**1. Introduction**

**Earthquakes**, as a nature disaster, not only causes deaths, physical disease, damage to the infrastructure and economic loss, it also keeps long-lasting **Mental Health** effects on individuals involved. There will always be cases of psychological disorders such as Post-Traumatic Stress Disorder (PTSD), depression, cognitive disorder, personality disorders, and so on, especially with individuals dealing pre-existing conditions.

At 3:42 am on July 28 1976, a magnitude 7.8 earthquake struck Tangshan, an industrial city of 1 million people in northern China, which had been built on the unstable soil of the Luanhe River's flood plain. Ninety-three percent of residential buildings and 78 percent of industrial buildings were completely destroyed. This alluvial soil liquefied during the quake, undermining entire neighborhoods. The entire earthquake lasted approximately 14 to 16 seconds and killed at least 242,000 people.

Although earthquakes are among the most common and devastating natural disasters, relatively little attention has been paid to their mental health consequences and associated risk factors long time after earthquake. There have been few studies of post-earthquake psychological problems using randomly selected samples of earthquake survivors. Fortunately, we have done a lot of studies about mental disorders due to Tangshan earthquake in China.

#### **1.1 Earthquake as a "trauma" related to mental health**

An earthquake, also known as a quake, tremor or temblor, is the result of a sudden release of energy in the Earth's crust. In its most general sense, the word earthquake is used to describe any seismic event — whether natural or caused by humans — that generates seismic waves. Earthquakes are caused mostly by rupture of geological faults, but also by other events such as volcanic activity, landslides, mine blasts, and nuclear tests. For humans who live on earth, an earthquake is a trauma. "Trauma" has both a medical and a psychiatric definition. Medically, "trauma" refers to a serious or critical bodily injury, wound, or shock. This definition is often associated with trauma medicine practiced in emergency rooms and represents a popular view of the term. In psychiatry, "trauma" has assumed a different meaning and refers to an experience that is emotionally

Earthquake and Mental Health 213

Disasters differ in scope and schedule. Some result mainly in loss anddisruption (loss of possessions and housing), whereas others involve also a threat to life. Some last a few seconds (e.g., earthquake), whereas others continue for years (e.g., war). Unlike traumas, disasters are characterized by the immediate, long-lasting and repeated exposure of victims to reminders of the disastrous event. Usually, three types of experience are combined: terror due to a danger to one's life or exposure to grotesque sights; grief following loss (e.g., human lives, basic trust, self-esteem); and the disruption of normal living. On the social level, there are shock, depression and mourning, confusion and social disarray, rage and blaming, crime and delinquent behavior, emergence of mythic ideologies, collapse of formal leadership, emergence of informal popular leadership, and social disintegration into primary affiliations. Children feel the disruption in their family, neighborhood and school. Since the pathological and recovery processes continue long after the disastrous event itself is over, even if it was restricted to a single point in time, theoretical, research and

The most recent large earthquake was a 9.0 magnitude earthquake in Japan, and it was the largest Japanese earthquake since records began. On March 11, 2011, an earthquake struck off the coast of Japan, churning up a devastating tsunami that swept over cities and farmland in the northern part of the country and set off warnings as far away the west coast of the United States and South America. By June 2011, the official count of dead and missing remained above 24,000. Tens of thousands of people remained housed in temporary shelters

Although the people in China had just experienced the Wenchuan earthquake in 2008, nobody could forget the Tangshan earthquake. At 3:42 am on July 28 1976, a magnitude 7.8 earthquake struck Tangshan, an industrial city of 1 million people in northern China, which had been built on the unstable soil of the Luanhe River's flood plain. Ninety-three percent of residential buildings and 78 percent of industrial buildings were completely destroyed. This alluvial soil liquefied during the quake, undermining entire neighborhoods. The entire earthquake lasted approximately 14 to 16 seconds and killed at least 242,000 people (the official death count). Some observers place the actual toll as high as 700,000, and many more were trapped in the rubble. Coal miners working deep underground in the region perished

