INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int J Geriatr Psychiatry 2004; 19: 333–343.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/gps.1095

Coping with post-traumatic stress: young, middle-agedand elderly comparisons

Man Cheung Chung1*, Julie Werrett2, Yvette Easthope3 and Steven Farmer4

1University of Plymouth, Plymouth, UK2University of Birmingham, Birmingham, UK3University of Manchester, Manchester, UK4University of Wolverhampton, Wolverhampton, UK

SUMMARY

Objectives Debate persists about whether people of different ages react similarly to traumatic events, and whether elderlypeople are more vulnerable to such events, or better able to cope with them. The first aim of this paper was to shed light onthis debate by comparing the post-traumatic responses of young, middle-aged and elderly community residents who hadbeen exposed to technological disasters. The second aim was to differentiate between these three age groups in terms ofcoping strategies.Methods One hundred and forty-eight community residents, who were exposed to two technological disasters, partici-pated in the study. They were assessed using the Impact of Event Scale (IES), the General Health Questionnaire (GHQ-28) and the Ways of Coping Checklists (WOC).Results The results showed that in terms of IES, GHQ and WOC scores, no significant differences were found across thethree age groups. However, main effects were found according to type of disaster and intensity of exposure to disaster. Onesignificant interaction effect was that residents exposed to the aircraft crash used significantly more confrontive coping thanthose exposed to the train collision, in all three age groups. Correlation coefficients results showed that for all three agegroups, on the whole, the more they experienced intrusive thoughts and avoidance behaviour, the more they experiencedgeneral health problems.Conclusions Following exposure to technological disasters, young, middle-aged and elderly community residents coulddisplay similar post-traumatic responses and employ similar coping strategies, which contradicts the vulnerability hypoth-esis and the inoculation hypothesis. Copyright # 2004 John Wiley & Sons, Ltd.

key words— post-traumatic stress; coping; young, middle-aged and elderly comparisons

INTRODUCTION

In post-traumatic stress literature, research has notbeen forthcoming with respect to the responses ofelderly people in the community, as non-patient sam-ples, to recent traumatic incidents (Kahana, 1992). Ofthe few studies that exist, only a limited number haveattempted to differentiate post-traumatic stressresponses or other psychiatric symptoms accordingto age (Hyman, 1997; Averill and Beck, 2000). Also,there are very few empirical studies which focus on

the strategies used by elderly people to cope withthe effects of a traumatic event and how they differfrom younger people (Averill and Beck, 2000).

Recent claims suggest that people of different agesreact to traumatic events in a similar fashion, with nosignificant differences in psychiatric symptomatology,prevalence or severity of post-traumatic stress disorder(Ollendick and Hoffman, 1982; Shore et al., 1986;Goenjian et al., 1994). A study focusing on elderlycommunity residents exposed to an aircraft disasterfound that both younger and elderly community resi-dents experienced a similar severity of intrusivethoughts about the disaster and avoidance behaviour,except that elderly people had higher rates of depres-sion and were more socially dysfunctional than

Received 6 October 2003Copyright # 2004 John Wiley & Sons, Ltd. Accepted 11 December 2003

*Correspondence to: Dr M. C. Chung, Department of Psychology,University of Plymouth, Drake Circus, Plymouth, Devon, PL48AA, UK. E-mail: m.chung@plymouth.ac.uk

younger people (Livingston et al., 1992). Three yearson, a small proportion of the elderly community resi-dents were, on the whole, better in terms of somaticproblems, anxiety and social dysfunction but not interms of severe depression (Livingston et al., 1994).

However, this claim that young and elderly peoplereact to traumatic events similarly has increasinglybeen challenged (Hyman, 1997). Some researchersbelieve that elderly people are more vulnerable toand react negatively to traumatic events, comparedto younger people (Lyons and McClendon, 1990).Following natural disasters, elderly victims werefound to be more at risk of experiencing post-traumatic stress disorder than younger victims(Ticehurst et al., 1996); middle-aged victims weremore at risk of post-traumatic adjustment difficultiesthan younger people (Gleser et al., 1981); elderlyvictims reported greater long-term distress (e.g.Kilijanek and Drabek, 1979) and perceived them-selves as being at greater risk of extended disaster-related traumatic stress (Melick and Logue, 1986).

The theoretical underpinning for the above view liesin the age-related differential vulnerability hypothesiswhich suggests that when people become older, theybecome more vulnerable (Fillenbaum, 1977–1978).Through aging, adaptive capacities, coping resources(Elwell and Maltbie-Crannel, 1981) and externalresources reduce, while exposure to traumatic eventsor illnesses increases. Thus, as they respond to certaintraumatic experiences, elderly people are more likelyto develop psychiatric problems than younger people.This is echoed in the additive burden hypothesis,which suggests that elderly people are at greater riskof experiencing negative outcomes, because they haveaccumulated many more stressful life experiences ornegative life events than younger people (Dohrenwendand Dohrenwend, 1981). Indeed, research has shown adose-response relationship between cumulative lifeevent stress and change in depressive symptomsamong the elderly (Glass et al., 1997).

Some of these stressful or negative life eventsmight include being war veterans or prisoners ofwar (POW). The impact of war experiences couldaffect the well-being or adjustment of later life (Zeissand Dickman, 1989). For example, one study showedthat 46.2% of the elderly former-veterans in the Viet-nam War, 30% in the Korean War and 18.5% in WWIIcontinued to have post-traumatic stress symptoms inlater life (Blake et al., 1990). More than 45 years afterWWII, 34.5% of Dutch resistance veterans in onestudy suffered from current post-traumatic stress(Aarts et al., 1996). Forty years after WWII, 29% ofthe elderly former-POWs in one study (Speed et al.,

1989) and 50% (Goldstein et al., 1987) in anotherrevealed that they continued to meet the diagnosticcriteria for post-traumatic stress. Lifetime diagnosesof PTSD were found in 67% of the elderly former-POWs (Kluznik et al., 1986).

