood victims (F ¼ 108, M ¼ 46)
were recruited from medical camps organized by a medical
aid foundation in Pakistan. These camps were set up
immediately after the flood to provide medical treatment
and general support for victims. An opportunistic sampling
method was adopted. Victims, who came to the camps
approximately one month after the onset of flood, were
invited consecutively to participate in the research until we
reached a sample size of 154. All invited victims participated
and completed the research; all met the screening criteria and
confirmed that they had been affected by the flood. The
purpose of the research was explained and after obtaining
informed consent, they were assessed using the questionnaires
described in the measures section. The inclusion criterion was
people who had been directly involved in the flood at least
four weeks prior to the study. This study was granted ethical
J Ment Health, Early Online: 1–8
approval from Karachi Medical and Dental College, Abbasi
Shaheed Hospital.
With the sample size of 154 and a set at 0.05, the study
generated a power of 0.95 (critical F ¼ 1.44). A small effect
size (f2 ¼ 0.09) was chosen for this power calculation and
was based on a study linking distorted cognitions and PTSD
outcome (Briere, 2000). Of the 154 flood victims, 30 were
adolescents, 50 young adults, 39 adults in their thirties and
35 middle-aged or older adults. On average, they were aged
16 (range: 13–18), 22 (range: 19–29), 32 (range: 30–39) and
49 (range: 40–80) years, respectively. The age range for
each group was mostly guided by published literature
(Chung et al., 2006; Lonigan et al., 1994), although we did
make an adjustment, for example, in creating the group for
the thirties to ensure convenient numbers of participants in
each group.
There were no significant differences between age groups
in gender, ethnicity and other significant illnesses. All were in
the low income category. There were significant differences
in marital status and educational level (Table 1).
Measures
Demographic information was collected on gender, age,
marital status, ethnicity, income bracket, education level and
previously diagnosed major life illness or cognitive impair-
ment. Posttraumatic Stress Diagnostic Scale (PDS) (Foa et al.,
1997) was used to measure the symptoms of PTSD. The PDS
not only provides a diagnosis of PTSD, but generates three
symptom clusters: re-experiencing, avoidance and hyperar-
ousal. This scale has shown good internal reliability and
validity and good agreement with the Structured Clinical
Interview for Diagnosis (k ¼ 0.65, agreement ¼ 82%, sensi-
tivity ¼ 0.89 and specificity ¼ 0.75). Based on this sample,
the internal reliability of PDS was high (re-experiencing,
a ¼ 0.97, avoidance, a ¼ 0.91, hyperarousal, a ¼ 0.93). The
General Health Questionnaire-28 (GHQ-28) (Goldberg &
Hillier, 1979) yields four subscales: somatic problems,
anxiety, social dysfunction and depression. In PTSD research,
the GHQ-28 is recommended as a standardized questionnaire
for measuring global dysfunction and diagnosing psychiatric
co-morbidity associated with PTSD (Raphael et al., 1989).
Based on this sample, the internal reliability of the four
subscales was high (somatic problems, a ¼ 0.94, anxiety,
a ¼ 0.92, social dysfunction, a ¼ 0.95, depression, a ¼ 0.94).
Cognitive Distortion Scales (CDS) (Briere, 2000) measures
dysfunctional cognitions (self-criticism, helplessness, hope-
lessness, self-blame and preoccupation with danger). The
internal reliability scores here were also high (self-criticism,
a ¼ 0.94, self-blame, a ¼ 0.93, helplessness, a ¼ 0.93, hope-
lessness, a ¼ 0.92, preoccupation with danger, a ¼ 0.94).
Data analysis plan
Due to non-normality, helplessness and hopelessness were
subjected to log-transformation. Self-criticism, self-blame,
preoccupation with danger and GHQ-total were subjected to
square root transformation. No outliers (Mahalanobis 3 SD)
were detected. Following exploration and transformation,
assumptions relating to multivariate normality, linearity and
homoscedasticity were met. Chi-square and Fisher’s exact
 DOI: 10.3109/09638237.2016.1149803 PTSD following floods 3
Table 1. Demographic information between age groups.