Survivors were faced with no water, no food, and no electricity. With so much damage, recovery was not easy. Some food was parachuted in, but the distribution was uneven. Water, even just for drinking, was extremely scarce. Many people drank out of pools or

Although earthquakes are among the most common and devastating natural disasters, relatively little attention has been paid to their mental health consequences and as social risk

Depression is a popular topic these days. The New Yorker magazine once estimated that more than fourteen million Americans suffer from major depression every year, with minor

factors. Posttraumatic stress disorder is a common outcome of major earthquakes.

intervention studies should follow both a systemic and a long-term design.

or evacuated their homes due to the nuclear crisis following this earthquake.

other locations that had become contaminated during the earthquake.

**1.2 Earthquake as a "trauma" in China** 

when the mines collapsed on them.

**2. Earthquake and depression** 

painful, distressful, or shocking, which often results in lasting mental and physical effects.

Although earthquakes are among the most common and devastating natural disasters, relatively little attention has been paid to their mental health consequences and associated risk factors. There have been few studies of post-earthquake psychological problems using randomly selected samples of earthquake survivors. Fortunately, we have done a lot of studies about mental disorders due to Tangshan earthquake.

One of our studies was to explore the long-term effect of Tangshan earthquake on psychosomatic health of paraplegic suffers. Sixty-four paraplegic suffers of Tangshan earthquake and 64 normal controls were interviewed and assessed with self administered questionnaire for psychosomatic health, SCL-90, SAS, SDS, CMI (Cornell Medical Index) and SSRS (Social Support Rating Scale). Six patients (9.38%) were diagnosed as PTSD according to Chinese Classification of Mental Disorders, Second Edition, Revised (CCMD-2- R)in sixty-four paraplegic suffers, however, there was no body who was diagnosed as PTSD in normal controls, the incidence of PTSD in paraplegic suffers was higher than that of normal citizen experienced the earthquake. At present, patients' group had poorer mental health than control reflected by SCL-90.The total score of SCL-90 in paralegic suffers was (143.98±49.22), and the total score of SCL-90 in normal controls was (111.20±23.13), there was significant difference in statistic (*t*=4.822, *P*<0.001) The severity of trauma both mentally and physically has great influence on mental health of suffers even after 25 years.

Another study was to investigate the long term effect of earthquake on mental and physical health of sufferers. Eight hundred and fifty eight first rank relatives of those who died in the earthquake 12 years ago formed the study group, as they experienced the earthquake themselves. Eight hundred and thirty-seven inhabitants who experienced the earthquake but did not lose any first rank relatives formed the control group. The research instruments included: SCL-90[study group/controls= (143.98±49.22)/ (111.20±23.13)], SAS [study group/controls= (40.05±9.47)/ (36.61±5.0)], SDS [study group/controls= (49.08±11.36)/ (42.66±11.74)]. The mental health of study group was worse than that of controls. At the same time, hypertension, ischemic brain disease were more common in study group. Trauma and Disaster

The literature distinguishes between "trauma" and "disaster". Traumas are experiences that threaten individual health and well being, render one helpless in the face of intolerable internal or external danger, overwhelm coping mechanisms, violate basic assumptions about survival, and stress the uncontrollability and unpredictability in the world. Traumas may be caused by an isolated, unanticipated event or long-lasting stressful experience, due to repeated exposure to several extreme external events.