The past trauma experiences are thought to be asso-ciated with vulnerability to recent trauma or stressamong these elderly. People could display delayedonset or reoccurrence of post-traumatic stress duringthe transition of middle to later life. The onset of post-traumatic stress frequently coincides with recentstressful events (e.g. loss of work, illness etc.) duringmiddle and later life (Aarts et al., 1996). A claim hasbeen made that elderly former-WWII combat veter-ans should be monitored for changes in post-traumaticstress symptoms when significant recent stressful lifeevents occur (Kaup et al., 1994). Indeed, research hasshown that severity of post-traumatic stress symp-toms, cumulative trauma and recent stress were sig-nificantly associated among elderly Holocaustsurvivors (Yehuda et al., 1995).

However, some researchers argue against this age-related differential vulnerability hypothesis or addi-tive burden hypothesis. Following a train disaster,one study showed that although elderly people weremore symptomatic than middle-aged people (45–64), younger people (18–24) showed similar symp-toms to elderly people, suggesting a non-linearrelationship between age and trauma-related sympto-matology (Hagstrom, 1995). Other researchers havesuggested that age could in fact be a protective factoragainst the development of post-traumatic stress dis-order following a traumatic event, particularly whenelderly people have dealt successfully with previoustrauma (Gibbs, 1989), were able to re-experience atrauma with a high degree of voluntary control, findmeaning in some outcome of the trauma, and findsocial support (Lyons, 1991). They argue that elderlypeople are in fact more resilient than younger peoplein coping with extreme stressors (e.g. Gleser et al.,1981; Taylor and Frazer, 1982).

This is supported by the inoculation hypothesisproposed by Eysenck (1983) which maintains thatexposure to stress or previous crisis could in factincrease resistance to subsequent stress and enableelderly people to develop the coping strategies toadapt successfully to the traumatic event (e.g. Norrisand Murrell, 1988; Phifer and Norris, 1989). Elderlypeople who have successfully adapted to previoustrauma would be predisposed to do so again (Gibbs,1989). Thus, they are not necessarily at greater riskthan younger people of negative psychiatric or psy-chosocial outcomes following their experience of

334 m. c. chung ET AL.

Copyright # 2004 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2004; 19: 333–343.

traumatic events. Rather, they might cope just as wellor at times better (Hyer and Sohnle, 2001). This mayexplain why, following natural disasters, elderly vic-tims have reported fewer symptoms than younger andmiddle-aged people (e.g. Gleser et al., 1981; Phiferand Norris, 1989; Green et al., 1996) and why elderlypeople who had previously experienced natural disas-ters were less distressed following a subsequent one(Norris and Murrell, 1988). It may also explain whyelderly victims were better able to recover thanyounger people (Kilijanek and Drabek, 1979; Bolinand Klenow, 1983) and why they reported a signifi-cant reduction in sleeplessness, depression, hypersen-sitivity and irritability sooner than younger people(Kato et al., 1996).

As was mentioned, literature on the coping strate-gies that elderly people use to deal with the effects oftraumatic events is few and far between. A few studiesshowed that elderly people used religion and helpingothers as their primary strategies to cope with theeffects of flood (Green et al., 1996), that they useddrugs to cope with the effects of train disasters (asopposed to younger people who used counsellingand support services) (Lundin, 1991), and that theyused behavioural and avoidance coping strategies,rather than seek support services, more than youngerpeople, following an earthquake. These elderly peo-ple tended to cope less well and were thus more at riskof experiencing post-traumatic stress reactions(Ticehurst et al., 1996). However, focusing on thecoping strategies that elderly people used in handlingday to day problems, they were less likely thanyounger people to admit that they were responsiblefor their existing problems, were less likely to useescape-avoidance coping, but were just as likely asyounger people to employ problem-focused copingstrategies. Elderly people who used problem-focused,rather than escape-avoidance coping strategies,tended to report higher levels of efficacy and lowerlevels of depressive symptoms (Aldwin, 1990, 1992).

On the whole, in disaster research, emotion-focused coping was a predictor to psychiatric sympto-matologies, such as anxiety and somatic problems(e.g. Zeidner and Hammer, 1992; Zeidner and Ben-Zur, 1993, 1994) and a predictor to receiving treat-ment for post-traumatic stress disorder (Blake et al.,1991). In particular, escape-avoidance coping (one typeof emotion-focused coping) was associated with severepost-traumatic distress (Charlton and Thompson,1996). On the other hand, problem-focused copingseemed to moderate the detrimental effects of emo-tion-focused coping on mental health (Solomonet al., 1991). One study, however, found that a wide

range of coping strategies were equally associatedwith the presence of post-traumatic stress disorder,including problem-focused coping, wishful thinking,detachment, seeking social support, focusing on posi-tive things, self-blame, tension reduction, and keepingto oneself (Spurrell and McFarlane, 1993).

As is shown clearly in the foregoing literature,there is a lack of research which aims to differentiatebetween the elderly and younger community residentsin terms of their post-traumatic stress responses torecent traumatic events such as technological disas-ters and their coping strategies. Debates exist as towhether people of different ages react in a similarfashion to traumatic events, whether elderly peopleare more vulnerable than younger people to theseevents (vulnerability hypothesis/additive burdenhypothesis) or whether elderly people are better atcoping with them (inoculation hypothesis). In thelight of the above, we wish to: (1) investigate and dif-ferentiate between the post-traumatic responses ofyoung, middle-aged and elderly community residentswho were exposed to technological disasters (an air-craft crash and a train collision) and (2) differentiatebetween these three age groups in terms of copingstrategies.

METHOD

The disasters

In 1994, a Boeing 737–2D6C was returning to Coven-try, UK, having unloaded a cargo of live animals inAmsterdam. It lost control, struck a pylon and startedto descend on the community of Willenhall. It clippedthe roofs of two houses and finally crashed into awoodland area close to the edge of the community.Five people on board died while hundreds of commu-nity residents escaped death. In 1996, in Rickerscote,Stafford, UK, a collision occurred between a freighttrain carrying liquid carbon dioxide tank wagonsand a postoffice train. The driver of the freight traindid not appear to be injured, while all of the employ-ees on the postoffice train were. One was killed in thegangway area between the first and second coacheswhich had received most damage during the disaster.On both sides of the collision site, there were residen-tial houses. Residents were evacuated in an operationto remove the carbon dioxide.

Participants

One hundred and forty-eight community residents(M¼ 51; F¼ 97), with a mean age of 52.36

coping with post-traumatic stress 335

Copyright # 2004 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2004; 19: 333–343.