Adolescents Young adults Age 30–39 years Middle aged/older

n (%) n (%) n (%) n (%) 2 F
Male 5 (17) 19 (38) 12 (31) 10 (29) 4.11 –
Female 25 (83) 31 (62) 27 (69) 25 (71)
Single 16 (53) 1 (2) – – 29.59** –
Married 14 (47) 47 (94) 31 (79) 18 (51)
Divorced – – 3 (8) 2 (6)
Widowed – 2 (4) 5 (13) 15 (43)
Sindhi 28 (93) 41 (82) 37 (95) 33 (94) 4.76a –
Saraiki 2 (7) 9 (18) 2 (5) 2 (6)
Low income 30 (100) 50 (100) 39 (100) 35 (100) – –
Primary education 5 (17) 13 (26) 9 (23) 1 (3) 9.38*a –
No education 25 (83) 37 (74) 30 (77) 34 (97)
No illness 29 (97) 43 (86) 36 (92) 34 (97) 3.93a –
Mean SD Mean SD Mean SD Mean SD
Age 15.83 1.62 22.38 2.72 32.43 2.89 49.25 8.79 – 326.51**
a
Fisher exact test.
*p50.05; **p50.01
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tests were used to compare the demographic variables of
different age groups. Multivariate analysis of variance
(MANOVA) was used to compare differences between age
groups in PTSD, psychiatric co-morbidity and distorted
cognitions. Bonferroni post hoc analyses were used for
multiple comparisons and correlation coefficients, including
point bi-serial correlations were used to identify the variables
associated with outcomes. These variables were then treated
as covariates for the multivariate analysis of co-variance
(MANCOVA). Multiple regressions were used to establish
patterns of association between distorted cognitions, PTSD
and psychiatric co-morbidity for different age groups.
Results
Differences between groups in outcome variables
MANOVA was used to compare differences between age
groups in PTSD, psychiatric co-morbidity and distorted
cognitions. Based on the PDS diagnostic criteria, all partici-
pants met the criteria for PTSD. The total scores of PTSD,
cognitive distortion and psychiatric co-morbidity differed
significantly between age groups. All flood victims, except
one, in the adolescent group scored at or above the cutoff for
GHQ cases indicating a high likelihood of a general
psychiatric disorder. Looking at subscale scores, there were
significant differences in all the variables except social
dysfunction and helplessness (Table 2).
Further analysis was carried out to compare differences,
controlling for demographic variables, because these ‘‘victim
variables’’ have been shown to relate to PTSD severity
(Friedman et al., 2007; Vogt et al., 2007). Correlation
coefficients including point bi-serial (rpb) were carried out
to establish which variables were associated with outcomes.
However, due to the fact that the majority were Sindhi (the
oldest and second largest ethnic group in Pakistan, most of
whom lived in the Sind province), received no education and
had no major illnesses, these variables were excluded. Neither
did we include income level on our correlation because they
were all in the low income category. We therefore carried out
correlation with gender and marital status and found that
gender was significantly correlated with PTSD (rpb ¼  0.26,
p50.001) and psychiatric co-morbidity (rpb ¼ 0.29,
p50.001). Marital status was not (PTSD: rpb ¼ 0.14, ns;
psychiatric co-morbidity: rpb ¼ 0.06, ns).
Differences between groups in outcome variables
after controlling for gender
MANCOVA was then used by adjusting gender as the
covariate. The results stayed virtually the same as before in
that PTSD and psychiatric co-morbidity were significantly
different between groups. Social dysfunction (difficulty in
keeping busy and making decisions for oneself, and feeling
dissatisfied with carrying out day-to-day activities) became
significant (social dysfunction: F(3,149) ¼ 3.09, p50.05)
where it was not, previously. There were also significant
differences between groups in cognitive distortions.
Helplessness remained nonsignificant.
To reduce the likelihood of Type I error due to multiple
comparisons, Bonferroni post hoc analyses were carried out.
Adolescents and young adults reported significantly fewer
symptoms of severe PTSD and psychiatric co-morbidity with
cognitive distortions than people who were older. In terms of
PTSD symptoms, young adults reported significantly fewer
avoidance symptoms than middle-aged/older victims
(p50.05). For psychiatric co-morbidity, young adults and
adolescents reported significantly fewer somatic symptoms
than those in their thirties and middle-aged/older people at the
levels of significance of 0.05 and 0.001. Otherwise, adoles-
cents reported significantly fewer anxiety (p50.01), social
dysfunction (p50.05) and depression (p50.01) problems.