Disasters are relatively sudden, more or less time-limited, and public events that extensively damage properties and lives, engendering a systemic continuously disruptive impact on the social network and basic daily routines of children and families. The community as a whole is compromised in its capacity to negotiate the recovery of its individual members (e.g., massive displacement and relocation). Matters are often made worse when resources are over-stretched and the community's infrastructure is affected. This can result in unemployment, lack of housing and food, poor health and mental health services, school closures, school and job absenteeism, family dysfunction, and displacement of large populations.

painful, distressful, or shocking, which often results in lasting mental and physical

Although earthquakes are among the most common and devastating natural disasters, relatively little attention has been paid to their mental health consequences and associated risk factors. There have been few studies of post-earthquake psychological problems using randomly selected samples of earthquake survivors. Fortunately, we have done a lot of

One of our studies was to explore the long-term effect of Tangshan earthquake on psychosomatic health of paraplegic suffers. Sixty-four paraplegic suffers of Tangshan earthquake and 64 normal controls were interviewed and assessed with self administered questionnaire for psychosomatic health, SCL-90, SAS, SDS, CMI (Cornell Medical Index) and SSRS (Social Support Rating Scale). Six patients (9.38%) were diagnosed as PTSD according to Chinese Classification of Mental Disorders, Second Edition, Revised (CCMD-2- R)in sixty-four paraplegic suffers, however, there was no body who was diagnosed as PTSD in normal controls, the incidence of PTSD in paraplegic suffers was higher than that of normal citizen experienced the earthquake. At present, patients' group had poorer mental health than control reflected by SCL-90.The total score of SCL-90 in paralegic suffers was (143.98±49.22), and the total score of SCL-90 in normal controls was (111.20±23.13), there was significant difference in statistic (*t*=4.822, *P*<0.001) The severity of trauma both mentally

and physically has great influence on mental health of suffers even after 25 years.

Another study was to investigate the long term effect of earthquake on mental and physical health of sufferers. Eight hundred and fifty eight first rank relatives of those who died in the earthquake 12 years ago formed the study group, as they experienced the earthquake themselves. Eight hundred and thirty-seven inhabitants who experienced the earthquake but did not lose any first rank relatives formed the control group. The research instruments included: SCL-90[study group/controls= (143.98±49.22)/ (111.20±23.13)], SAS [study group/controls= (40.05±9.47)/ (36.61±5.0)], SDS [study group/controls= (49.08±11.36)/ (42.66±11.74)]. The mental health of study group was worse than that of controls. At the same time, hypertension, ischemic brain disease were more common in study group.

The literature distinguishes between "trauma" and "disaster". Traumas are experiences that threaten individual health and well being, render one helpless in the face of intolerable internal or external danger, overwhelm coping mechanisms, violate basic assumptions about survival, and stress the uncontrollability and unpredictability in the world. Traumas may be caused by an isolated, unanticipated event or long-lasting stressful experience, due

Disasters are relatively sudden, more or less time-limited, and public events that extensively damage properties and lives, engendering a systemic continuously disruptive impact on the social network and basic daily routines of children and families. The community as a whole is compromised in its capacity to negotiate the recovery of its individual members (e.g., massive displacement and relocation). Matters are often made worse when resources are over-stretched and the community's infrastructure is affected. This can result in unemployment, lack of housing and food, poor health and mental health services, school closures, school and job absenteeism, family dysfunction, and displacement of large

studies about mental disorders due to Tangshan earthquake.

to repeated exposure to several extreme external events.

effects.

Trauma and Disaster

populations.

Disasters differ in scope and schedule. Some result mainly in loss anddisruption (loss of possessions and housing), whereas others involve also a threat to life. Some last a few seconds (e.g., earthquake), whereas others continue for years (e.g., war). Unlike traumas, disasters are characterized by the immediate, long-lasting and repeated exposure of victims to reminders of the disastrous event. Usually, three types of experience are combined: terror due to a danger to one's life or exposure to grotesque sights; grief following loss (e.g., human lives, basic trust, self-esteem); and the disruption of normal living. On the social level, there are shock, depression and mourning, confusion and social disarray, rage and blaming, crime and delinquent behavior, emergence of mythic ideologies, collapse of formal leadership, emergence of informal popular leadership, and social disintegration into primary affiliations. Children feel the disruption in their family, neighborhood and school. Since the pathological and recovery processes continue long after the disastrous event itself is over, even if it was restricted to a single point in time, theoretical, research and intervention studies should follow both a systemic and a long-term design.