(SD¼ 19.30) participated in the study. Eighty-two(M¼ 29, F¼ 53) and 66 (M¼ 22, F¼ 44) residentswere exposed to the aircraft crash and the train colli-sion respectively. The 148 community residents werethen classified into young (18–39, n¼ 47, M¼ 13,F¼ 34), middle-aged (40–64, n¼ 48, M¼ 20,F¼ 28) and elderly (65þ, n¼ 53, M¼ 18, F¼ 35).The division of the age groups largely followed fromthat of Hagstrom’s (1995) study mentioned in theintroduction. However, in order not to omit cases inthe young and middle-aged groups, we modifiedslightly the age range from 18 to 39 (as opposed to18 to 24 suggested by Hagstrom) for the young groupand 40 to 64 (as opposed to 45 to 64) for the middle-aged group. Almost all were Caucasian (99%), andtwo were Afro-Caribbean. Just over half (51%) ofthe cohort were married; just under a quarter (23%)were widowed; 16% were single. The rest (10%) weredivorced or separated. The average length of resi-dence in their communities was 12 years(SD¼ 11.28). Forty percent were retired, 21% unem-ployed, 9% housewives, and the rest worked as edu-cators, factory workers, engineers, mechanics, nurses,social servants, shop assistants or waitresses.

The 148 community residents were exposed to thedisasters at different intensities. For the present analy-sis, we divided the cohort into low, medium and highexposure groups. The low exposure group consistedof community residents (n¼ 12) who lived furtheraway from the crash site and were not at home whenthe disasters occurred. The medium exposure groupconsisted of community residents (n¼ 47) who livednear to the crash site but were not at home when thedisaster occurred or who lived further away from thecrash site but were at home when the disasteroccurred. The high exposure group consisted of com-munity residents who lived near to the crash site andwere at home as the disaster occurred (n¼ 89). Forthe present analysis, the low and medium groups havebeen combined. Due to the reasonably small samplesize of the low exposure group, results derived fromthis group alone would probably not produce a reli-able estimate. No community residents sustainedinjury and none died or knew the deceased. The com-munity residents’ homes were not destroyed duringthe disasters apart from the roofs of two houses whichwere clipped by the aircraft as it lost control and des-cended on the community.

The control group comprised 90 people from thegeneral public (M¼ 48, F¼ 42), with a mean age of52.05 (SD¼ 18.01), who lived in another city andwere not exposed to either of the technological disas-ters. The majority (89%) were Caucasian, the rest

Afro-Caribbean (3%) or Asian (8%). Less than half(44%) were married, 37% were single and the restwere divorced (9%) or widowed (1%). Thirty-sevenpercent were retired, 4% were housewives and 7%were unemployed. The rest worked in a variety ofjobs including engineers, nurses, civil servants,administrators and educators.

Procedure

The study commenced approximately 6 to 7 monthsafter the disasters. The researchers designated an areaof each of the two communities thought to be nearestto the crash sites (between 10 and 300 metres away).Approximately 150 households near the aircraft crashand 95 households (on both sides of the track) near thetrain collision were within the designated areas. Wedistributed letters, explaining the purpose of theresearch, to all households. The letter also informedcommunity residents that the research team wouldbe paying them a visit for an interview. Twenty-fourcommunity residents refused to participate in thestudy. Two were not relevant because they had movedthere after the crash. Two had moved house since thecrash. Sixty-nine community residents were not athome when visited and revisited (2 or 3 times) andthe remaining 148 were interviewed. This yielded a60% response rate. Both disaster groups wereassessed using the Impact of Event Scale, the GeneralHealth Questionnaire and the Ways of Coping Check-lists. For the control group, by means of advertise-ments at a university campus, leisure clubs, shops,churches and by approaching people on high streets,we invited members of the general public fromanother city in the UK to participate in a study mea-suring general health. They were assessed using theGeneral Health Questionnaire. They had not beenexposed to either of the two disasters. All the assess-ments for both the disaster and control groups werecarried out by an experienced psychologist with adoctoral qualification in psychology and three psy-chologist assistants, all of whom had a bachelor qua-lification in psychology and had been trained to carryout the assessments.

Measures

The Impact of Event Scale (IES). (Horowitz et al.,1979) is a 15-item, four-point scale (0¼ not at all,1¼ rarely, 3¼ sometimes, 5¼ often), self-reportinstrument which aims to measure intrusive thoughtsrelated to the traumatic event and consequent avoid-ance behaviour.

336 m. c. chung ET AL.

Copyright # 2004 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2004; 19: 333–343.

The General Health Questionnaire (GHQ-28).(Goldberg and Hillier, 1979) was designed as ascreening instrument which attempts to estimate thelikelihood of subjects being assessed as psychiatriccases at interview. The questions were scored usingthe scoring method of 0–0–1–1. As the total GHQscore exceeds the recommended cutoff point of 4,the probability of becoming a psychiatric caseincreases. As we compared the mean scores of theGHQ, however, we based the analyses on the ratingscale of 1–2–3–4. The questionnaire yields four sub-scales which are somatic, anxiety, social dysfunctionand depression.

The Ways of Coping Checklist (WOC). (Folkman andLazarus, 1988) is a 67-item, four-point scale (0¼ notused, 1¼ used somewhat, 2¼ used quite a bit,3¼ used a great deal) which aims to explore the roleof coping in the relationship between stress and adap-tational outcomes. The items on the original WOCwere classified on the basis of ‘problem-focused’ or‘emotion-focused’ functions of coping. Problem-focused coping consists of confrontive coping,accepting responsibility, and planful problem solving.Emotion-focused coping consists of distancing, self-controlling, seeking social support, escape-avoidance,and positive reappraisal.

RESULTS

In analysing the study, we followed Fields’s (1996)suggestion of formulating comparison groups: elderlypeople exposed to traumatic experiences of differenttypes and severities, matched elderly people notexposed to trauma, and younger people exposed tothe same traumatic events as the elderly people.