Turning to distorted cognitions, young adults reported
significantly fewer cognitions related to hopelessness, self-
criticism, self-blame and preoccupation with danger (all at the
significance level of 0.05) than middle-aged/older people.
Regression analysis for different age groups with
PTSD symptoms and psychiatric co-morbidity as the
dependent variables
To establish whether the association between distorted cogni-
tions, PTSD and psychiatric co-morbidity differed according to
age, multiple regressions were used for each age group. For
 4 M. C. Chung et al. J Ment Health, Early Online: 1–8

Table 2. Comparison between age groups in terms of posttraumatic stress symptoms, co-morbid psychiatric symptoms and cognitive distortions.

Adolescents Young adults Age 30–39 years Middle aged/older

Mean (SD) Mean (SD) Mean (SD) Mean (SD) F (3,150) Z2 F (3,149)a Z2
Re-experience 13.30 (2.78) 13.00 (2.72) 14.17 (1.95) 14.34 (1.71) 3.14* 0.05 3.31* 0.06
Avoidance 18.16 (3.57) 17.56 (4.00) 19.46 (2.71) 19.60 (2.14) 3.88** 0.07 3.86* 0.07
Arousal 13.10 (2.73) 12.94 (2.83) 14.02 (1.93) 14.22 (1.88) 2.83* 0.05 2.92* 0.05
PDS total 44.56 (8.78) 43.50 (9.18) 47.66 (6.37) 48.17 (5.33) 3.61* 0.06 3.69* 0.06
Somatic 24.06 (3.75) 24.66 (3.45) 26.76 (2.48) 26.85 (2.23) 7.98*** 0.13 8.87** 0.15
Anxiety 24.06 (3.80) 24.58 (3.52) 26.07 (2.57) 26.31 (2.57) 4.34** 0.08 5.47** 0.09
Social dysfunction 23.06 (3.78) 23.78 (3.71) 24.76 (3.37) 25.05 (3.09) 2.31 0.04 3.09* 0.05
Depression 18.73 (6.03) 19.90 (6.04) 21.58 (6.29) 23.05 (4.19) 3.74* 0.07 4.30* 0.08
GHQ total 89.93 (16.09) 92.92 (14.85) 99.20 (13.07) 101.28 (10.44) 5.17** 0.09 6.29*** 0.11
Hopeless 31.26 (8.53) 30.58 (8.34) 34.20 (6.84) 35.31 (5.30) 3.71* 0.06 3.86* 0.07
Helpless 34.20 (5.56) 33.54 (7.47) 36.28 (5.72) 36.17 (4.63) 2.11 0.04 2.23 0.04
Self-critical 30.80 (7.37) 28.04 (8.60) 32.35 (7.54) 33.05 (7.08) 3.60* 0.06 3.36* 0.06
Self-blame 31.13 (7.14) 28.12 (8.57) 32.00 (7.99) 33.25 (6.28) 3.55* 0.06 3.19* 0.06
Danger 32.13 (7.34) 30.12 (7.88) 33.30 (7.09) 34.74 (6.39) 3.07* 0.05 2.94* 0.05
CDS total 159.53 (34.45) 150.40 (39.19) 168.15 (34.05) 172.54 (28.10) 3.39* 0.06 3.30* 0.06
a
After controlling for gender.
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*p50.05; **p50.01; ***p50.001

Table 3. Multiple regression examining the relationship between posttraumatic stress symptom severity and cognitive distortions for different age
groups.

Adolescentsa Young adultsb Age 30–39 yearsc Middle aged/olderd

B SE B b B SE B b B SE B b B SE B b
Hopeless 0.21 0.24 0.20 0.28 0.29 0.26 0.85 0.23 0.91** 0.55 0.19 0.54**
Helpless 6.08 6.37 0.27 0.93 0.36 0.76** 0.48 3.75 0.03 4.26 4.80 0.32
Selfblame 2.23 3.82 0.29 0.09 0.26 0.08 1.56 1.29 0.32 0.89 1.15 0.04
Danger 6.47 2.97 0.91** 0.20 0.47 0.17 1.01 1.60 0.19 2.77 1.91 0.60

**p50.01; aF (4,25) ¼ 10.78**, f2 ¼ 1.27, adjusted R2 ¼ 0.57; bF (4,45) ¼ 15.68**, f2 ¼ 0.39, adjusted R2 ¼ 0.54; cF (4,34) ¼ 14.06**, f2 ¼ 1.28,
adjusted R2 ¼ 0.57; dF (4,29) ¼ 11.29**, f2 ¼ 0.45, adjusted R2 ¼ 0.55.