#### **1.2 Earthquake as a "trauma" in China**

The most recent large earthquake was a 9.0 magnitude earthquake in Japan, and it was the largest Japanese earthquake since records began. On March 11, 2011, an earthquake struck off the coast of Japan, churning up a devastating tsunami that swept over cities and farmland in the northern part of the country and set off warnings as far away the west coast of the United States and South America. By June 2011, the official count of dead and missing remained above 24,000. Tens of thousands of people remained housed in temporary shelters or evacuated their homes due to the nuclear crisis following this earthquake.

Although the people in China had just experienced the Wenchuan earthquake in 2008, nobody could forget the Tangshan earthquake. At 3:42 am on July 28 1976, a magnitude 7.8 earthquake struck Tangshan, an industrial city of 1 million people in northern China, which had been built on the unstable soil of the Luanhe River's flood plain. Ninety-three percent of residential buildings and 78 percent of industrial buildings were completely destroyed. This alluvial soil liquefied during the quake, undermining entire neighborhoods. The entire earthquake lasted approximately 14 to 16 seconds and killed at least 242,000 people (the official death count). Some observers place the actual toll as high as 700,000, and many more were trapped in the rubble. Coal miners working deep underground in the region perished when the mines collapsed on them.

Survivors were faced with no water, no food, and no electricity. With so much damage, recovery was not easy. Some food was parachuted in, but the distribution was uneven. Water, even just for drinking, was extremely scarce. Many people drank out of pools or other locations that had become contaminated during the earthquake.

Although earthquakes are among the most common and devastating natural disasters, relatively little attention has been paid to their mental health consequences and as social risk factors. Posttraumatic stress disorder is a common outcome of major earthquakes.

#### **2. Earthquake and depression**

Depression is a popular topic these days. The New Yorker magazine once estimated that more than fourteen million Americans suffer from major depression every year, with minor

Earthquake and Mental Health 215

These findings provide evidence that at least one type of SD may be related to exposure in urero to a stressful event related to maternal experience of earthquake. Furthermore, our results indicate that exposure to maternal stress related to earthquake during the first and second trimesters significantly increases the risk of developing depression in adulthood, which supports previously reported results [Zhang Ben, et al.2000;Wang Xueyi, et al.2005]. Our findings that males exposed during the second trimester exhibited the highest rates of depression and that males overall reported more depression are comparable to previous studies regarding teratogenic and affective disorders following earthquakes [Zhang Ben, et al.2001; Wang Xueyi, et al.2005]. In addition the markedly high rate of depression in the males exposed during second trimester of fetal development provides evidence for a neurodevelopmental hypothesis of the etiology of depression [Zhang Ben, et al.1999; Wang Xueyi,

In Schizotypical personality disorder, people exhibit odd behavior, respond inappropriately to social cues and hold peculiar beliefs. Schizotypical personality disorder occurs in 3% of the general population and occurs slightly more commonly in males than females. People with classic schizotypical personalities are apt to be loners. They feel extremely anxious in social situations, but they're likely to blame their social failings on others. They view themselves as alien or outcast, and this isolation causes pain as they avoid relationships and the outside world. People with schizotypical personalities may ramble oddly and endlessly during a conversation. They may dress in peculiar ways and have very strange ways of viewing the world around them. Often they believe in unusual ideas, such as the powers of Extra Sensory Perception (ESP) or a sixth sense. At times, they believe they can magically influence people's thoughts, actions and emotions. In adolescence, signs of a schizotypical personality may begin as an increased interest in solitary activities or a high level of social anxiety. The child may be an underperformer in school or appear socially out-of-step with peers, and as a result often becomes the subject of bullying or teasing. Schizotypical personality disorder typically begins in early adulthood and is likely to endure, though