A 2 (aircraft, train)� 3 (young, middle, elderly)� 2(low/medium exposure, high exposure) analysis ofvariance (ANOVA) was carried out to compare agedifferences in terms of the impact of the disasters uponthe community residents. The results showed no maineffects of intrusion [F(2, 126)¼ 0.33, ns], avoidance[F(2, 126)¼ 0.82, ns] and IES total [F(2, 126)¼0.22, ns]. However, main effects were found accordingto type of disaster and intensity of exposure to disaster.The aircraft community residents experienced signifi-cantly more intrusive thoughts [F(1, 126)¼ 10.35,p< 0.002], avoidance [F(1, 126)¼ 11.27, p< 0.001]and total impact of the disaster [F(1, 126)¼ 12.42,p< 0.001] than those of the train disaster. The com-munity residents with the highest intensity of exposurewere found to experience significantly more intrusivethoughts [F(1, 126)¼ 6.62, p< 0.011], avoidance

behaviour [F(1, 126)¼ 6.88, p< 0.010] and totalimpact of disaster [F(1, 126)¼ 7.76, p< 0.006]. Nosignificant two-way (age difference� disaster type)or three-way (age difference� disaster type� expo-sure) interactions were ascertained (see Table 1).

A 3 (aircraft, train, control)� 3 (young, middle,elderly)� 2 (low/medium exposure, high exposure)analysis of variance (ANOVA) was then carried outto compare the differences in terms of communityresidents’ general health. The results showed thatgeneral health did not differ significantly betweenage group [somatic: F(2, 213)¼ 0.61, ns; anxiety:F(2, 213)¼ 2.13, ns; social dysfunction: F(2, 213)¼0.46, ns; depression: F(2, 213)¼ 0.90, ns; GHQ total:F(2, 213)¼ 0.87, ns]. However, significant effectswere found on general health according to type of dis-aster [somatic: F(1, 213)¼ 5.77, p< 0.017; anxiety:F(1, 213)¼ 12.18, p< 0.001; social dysfunction:F(1, 213)¼ 8.13, p< 0.005; depression: F(1, 213)¼11.20, p< 0.001; GHQ total: F(1, 213)¼ 14.05,p< 0.0001]. The community residents near the air-craft disaster experienced significantly more generalhealth problems than those near the train disaster(somatic, p< 0.015; anxiety, p< 0.001; social dys-function, p< 0.011; depression, p< 0.001; GHQtotal, p< 0.001) and the control (somatic, p< 0.001;anxiety, p< 0.001; social dysfunction, p< 0.002;depression, p< 0.001; GHQ total, p< 0.001). Signif-icant effects were also found on general healthaccording to intensity of exposure. The communityresidents with high intensity of exposure experiencedsignificantly more somatic problems [F(1, 213)¼14.86, p< 0.001], anxiety [F(1, 213)¼ 17.20, p<0.001], social dysfunction [F(1, 213)¼ 7.02,p< 0.009], depression [F(1, 213)¼ 4.03, p< 0.046]and total general health problems [F(1, 213)¼16.61, p< 0.001]. There was a significant two-wayinteraction effect between age difference and typeof disaster upon somatic problems [F(2, 213)¼ 3.04,p¼ 0.50], suggesting that younger, middle-aged andelderly community residents who had been exposedto the aircraft crash or the train collision or to neitherof the disasters differed in their somatic problems.This probably reflected the fact that the younger, mid-dle-aged and elderly community residents of the con-trol group were consistently lower in somaticproblems than those of the disaster groups. No othersignificant two-way or three-way interaction effectswere found (see Table 2).

A 2 (aircraft, train)� 3 (young, middle, elderly)�2 (low/medium exposure, high exposure) analysisof variance (ANOVA) was carried out to comparedifferences in terms of the coping strategies used

coping with post-traumatic stress 337

Copyright # 2004 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2004; 19: 333–343.

Tab

le1.

The

IES

resu

lts

acco

rdin

gto

dis

aste

rty

pe,

age

dif

fere

nce

and

inte

nsi

tyof

exposu

re

Air

craf

tT

rain

Yo

un

gM

idd

leE

lder

lyY

ou

ng

Mid

dle

Eld

erly

L/M

Hi

L/M

Hi

L/M

Hi

L/M

Hi

L/M

Hi

L/M

Hi

Intr

usi

on

18.0

0(7

.60)

22.3

0(9

.22)

16.2

3(1

1.1

2)

22.0

0(1

2.4

2)

10.0

0(9

.05)

18.3

1(1

1.0

5)

6.1

6(8

.95)

10.1

8(6

.11)

11.0

0(1

1.5

3)

13.7

7(9

.44)

11.6

0(1

0.5

4)

16.5

0(1

3.0

6)

Avoid

ance

15.7

5(8

.25)

18.1

5(1

1.1

3)

10.1

5(1

0.0

9)

23.2

0(1

1.2

4)

13.5

7(1

1.7

0)

20.3

1(1

1.5

4)

5.6

6(1

0.1

7)

10.0

9(8

.84)

8.4

5(9

.50)

10.2

2(6

.55)

12.8

0(8

.72)

14.9

0(1

2.6

6)

Tota

l33.7

5(1

4.4

1)

40.4

6(1

9.7

8)

26.3

8(1

8.4

3)

45.2

0(2

2.1

8)

23.5

7(1

9.7

2)

38.6

2(2

1.3

7)

11.8

3(1

9.0

3)

20.2

7(1

3.4

1)

19.4

5(2

0.7

5)

24.0

0(1

4.0

9)

24

.40

(16.9

2)

31.4

0(2

4.1

5)

Tab

le2

.T

he

GH

Qre

sult

sac

cord

ing

tod

isas

ter

typ

e,ag

ed

iffe

ren

cean

din

ten

sity

of

exp

osu

re

Air

craf

tT

rain

Contr

ol

Yo

un

gM

idd

leE

lder

lyY

ou

ng

Mid

dle

Eld

erly

Yo

un

gM

idd

leE

lder

ly

L/M

Hi

L/M

Hi

L/M

Hi

L/M

Hi

L/M

Hi

L/M

Hi

So

mat

ic1

3.2

51

6.6

91

3.2

51

6.1

31

1.2

81

5.5

01

0.0

01

2.2

71

1.5

41

4.6

61

3.8

31

3.8

59

.56

9.5

71

0.5

6(2

.80

)(6

.58

)(3

.64

)(5

.12

)(1

.38

)(5

.11

)(4

.00

)(1

.73

)(3

.64

)(3

.93

)(4

.35

)(5

.02

)(2

.46

)(2

.41

)(2

.92

)A

nx

iety

15

.08

18

.07

15

.69

17

.73

10

.57

16

.50

9.3

31

1.9

01

2.0

91

5.3

31

0.5

01

5.0

09

.20

10

.80

10

.13

(3.4

7)