each group, the cognition distortion subscales were entered
into the regression as independent variables, whereas PTSD
and psychiatric co-morbidity were used as dependent vari-
ables. The Enter method was used (i.e. all independent
variables were forced into the model simultaneously). In
terms of PTSD symptoms, multicollinearity diagnostics
showed a high variance inflation factor (VIF) value (410) for
self-critical. As a result, it was removed from the regression
analyses. Table 3 shows that preoccupation with danger made a
significant contribution to the model for adolescents.
Helplessness made a significant contribution to the model for
young adults. Hopelessness was a significant predictor for both
people in their thirties and middle-aged/older people. With
regard to psychiatric co-morbidity, self-blame was taken out of
the analysis due to the high VIF value (410). Preoccupation
with danger contributed significantly to the model for adoles-
cents. Hopelessness and preoccupation with danger were the
significant predictors for young adults. Hopelessness predicted
psychiatric co-morbidity for both people in their thirties and
middle-aged/older people (Table 4).
Discussion
This study examined whether flood-related PTSD, psychiatric
co-morbidity and distorted cognitions would differ according
to age, and whether distinctive patterns of association existed
between distorted cognitions, flood-related PTSD and psychi-
atric co-morbidity. Inconsistent with hypothesis 1, adolescents
and young adults reported significantly fewer PTSD symptoms
(particularly avoidance), co-morbid psychiatric symptoms and
distorted cognitions than those older than them. Regarding
patterns of association between distorted cognitions, PTSD and
psychiatric co-morbidity according to age, consistent with
hypothesis 2, the results showed some variation. For adoles-
cents, preoccupation with danger was associated with PTSD
and psychiatric co-morbidity. For young adults, although
helplessness was associated with PTSD, it was not associated
with psychiatric co-morbidity; Hopelessness and preoccupa-
tion with danger were. For victims in their thirties and middle-
aged/older victims, hopelessness was associated with both
PTSD and psychiatric co-morbidity.
These results echoed studies suggesting that younger
victims are more resilient when faced with disaster
(Cheung, 1994; Kim-Goh et al., 1995; Lahad & Leykin,
2010; Ticehurst et al., 1996; Weine et al., 1998). Resilience
refers to the capacity for successful adaptation (Cicchetti &
Rogosch, 1997) or recovery following disaster along with
reduced distress symptoms (Garmezy, 1993). In terms of
PTSD symptoms (avoidance in particular), young adults in
this study were more adaptive than the middle-aged/older
victims in that they were more willing to confront the
emotionally distressing experience of the flood. They were
less concerned with preventing themselves from becoming
emotionally exhausted (Horowitz, 1986).
Turning to psychiatric co-morbidity, adolescents reported
significantly fewer symptoms than middle-aged/older people
 DOI: 10.3109/09638237.2016.1149803
Table 4. Multiple regression examining the relationship between co-morbid psychiatric symptom severity and cognitive distortions for different age
groups.
Adolescentsa Young adultsb
B SE B b B SE B
Hopeless 4.58 8.25 0.14 0.84 0.39
Helpless 9.79 11.59 0.24 9.73 8.83
Self-critical 6.03 4.80 0.44 1.51 2.87
Danger 10.85 4.95 0.83** 8.85 4.25
*p50.05; **p50.01; aF (4,25) ¼ 10.10**, f2 ¼ 0.73, adjusted R2 ¼ 0.55; bF (4,45) ¼ 19.54**, f2 ¼ 1.32, adjusted R2 ¼ 0.60; cF (4,34) ¼ 24.65**,
f2 ¼ 2.10, adjusted R2 ¼ 0.71; dF (4,29) ¼ 18.20**, f2 ¼ 1.55, adjusted R2 ¼ 0.67
in all four domains. High-risk children/adolescents can be
competent in facing adversity (Masten, 2001). Although they
may show adult-like traumatic responses (Shooter, 2005), they
also show evidence of adapting to the trauma with little
evidence of distress. Some of them may even develop new
Downloaded by [University of California, San Diego] at 23:58 08 March 2016
strength as a result of the trauma (Laufer & Solomon, 2006;
Luthar & Cicchetti, 2000). Their strength or resilience was
reflected in the negative b values between preoccupation with
danger and distress outcomes. Elevated degree of danger
preoccupation was associated with reduced PTSD and
psychiatric co-morbid symptoms. Adolescents possess quali-
ties that allow them to withstand adversity, cope with
sustained and acute stressors and recover fast (Masten et al.,
1990). These qualities include temperament and ego resili-
ency (Block & Kremen, 1996), competent parenting and
social competence (Garmezy & Masten, 1994; Werner &
Smith, 1992). These qualities might have helped the adoles-
cent flood victims to ‘‘bounce back’’ from the flood (Tugade
& Fredrickson, 2004).