Experiencing trauma is a factor that appears to increase the risk of schizotypical personality disorder. In a sample of 75 women recruited from the community, researchers measured trauma/maltreatment history and symptoms of schizotypical personality disorder, using both questionnaire and interview measures [Howard Berenbaum, et al. 2003]. As hypothesized, individuals with histories of trauma/maltreatment had elevated levels of schizotypical symptoms. Among types of trauma, maltreatment was especially strongly associated with schizotypical symptoms. Although posttraumatic stress disorder symptom severity, depression, dissociation, and difficulty identifying one's emotions were all associated with schizotypical symptoms, they could not account completely for the

Previous research has demonstrated that prenatal exposure to maternal stress is a possible risk factor for development of schizophrenia-spectrum diagnoses among adult offspring; however, research examining the effects of prenatal stress exposure on sub-threshold psychotic symptoms is lacking. Similarly, there is a paucity of research investigating

association between trauma/maltreatment and schizotypical symptoms.

et al.2005].

**3. Earthquake and schizotypical personality** 

symptoms may improve with age.

depression affecting more than three million. National Public Radio's Depression Out of the Shadows website reports that by 2020 depression will be the second most common health problem in the world. Previous assessments among survivors of earthquake have shown that depression and other mental health problems are common. Depression and posttraumatic stress disorder may arise weeks or months after earthquake. Earthquakes stir up concerns in people not directly affected. They also trigger both a desire to help and a sense of overwhelming hopelessness. This cluster of emotions, helplessness, hopelessness and a sense of being overwhelmed are classic symptoms of depression.

In 1976 a severe earthquake struck Tangshan, China, resulting in 240,000 deaths, thousands of injuries, and widespread destruction of houses and basic services. The United States Geological Survey has termed this event as the worst earthquake in the past four centuries. This catastrophic event might serve as a natural experiment since all Tangshan women who were pregnant at the time were stressed by the quake. We assessed symptoms of depression in young adult offspring exposed to the earthquake prenatally and controls that were not exposed to the earthquake. The pregnant women of Tangshan endured severed stress during the earthquake. Animal and human literature suggests that exposure to prenatal stress can alter the developing hypothalamo-pituitary-adrenal axis and have negative, longterm effects on the offspring. [E.J.H. Mulder,et al. 2002] The animal and human research has demonstrated an association between prenatal stress and adult depression. In our study we found that young adults who were exposed to the earthquake in utero demonstrated a marked increase in severe depression when compared to controls [Lu Lin, Wang Xueyi, Li Jing, et al.1999; Zhang Ben, et al. 2002a]. In addition, the effect was stronger in males than females; males exposed to the earthquake during the second trimester of fetal development exhibited the highest proportion of severe depression [Wang Xueyi, et al.2006, Zhang Ben, et al. 2002b].

In this research, we hypothesized: Firstly, a higher proportion of severe depression will be observed in the earthquake exposed subjects as compared to the non-exposed subjects; Secondly, the effect will be more pronounced in males; Thirdly, subjects exposed to the earthquake during the second trimester of gestation will exhibit higher rates of severe depression than those not exposed or those exposed during the first or third trimester; Fourthly, the second-trimester effect will be stronger in males, and the fifthly, offspring whose mothers reported higher levels of emotional stress due to the earthquake will have higher rates of severe depression.

The purpose of this study was to determine if exposure to a severe maternal stress (major earthquake) in utero increased risk for adult depression. We found that individuals who were exposed to the earthquake in utero demonstrated a marked increase in SD (as measured by the Hamilton depression scale, HAMD) when compared to age and season-ofbirth matched controls; in addition, the effect was stronger in males than females. The timing of exposure to the earthquake also proved to be significantly related to the proportion of SD. Males exposed to the earthquake during the second trimester of fetal development exhibited the highest proportion of SD when compared to males exposed during trimesters one and three and females exposed during the first, second, and third trimesters. We also found that the offspring of mothers who were exposed prenatally to a severe earthquake have a lower level of emotional stress. Thus, the mothers who endorsed symptoms such as "After the earthquake, I felt sad, frightened, and/or nervous," had offspring who later reported higher rates of SD. [Zhang Ben, et al.1999]

depression affecting more than three million. National Public Radio's Depression Out of the Shadows website reports that by 2020 depression will be the second most common health problem in the world. Previous assessments among survivors of earthquake have shown that depression and other mental health problems are common. Depression and posttraumatic stress disorder may arise weeks or months after earthquake. Earthquakes stir up concerns in people not directly affected. They also trigger both a desire to help and a sense of overwhelming hopelessness. This cluster of emotions, helplessness, hopelessness