(6.9

4)

(5.4

3)

(6.3

4)

(4.8

5)

(6.6

2)

(4.3

2)

(2.3

8)

(5.3

1)

(7.2

6)

(4.0

3)

(6.6

2)

(2.8

4)

(3.5

7)

(3.6

0)

So

cial

14

.41

17

.07

15

.75

16

.13

13

.57

15

.37

12

.83

14

.18

14

.45

14

.33

13

.83

14

.95

14

.08

14

.00

14

.60

dy

sfu

nct

ion

(1.8

3)

(5.0

7)

(2.3

0)

(4.2

0)

(1.1

3)

(2.7

0)

(2.8

5)

(0.6

0)

(2.7

7)

(1.5

0)

(0.4

0)

(3.1

8)

(1.3

2)

(1.3

5)

(1.9

4)

Dep

ress

ion

9.0

81

3.3

81

0.3

01

0.4

09

.42

9.9

37

.83

8.3

69

.36

9.0

07

.00

7.8

57

.92

7.8

08

.03

(1.9

7)

(6.5

5)

(5.5

8)

(4.6

5)

(4.0

3)

(4.5

3)

(2.0

4)

(4.2

0)

(4.4

7)

(2.4

4)

(0.0

0)

(2.1

8)

(2.0

1)

(1.6

5)

(2.0

7)

To

tal

51

.83

65

.23

52

.76

60

.40

44

.85

57

.31

40

.00

46

.72

47

.45

53

.33

45

.16

51

.65

40

.76

42

.17

43

.33

(7.3

3)

(23

.33)

(10

.94)

(17

.66)

(7.0

5)

(15

.85)

(11

.31)

(6.7

8)

(14

.54)

(12

.27)

(6.7

9)

(14

.44)

(4.7

8)

(6.2

4)

(8.4

7)

338 m. c. chung ET AL.

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by the community residents. Remaining consis-tent with the above results on the IES and GHQ, theresults did not show significant differences in copingstrategies according to age [confrontive, F(2, 124)¼0.90, ns; distancing, F(2, 124)¼ 0.81, ns; self-controlling, F(2, 124)¼ 2.01, ns; seeking social sup-port, F(2, 124)¼ 0.68, ns; accepting responsibility,F(2, 124)¼ 1.24, ns; escape-avoidance, F(2, 124)¼2.12, ns; planful problem solving, F(2, 124)¼ 1.27,ns; positive reappraisal, F(2, 124)¼ 1.25, ns]. Onthe other hand, the results showed that communityresidents used significantly more coping strategiesin dealing with the effects of the aircraft crash thanthose of the train collision. They used significantlymore confrontive [F(1, 124)¼ 10.21, p< 0.002], self-controlling [F(1, 124)¼ 11.07, p< 0.001], acceptingresponsibility [F(1, 124)¼ 7.15, p< 0.009], escape-avoidance [F(1, 124)¼ 16.44, p< 0.001], planfulproblem solving [F(1, 124)¼ 7.25, p< 0.008] andpositive reappraisal coping strategies [F(1, 124)¼17.18, p< 0.001]. Also, the community residents withhigh intensity of exposure used significantly more ofthe distancing [F(1, 124)¼ 4.97, p< 0.027], self-controlling [F(1, 124)¼ 4.43, p< 0.037], acceptingresponsibility [F(1, 124)¼ 5.25, p< 0.024] andescape-avoidance [F(1, 124)¼ 7.45, p< 0.007] cop-ing strategies.

One significant interaction effect was that young,middle-aged and elderly community residentsexposed to the aircraft crash, used significantly moreconfrontive coping than those exposed to the traincollision [F(2, 124)¼ 3.74, p< 0.026]. Otherwise,no two-way or three-way interaction effects werefound (see Table 3).

The correlation coefficients carried out in order toidentify relationships between post-traumatic stresssymptoms and general health problems for each agegroup are presented in Table 4. For all three agegroups, the more they experienced intrusion andavoidance, the more they experienced somatic pro-blems, anxiety, social dysfunction and depression,apart from the correlation between intrusion anddepression for the elderly community residents.

DISCUSSION

The overall impression from the findings of the pre-sent study is that there were many similaritiesbetween young, middle-aged and elderly communityresidents in their responses to and ways of copingwith the traumatic effects of the technological disas-ters. In other words, the findings seem to favour theidea that people of different ages react to traumatic T

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coping with post-traumatic stress 339

Copyright # 2004 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2004; 19: 333–343.

events in a similar fashion, rather than the vulnerabil-ity thesis or the inoculation hypothesis. With regard totraumatic responses, all three age groups reacted tothe disasters similarly, in that their levels of intrusivethoughts, avoidance behaviour, and subsequent gen-eral health problems were similar. The more of thetraumatic impact that community residents experi-enced, the more they experienced general health pro-blems. This similarity in traumatic responses amongresidents confirmed previous findings among floodvictims (Ollendick and Hoffman, 1982), earthquakevictims (Goenjian et al., 1994), volcanic eruption vic-tims (Shore et al., 1986) and aircraft disaster victims(Livingston et al., 1992).

Neither did the three groups vary much on theextent to which they used coping strategies to dealwith the effects of the disasters. This finding wasnot consistent with literature which suggested that dif-ferent coping strategies are used by young and elderlypeople (Aldwin, 1990; Lundin, 1991; Aldwin, 1992;Ticehurst et al., 1996). The present study suggestedthat the more they used both emotion-focused (i.e.escape-avoidance, self-controlling, seeking socialsupport, positive reappraisal) and problem-focused(i.e. confrontive coping, planful problem solving)coping strategies, the more they experienced post-traumatic stress symptoms and general health pro-blems. This is borne out in previous research whichsuggested that a wide range of coping strategies,including both emotion-focused and problem-focused, are associated with post-traumatic stress(Spurrell and McFarlane, 1993). In particular,escape-avoidance correlated with all of the IES andGHQ items across all three age groups, suggestingthat the link between increased use of escape-avoid-ance and increased post-traumatic problems andhealth problems was a generic phenomenon acrossall age groups. Previous research suggests such a link(e.g. Charlton and Thompson, 1996). On the whole,accepting responsibility as a way of coping was notassociated with distress across the groups. This wasnot surprising in that most, if not all, of the commu-

nity residents thought that the aircraft and train com-panies, rather than the residents, were responsible forthese disasters.