The foregoing implies that younger people were ‘‘intrin-
sically’’ more resilient than middle-aged/older people.
Although this might be the case, middle-aged/older people
could have been equally as resilient had they not experienced
such a degree of loss or trauma exposure. In other words, their
level of resilience could have been hampered by external
factors to which we now turn to in more detail. Research shows
that the loss of object (home), condition (stable employment),
personal (sense of personal efficacy) and energy resources
(money) can affect reactions to extreme stress (Hobfoll et al.,
1996) and ultimately distort cognitions. The impact of such
loss during the flood was possibly greater for middle-aged/
older people than for young adults. According to Erikson
(1963, 1968), middle-aged/older people are usually concerned
with maintaining a career and the well-being of the next
generation. Thus, their resources would be important to them
and losing them would have a major impact on how they react
to a flood. However, developmentally speaking, young adults
have just come through adolescence and are now primarily
concerned with strengthening self-identity, intimacy or avoid-
ing isolation (Erikson, 1963, 1968).
Also, the fact that middle-aged/older victims becoming
less resilient could be simply due to greater trauma exposure,
which has been associated with increased PTSD reactions and
psychological well-being (Chan et al., 2011; Chung et al.,
1999; Wang et al., 2012). Unfortunately, we lack the data
necessary to verify this. Also, the aftermath of the flood such
as reduced mobility and access to food, delay in rescue due to
logistic issues and general unpreparedness for natural
PTSD following floods 5
Age 30–39 yearsc Middle aged/olderd
b B SE B b B SE B b
0.47* 0.86 0.39 0.45* 0.91 0.30 0.49**
0.29 0.12 6.57 0.00 13.54 7.58 0.55
0.13 3.59 2.27 0.35 0.47 2.03 0.05
0.73** 0.85 2.57 0.08 0.80 3.36 0.09
disasters (Sajid, 2007) could have impacted middle-aged/
older victims to a greater degree. One further interpretation
could be that these middle-aged/older victims usually bore the
responsibility of caring for family members. The flood
represented a major assault on their ability to do this due to
the loss of resources mentioned earlier. It could also have
affected their self-belief as someone who could protect the
family. All these might in turn have impacted on their
psychological well-being.
According to the ecological model of ageing (Lawton &
Nahemow, 1973), for older people, the interaction between
competence (physical and mental well-being, ego strength)
and the environmental press (the limiting aspect of the
environment) needs to be appropriately matched in order to
maintain psychological adaptation. Understandably, the flood
affected levels of competence and created challenges within
the environment, resulting in a low level of adaptation and the
sizeable incongruence between these two factors.
With regard to the differences between groups in distorted
cognitions, it is also striking that young adults reported
significantly fewer distorted cognitions than middle-aged/
older victims in all domains except helplessness. This feeling
of helplessness was not peculiar to a specific age-group.
Young adults have been shown to use repressive coping in
dealing with the effects of trauma (Smeets et al., 2010). This
coping could be an attempt to protect oneself and could
minimize the likelihood of personal cognitions being
distorted.
Turning to the results on distinctive patterns of association
between distorted cognitions, flood-related PTSD and psy-
chiatric co-morbidity across age groups, according to
Erikson’s (1963, 1968) stages of ego development, most
adolescents would have been going through an identity crisis.
This is an unsettling and confusing period characterized by a
heightened sense of risk. When they experienced the life-
threatening danger of the flood, they were already preoccu-
pied with unstable and risky feelings. The danger could have
been exacerbated and expressed through an increase in non-
specific distress reactions characterized by PTSD and other
psychiatric problems. On the contrary, however, as mentioned
earlier, they emerged as resilient individuals who showed a
low level of distress symptoms as their preoccupation with
danger increased. This notion of adolescent resilience has
been discussed previously.