In 1976 a severe earthquake struck Tangshan, China, resulting in 240,000 deaths, thousands of injuries, and widespread destruction of houses and basic services. The United States Geological Survey has termed this event as the worst earthquake in the past four centuries. This catastrophic event might serve as a natural experiment since all Tangshan women who were pregnant at the time were stressed by the quake. We assessed symptoms of depression in young adult offspring exposed to the earthquake prenatally and controls that were not exposed to the earthquake. The pregnant women of Tangshan endured severed stress during the earthquake. Animal and human literature suggests that exposure to prenatal stress can alter the developing hypothalamo-pituitary-adrenal axis and have negative, longterm effects on the offspring. [E.J.H. Mulder,et al. 2002] The animal and human research has demonstrated an association between prenatal stress and adult depression. In our study we found that young adults who were exposed to the earthquake in utero demonstrated a marked increase in severe depression when compared to controls [Lu Lin, Wang Xueyi, Li Jing, et al.1999; Zhang Ben, et al. 2002a]. In addition, the effect was stronger in males than females; males exposed to the earthquake during the second trimester of fetal development exhibited the highest proportion of severe depression [Wang Xueyi, et al.2006, Zhang Ben, et

In this research, we hypothesized: Firstly, a higher proportion of severe depression will be observed in the earthquake exposed subjects as compared to the non-exposed subjects; Secondly, the effect will be more pronounced in males; Thirdly, subjects exposed to the earthquake during the second trimester of gestation will exhibit higher rates of severe depression than those not exposed or those exposed during the first or third trimester; Fourthly, the second-trimester effect will be stronger in males, and the fifthly, offspring whose mothers reported higher levels of emotional stress due to the earthquake will have

The purpose of this study was to determine if exposure to a severe maternal stress (major earthquake) in utero increased risk for adult depression. We found that individuals who were exposed to the earthquake in utero demonstrated a marked increase in SD (as measured by the Hamilton depression scale, HAMD) when compared to age and season-ofbirth matched controls; in addition, the effect was stronger in males than females. The timing of exposure to the earthquake also proved to be significantly related to the proportion of SD. Males exposed to the earthquake during the second trimester of fetal development exhibited the highest proportion of SD when compared to males exposed during trimesters one and three and females exposed during the first, second, and third trimesters. We also found that the offspring of mothers who were exposed prenatally to a severe earthquake have a lower level of emotional stress. Thus, the mothers who endorsed symptoms such as "After the earthquake, I felt sad, frightened, and/or nervous," had

offspring who later reported higher rates of SD. [Zhang Ben, et al.1999]

and a sense of being overwhelmed are classic symptoms of depression.

al. 2002b].

higher rates of severe depression.

These findings provide evidence that at least one type of SD may be related to exposure in urero to a stressful event related to maternal experience of earthquake. Furthermore, our results indicate that exposure to maternal stress related to earthquake during the first and second trimesters significantly increases the risk of developing depression in adulthood, which supports previously reported results [Zhang Ben, et al.2000;Wang Xueyi, et al.2005]. Our findings that males exposed during the second trimester exhibited the highest rates of depression and that males overall reported more depression are comparable to previous studies regarding teratogenic and affective disorders following earthquakes [Zhang Ben, et al.2001; Wang Xueyi, et al.2005]. In addition the markedly high rate of depression in the males exposed during second trimester of fetal development provides evidence for a neurodevelopmental hypothesis of the etiology of depression [Zhang Ben, et al.1999; Wang Xueyi, et al.2005].