An exact interpretation of the above finding (i.e.young, middle-aged and elderly community residentsreacted similarly in their responses to and ways ofcoping with the traumatic effects of the technologicaldisasters) is difficult to produce. One explanationworthy of exploration concerns the way in whichthese community residents perceived the threat fromthe technological disasters. Research has informed usthat perception of threat during the traumatic eventcould account for the long term persistence of post-traumatic stress (Ehlers et al., 1998; Mayou et al.,2002). It may be the case that the degree of threat thatthe community residents perceived from these disas-ters was somewhat similar which led to similar trau-matic responses and ways of coping. During thedisasters, most people’s property was not damaged(apart from two roofs being clipped by the aircraftas it descended on the community); no communityresidents were injured; no relatives of the communityresidents were killed and no community residentsknew the people who died in the disasters. Theymay even have shared similar belief systems andattributed similar meanings to the disasters, i.e. thedisasters occurred by accident rather than by any actof terrorism or punishment by God. They may alsohave shared the belief that the aircraft and train com-panies were responsible for the disasters and that theywere simply unlucky to be there at the time of the dis-aster. Such similarities may have helped to form asimilar perception of the degree of threat from the dis-asters, thereby preventing a dramatic variation in thetraumatic and coping responses occurring.

On the other hand, if there were a big discrepancyin the perception of threat between the three groups, itwould not be unreasonable to expect a degree of var-iation between three groups, in terms of post-trau-matic stress responses and coping strategies.Research has shown us that the greater people per-ceive the threat of an event to be, the more likely they

Table 4. Correlations between IES and GHQ according to age difference

Young Middle Elderly

Intrusion Avoidance Intrusion Avoidance Intrusion Avoidance

Somatization 0.74** 0.66** 0.66** 0.56** 0.63** 0.62**Anxiety 0.83** 0.75** 0.82** 0.58** 0.84** 0.70**Social dysfunction 0.56** 0.50** 0.41** 0.49** 0.47** 0.32*Depression 0.59** 0.55** 0.43** 0.40** ns 0.33*

*p< 0.05.**p< 0.01.

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are to exhibit post-traumatic stress symptoms(Marmar et al., 1996). For example, a high level ofperceived threat was found to be associated with highpost-traumatic stress among victims of road trafficaccidents (Conlon et al., 1999; Jeavons et al.,2000), victims of robbery (Kamphuis and Emmelk-amp, 1998) and Vietnam veterans (King et al., 1999).

An alternative explanation for the finding that thethree age groups reacted similarly in their post-traumatic responses to and ways of coping with thetraumatic effects of the technological disasters is thedegree of dissociation that they displayed (i.e. dissoci-ate themselves from the traumatic impact of the disas-ters). Due to the similar degree of threat that theyexperienced, as was mentioned previously, these com-munity residents may have experienced a similardegree of dissociation which, in turn, prompted simi-lar post-traumatic stress responses and coping strate-gies. On the other hand, if there were a bigdiscrepancy between groups in terms of the threat,one would expect a variation in terms of the degreeof dissociation that they experienced which wouldlead to variation in post-traumatic stress responsesand coping strategies. Indeed, research shows us thatdissociative experiences are significantly associatedwith post-traumatic stress symptom severity (Yehudaet al., 1996) in that people who report greater expo-sure to and perceived threat to life from a disaster tendto report greater dissociative symptoms, peri-traumatic dissociation and peri-traumatic emotionaldistress which, in turn, is a robust predictor to post-traumatic stress (Birmes et al., 2003; Marmar et al.,1996; Morgan et al., 2001). We admit that the twoforegoing explanations will remain speculations sincerobust measures and procedures need to be in place inorder to verify them.

The present findings revealed clearly that while agedid not seem to play a major role in differentiatingtraumatic and coping responses of this cohort of com-munity residents, disaster type and intensity of expo-sure did. This is consistent with literature whichsuggests that psychological reactions to traumaticevents vary depending on disaster type (Ursano et al.,1994; Weisaeth, 1994), and that people who experi-ence the highest exposure or are in closest proximityto the disaster tend to suffer more severe psychologi-cal symptoms (Selley et al., 1997; Smith et al., 1990;Tyano et al., 1996), though some researchers haveclaimed that exposure to a disaster is necessary totrigger but not sufficient to explain the onset and pat-tern of post-traumatic morbidity (McFarlane, 1988a,1988b, 1989). From the lack of significant interactioneffects, it can be deduced that both disaster type and

intensity of exposure were independent factors, inde-pendently affecting the psychological responses andcoping strategies of the community residents.

To close the discussion, it is noted that the way inwhich the intensity of exposure to the disasters wasmeasured in the present study is somewhat crude(i.e. mainly based on the community residents’ dis-tance from the epicentre of the disaster, and whetherthey were at home or not at the time of the disasters).Despite the fact that this way of classifying peopleinto different groups of trauma exposure is notuncommon in disaster literature, we admit that it isone limitation of the study which could have beenaddressed by measuring the degree of perceived threatof the disasters in some detail. The objective data onthe community residents’ perception of threat of thedisasters would probably have given us a more robustway of allocating people into groups of trauma expo-sure. Also, the data from perceived threat would haveprobably helped us explain some of the findings, par-ticularly concerning coping strategies.

To conclude, the findings of the present studyseemed to suggest that neither the vulnerabilityhypothesis nor the inoculation hypothesis applied tothis cohort of community residents. Instead, the resultsseemed to support the idea that people of differentages react similarly to traumatic events and employsimilar coping strategies. Other factors such as disastertype and intensity of exposure appeared to be strongerin differentiating between traumatic and copingresponses among these community residents.