Some researchers have argued that as they mature,
adolescents actively construct a worldview of who they are
and develop cognitive schemas that help them understand and
organize life experiences (Renshaw et al., 2014). Our results
 6 M. C. Chung et al.
suggest that even when their cognitive schemas have been
distorted in the sense of increased preoccupation with danger,
their awareness of human existence and psychological growth
continues to increase (Tedeschi & Calhoun, 1995). This might
reflect the notion of co-vitality embedded within these
adolescents, i.e. positive mental health within adversity due
to their positive psychological building blocks (Renshaw
et al., 2014). They therefore did not need to rely so much on
maladaptive defenses such as dissociation which has been
shown to be a coping strategy for flood victims (Craparo
et al., 2014). How one develops such co-vitality warrants
further study.
For young adult victims, whereas helplessness was
associated with PTSD, hopelessness and preoccupation with
danger were associated with psychiatric co-morbidity.
Developmentally, although these young adults would have
been at the stage where they try to formulate a sense of self,
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linking the past with the present, following a traumatic event,
they could lose both a sense of personal sameness/historical
continuity and their central control (loss of ego identity)
(Erikson, 1968). This would herald the emergence of distress
symptoms (Marcia, 2002; Marcia & Friedman, 1970; Wautier
& Blume, 2004). Our results suggest that these symptoms had
been associated with specific types of inner cognitive change
following the flood. This basically extends the cognitive
model of psychological distress suggesting that emotional
problems are related not only to the external reality of the
flood, but also to people’s maladaptive interpretations of the
external event (Beck, 1991). The ‘‘types’’ of maladaptive
interpretations (whether they interpret the situation as a
helpless, hopeless or extremely dangerous one) might trigger
specific types of emotional problem.
For people in their thirties and middle-aged/older victims,
hopelessness was associated with PTSD and co-morbid
psychiatric outcomes. In other words, this particular cognitive
distortion was not disorder-specific for these two age groups.
Among victims in their thirties, developmentally, they were at
the stage where they experience a great deal of stress from
having to reconsider the existing life structure, create space
for a new one and explore possible changes in the self; they
also make important choices and commit to them, forming a
new life structure (Levinson, 1986). However, this sample did
not experience the natural developmental transition. The
flood opened up new and unforeseen challenges that they
needed to assimilate. This would likely have enhanced their
overall level of distress.
Middle-aged/older victims, according to Erikson’s stages,
can experience different degrees of despair, depending on
whether they are able to accept failure and regret about life’s
choices and their consequences. They despair because they
know that the hope of creating some new path for themselves
is fading because time is running out. Such feelings of
hopelessness could have been exacerbated by the loss of
home, property, possessions or loved ones leading to the
emergence of non-specific distress symptoms.
Several limitations in this study are noteworthy. First,
although the required sample size was achieved, we were
unable to recruit a sufficient number of elderly people (age 65
years and above). A larger elderly group might have altered
the results. Elderly people respond to trauma differently than
J Ment Health, Early Online: 1–8
younger people, although it is still debatable as to whether
responses were adaptive or maladaptive in nature (Chung
et al., 2004). Second, the generalizability of the findings is
called into question. All participants were on a low income
and had a low level of education. Also, victims were self-
selected with the intention to get help. Third, we relied on the
general literature on the impact of age differences on PTSD
due to the lack of research evidence specifically on age and
flood-related PTSD. To what extent the flood victims’
reactions differed from those of non-flood victims remains
to be seen. Finally, we collected no data on whether the
participants were independent of each other. Members from
the same family might have been included and affected the
results. Couples’ post-disaster symptoms, for example, could
cross-correlate. Perceived social support or negative support
could relate to the decrease or increase of distress, respect-
ively. Also, the degree of security in adult intimate relation-
ships was related to emotional regulation, a cognitive
processing of traumatic information. This could in turn
influence distress outcomes (Monson et al., 2012).
To conclude, adolescents and young adults appear to be
more resilient than those older than them. Preoccupation with
danger, and feelings of helplessness and hopelessness were
dominant cognitive distortions that related to distress symp-
toms differently for victims of different ages.
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of the article.
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