REFERENCES

Aarts PGH, Op den Velde W, Falger PR, Hovens JE, De GroenJHM, van Duijn H. 1996. Late onset of post-traumatic stress dis-order in aging resistance veterans in the Netherlands. In Agingand Post-traumatic Stress Disorder, Ruskin PE, Talbott JA(eds). American Psychiatric Press: Washington, DC; 53–76.

Aldwin C. 1990. Change and stability in mental health over the life-span. Gerontologist 30: 333A–334A.

Aldwin CM. 1992. Aging, coping and efficacy: theoretical frame-work for examining coping in life-span developmental context.In Stress and Health Among the Elderly, Wykle ML, Kahana E,Kowal J (eds). Springer Publishing Company: New York; 96–113.

Averill PM, Beck JG. 2000. Post-traumatic stress disorder in olderadults: a conceptual review. J Anxiety Disord 14: 133–156.

Birmes P, Brunet A, Carreras D, et al. 2003. The predictive powerof peritraumatic dissociation and acute stress symptoms for post-traumatic stress symptoms: a three-month prospective study. AmJ Psychiatry 160(7): 1337–1339.

Blake DD, Keane TM, Wine PR. 1990. Prevalence of PTSD symp-toms in combat veterans seeking medical treatment. J TraumaticStress 3: 15–27.

Blake DD, Cook JD, Keane TM. 1991. Post-traumatic stress disor-der and coping in veterans who are seeking medical treatment. JClin Psychol 48(6): 695–704.

coping with post-traumatic stress 341

Copyright # 2004 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2004; 19: 333–343.

Bolin R, Klenow DJ. 1983. Response of the elderly to disaster:an age-stratified analysis. Int J Aging Hum Develop 16:283–296.

Charlton PFC, Thompson JA. 1996. Ways of coping withpsychological distress after trauma. Br J Clin Psychol 35:517–530.

Conlon L, Fahy TJ, Conroy R. 1999. PTSD in ambulant RTA vic-tims: a randomized controlled trial of debriefing. J PsychosomatRes 46(1): 37–44.

Dohrenwend BS, Dohrenwend BP (eds). 1981. Stressful Life Eventsand Their Context. Neale Watson: New York.

Ehlers A, Mayou RA, Bryant B. 1998. Psychological predictors ofchronic post-traumatic stress disorder after motor vehicle acci-dents. J Abnormal Psychol 107(3): 508–519.

Elwell F, Maltbie-Crannel AD. 1981. The impact of role loss uponcoping resources and life satisfaction of the elderly. J Gerontol36: 223–232.

Eysenck H. 1983. Stress, disease, and personality: the ‘inoculation’effect. In Stress Research, Cooper CJ (ed.). Wiley: New York;121–146.

Fields R. 1996. Severe stress and the elderly. In Aging and Post-traumatic Stress Disorder, Ruskin P, Talbott J (eds). AmericanPsychiatric Press: Washington, DC; 79–100.

Fillenbaum GG. 1977–1978. An examination of the vulnerabilityhypothesis. Int J Aging Hum Develop 8(2): 155–160.

Folkman S, Lazarus RS. 1988. Manual for the Ways of CopingQuestionnaire. Consulting Psychologist Press: Palo Alto, CA.

Gibbs M. 1989. Factors in the victim that mediate between disasterand psychopathology: a review. J Traumat Stress 2(4): 489–514.

Glass TA, Kasl SV, Berkman LF. 1997. Stressful life events anddepressive symptoms among the elderly. J Aging Health 9(1):70–89.

Gleser G, Green B, Winget C. 1981. Prolonged PsychologicalEffects of Disaster. Academic Press: New York.

Goenjian AK, Najarian LM, Pynoos RS, et al. 1994. Post-traumaticstress disorder in elderly and younger adults after the 1988 earth-quake in Armenia. Am J Psychiatry 151: 895–901.

Goldberg DP, Hillier VF. 1979. A scaled version of the GeneralHealth Questionnaire. Psycholog Med 9: 139–145.

Goldstein G, van Kammen W, Shelly C. 1987. Survivors of impri-sonment in the Pacific theater during world war II. Am J Psychia-try 144: 1210–1213.

Green BL, Gleser GC, Lindy JD, Grace MC, Leonard A. 1996.Age-related reactions to the Buffalo Greek Dam collapse: effectsin the second decade. In Aging and Post-traumatic Stress Disor-der, Ruskin PE, Talbott JA (eds). American Psychiatric Press,Inc: Washington, DC; 101–125.

Hagstrom R. 1995. The acute psychological impact on survivorsfollowing a train accident. J Traumat Stress 8(3): 391–402.

Horowitz M, Wilner N, Alvarez W. 1979. Impact of events scale: ameasure of subjective stress. Psychosomat Med 41(3): 209–218.

Hyer LA, Sohnle SJ. 2001. Trauma Among older People. Brunner-Routledge: Hove.

Hyman I. 1997. Post-traumatic stress disorder in the elderly. InPsychological Trauma: A Developmental Approach, Black D,Newman M, Harris-Hendriks J, Mezey G (eds). Gaskell:London; 199–204.

Jeavons S, Greenwood KM, de L Horne DJ. 2000. Accident cogni-tions and subsequent psychological trauma. J Traumat Stress13(2): 359–365.

Kahana B. 1992. Late-life adaptation in the aftermath of extremestress. In Stress and Health Among the Elderly, Wykle ML,Kahana E, Kowal J (eds). Springer Publisher Company: NewYork; 151–171.

Kamphuis JH, Emmerlkamp PMG. 1998. Crime-related trauma:psychological distress in victims of bankrobbery. J Anxiety Dis-ord 12(3): 199–208.

Kato H, Asukai N, Miyake Y, Minakawa K, Nishiyama A. 1996.Post-traumatic symptoms among younger and elderly evacueesin the early stages following the 1995 Hanshin-Awaji earthquakein Japan. Acta Psychiatrica Scand 93: 477–481.

Kaup BA, Ruskin PE, Nyman G. 1994. Significant life events andPTSD in elderly world war II veterans. Am J Geriatr Psychiatry2(3): 239–243.

Kilijanek T, Drabek T. 1979. Assessing long-term impacts of a nat-ural disaster: a focus on the elderly. Gerontologist 19: 555–556.

King DW, King LA, Foy DW, Keane TM, Fairbank JA. 1999. Post-traumatic stress disorder in a national sample of female and maleVietnam veterans: risk factors, war-zone stressors and resilience-recovery variables. J Abnormal Psychol 108(1): 164–170.

Kluznik JC, Speed N, van Valkenburg C. 1986. Forty-year follow-up of United States prisoners of war. Am J Psychiatry 143:1443–1446.

Livingston HM, Livingston MG, Brooks DN, McKinlay WW. 1992.Elderly survivors of the Lockerbie air disaster. Int J Geriatr Psy-chiatry 7: 725–729.

Livingston HM, Livingston MG, Fell S. 1994. The Lockerbie dis-aster: a 3-year follow up of elderly victims. Int J Geriatr Psy-chiatry 9: 989–994.

Lundin T. 1991. Train disaster survivors: long-term effects on men-tal health and well-being. Stress Med 7: 87–91.

Lyons J. 1991. Strategies for assessing the potential for positiveadjustment following trauma. J Traumatic Stress 4: 93–111.

Lyons J, McClendon O. 1990. Changes in PTSD symptomatologyas a function of aging. Nova-Psy Newsletter 8: 13–18.

Marmar CR, Weiss DS, Metzler TJ, Delucchi K. 1996. Character-istics of emergency services personnel related to peritraumaticdissociation during critical incident exposure. Am J Psychiatry153(Suppl): 94–102.

Mayou RA, Ehlers A, Bryant B. 2002. Post-traumatic stress disor-der after motor vehicle accidents: 3-year follow-up of a prospec-tive longitudinal study. Behav Res Ther 40(6): 665–675.

McFarlane AC. 1988a. The aetiology of post-traumatic stress disor-ders following a natural disaster. Br J Psychiatry 152: 116–121.

McFarlane AC. 1988b. The longitudinal course of post-traumaticmorbidity. The range of outcomes and their predictors. J NervousMent Dise 176(1): 30–39.

McFarlane AC. 1989. The aetiology of post-traumatic morbidity:predisposing, precipitating and perpetuating factors. Br JPsychiatry 154: 221–228.

Melick ME, Logue JN. 1986. The effect of disaster on healthand well-being of older women. Int J Aging Hum Develop 21:27–38.

Morgan CA, Hazlett G, Wang S, Richardson EG, Schnurr P,Southwick SM. 2001. Symptoms of dissociation in humansexperiencing acute, uncontrollable stress: a prospective investi-gation. Am J Psychiatry 158(8): 1239–1247.

Norris F, Murrell S. 1988. Prior experience as a moderator of dis-aster impact on anxiety symptoms in older adults. Am J CommPsychol 16: 665–683.

Ollendick D, Hoffman M. 1982. Assessment of psychological reac-tions in disaster victims. J Commun Psychol 10: 157–167.

Phifer JF, Norris FH. 1989. Psychological symptoms in older adultsfollowing natural disaster: nature, timing, duration, and course. JGerontol Soc Sci 44(6): S207–S217.

Selley C, King E, Peveler R, Osola K, Martin N, Thompson C.1997. Post-traumatic stress disorder symptoms and the Claphamrail accident. Br J Psychiatry 171: 478–482.

342 m. c. chung ET AL.

Copyright # 2004 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2004; 19: 333–343.

Shore JH, Tatum EL, Vollmer WM. 1986. Psychiatric reactions todisaster: the Mount St. Helens experience. Am J Psychiatry 143:590–595.

Smith EM, North CS, McCool RE, Shea JM. 1990. Acute postdisa-ster psychiatric disorders: identification of persons at risk. Am JPsychiatry 147: 202–206.

Solomon Z, Mikulincer M, Arad R. 1991. Monitoring and blunting:implications for combat-related post-traumatic stress disorder. JTraumatic Stress 4(2): 209–221.

Speed N, Engdahl B, Schwartz J. 1989. Post-traumatic stress disor-der as a consequence of the POW experience. J Nervous MentDis 177: 147–153.

Spurrell MT, McFarlane AC. 1993. Post-traumatic stress disorderand coping after a natural disaster. Soc Psychiatry Psychiatr Epi-demiol 28: 194–200.

Taylor AJW, Frazer AG. 1982. The stress of post-disaster, bodyhandling and victim identification work. J Hum Stress 8(4):4–12.

Ticehurst S, Webster RA, Carr VJ, Lewin TJ. 1996. The psychoso-cial impact of an earthquake on the elderly. Int J Geriatr Psy-chiatry 11: 943–951.

Tyano S, Iancu I, Solomon Z, et al. 1996. Seven-year follow-up ofchild survivors of a bus-train collision. J Am Academic ChildAdoles Psychiatry 35(3): 365–373.

Ursano RJ, McCaughey BG, Fullerton CS (eds). 1994. Individualand Community Responses to Trauma and Disaster. CambridgeUniversity Press: Cambridge.

Weisaeth L. 1994. Psychological and psychiatric aspects of techno-logical disasters. In Individual and Community Responses toTrauma and Disaster, Ursano RJ, McCaughey BG, FullertonCS (eds). Cambridge University Press: Cambridge; 72–102.

Yehuda R, Kahana B, Schmeidler J, Southwick SM. 1995. Impactof cumulative lifetime trauma and recent stress on current post-traumatic stress disorder symptoms in Holocaust survivors. Am JPsychiatry 152(12): 1815–1818.

Yehuda R, Elkin A, Binder-Brynes B, Kahana B. 1996. Dissociationin aging Holocaust survivors. Am J Psychiatry 153(7): 935–940.

Zeidner M, Ben-Zur H. 1993. Coping with a national crisis: theIsraeli experience with the threat of missile attacks. PersonalityIndividual Differe 14(1): 209–224.

Zeidner M, Ben-Zur H. 1994. Individual differences in anxiety, cop-ing and post-traumatic stress in the aftermath of the Persian GulfWar. Personality Individual Differen 16(3): 459–476.

Zeidner M, Hammer AL. 1992. Coping with missile attack:resources, strategies and outcomes. J Personality 60(4): 709–746.

Zeiss RA, Dickman HR. 1989. PTSD 40 years later: incidence andperson-situation correlates in former POWs. J Clin Psychol 45:80–87.

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