Evaluation of the psychology of earthquake victims referred to plastic surgery service after crush injury: a cross-sectional study

Abstract

Background:

Following the 6 February 2023 earthquake, a significant number of people living in various urban areas suffered crush injuries while trapped under the rubble of collapsed buildings. A significant number of people affected by the earthquake, who were hospitalized for long periods and underwent various surgical interventions for significant injuries, including limb loss, were treated in the plastic surgery department. This study aimed to assess the psychological well-being of patients under our care after the earthquake.

Methods:

A total of 33 patients (15 males, 18 females) with crush injuries who were referred to our clinic and agreed to undergo psychological examination were included in the study. Our team collaborated with plastic surgeons, psychologists, and allied physicians to carry out interventions, assessments, and interviews. Demographic, injury, psychological, and social support information was collected for evaluation after hospitalization.

Results:

The study found that, in terms of personal factors, aggression and depression levels were significantly higher in men than in women. As for age, verbal aggression level (r = −0.405), depression level (r = −0.369), and numerous psychotic symptoms (r = −0.439) were inversely correlated with age. When social factors were investigated, verbal aggression (r = 0.376) and self-confidence (r = 0.432) were directly proportional to higher education levels. Depression and psychosis levels were found to be statistically significantly higher in patients with lower incomes (P < 0.05). Patients who lost their next of kin were found to be statistically significantly affected by acute stress (P = 0.003). As for medical factors, several psychotic symptoms were inversely correlated with larger areas of injury (r = −0.385). Increasing numbers of debridement sessions were also found to be directly correlated with anxiety symptoms (r = 0.345).

Conclusions:

The surgical team responsible for providing medical care to patients after an earthquake should be aware of the psychological state of the individuals they treat. Providing psychological and social support by the surgical team in the early stages after the earthquake, particularly for young patients, patients with low incomes, and those who have lost family members, may be considered a potentially beneficial component of multidisciplinary post-disaster care.

Introduction

On 6 February 2023, the earthquake caused crush injuries to people in several cities as they were trapped under collapsed structures. Many earthquake survivors were operated on in the plastic surgery service after being hospitalized for a long period of time, undergoing repeated surgeries, losing limbs, and suffering extensive wounds. This affects patients’ mental health as well as their physical health. Earthquake victims in the plastic surgery service should also be provided with mental health support. In a large meta-analysis conducted after the 2011 Japan earthquake, 32.1% were diagnosed with Post-Traumatic Stress Disorder (PTSD), 21.4% with general psychological disorders, and 7.2% with melancholia[1]. Moreover, a previous study showed that being unmarried, being female, and losing family members had a serious effect on PTSD symptoms and that these psychological effects caused by the earthquake would continue for a long time^[2,3^].

HIGHLIGHTS

• This study evaluated the psychological outcomes of earthquake survivors with crush injuries who were treated at a plastic surgery service.

• Younger age, male sex, lower socioeconomic status, and family loss were associated with less favorable psychological outcomes following earthquake-related injuries.

• Repeated surgical interventions and injury-related factors may influence psychological well-being during recovery.

• Early psychological assessment and multidisciplinary psychosocial support may be beneficial components of post-disaster reconstructive care.

• The findings provide preliminary evidence and highlight the need for larger multicenter longitudinal studies.

The earthquake zone is approximately 700 km from the hospital where the study was conducted. Therefore, most of the patients admitted arrived late or were awaiting secondary intervention. Compartment syndrome resulting from crush injury occurred in many of them and was related to the duration of time spent under the rubble. In addition, earthquake victims admitted to our hospital and referred to the plastic surgery service had mostly hand injuries, large tissue defects, and maxillofacial injuries[4].

After the earthquake, a large number of patients consulted plastic surgery clinics. Consequently, many reconstruction operations were performed, each involving multiple reconstruction steps for each patient. We consider it essential to evaluate the psychological impact of all these complex processes on plastic surgery patients with injuries such as crush injuries. These psychologically challenging factors included multiple trauma, loss of limb or limb function, loss of family members, and accommodation problems (Fig. 1).

Figure 1.

Common plastic surgery issues observed in earthquake victims.

Recent literature has increasingly emphasized the importance of integrating psychological assessment and mental health support into surgical treatment pathways, particularly in trauma and disaster settings. Hsu et al have highlighted the need to incorporate psychological care into surgical management to improve overall patient outcomes. Furthermore, emerging frameworks from the Middle East have emphasized culturally sensitive and multidisciplinary approaches to mental health care following large-scale traumatic events, including natural disasters and conflict-related injuries. These perspectives support the growing recognition that psychological recovery should be considered alongside physical rehabilitation in disaster survivors^[5–7^].

This study aims to evaluate the psychological impact of the earthquake on plastic surgery patients who survived it and to compare the results with the broader psychological literature on earthquakes. Additionally, it seeks to determine the psychological management of severely traumatized patients hospitalized in plastic surgery units and to identify situations that require attention. This cross-sectional study has been reported in accordance with the STROCSS 2025 guidelines.

Methods

A total of 42 patients with earthquake-related crush injuries who were referred to the plastic and reconstructive surgery department between February and May 2023 were assessed for eligibility. Two patients were excluded because they were unable to complete the psychological assessment process, and seven patients declined participation. Consequently, 33 patients provided informed consent and were included in the final analysis. Eligible patients were consecutively recruited during the study period. The participant selection process is illustrated in Fig. 2. Due to the exploratory nature of the study and the limited number of eligible earthquake survivors available during the study period, eligible patients were consecutively recruited until the end of the study. To treat crush injuries, patients underwent repeated debridement and negative-pressure wound therapy after fasciotomy when necessary. During these treatments, psychiatric consultation and supportive interviews were provided for patients. Plastic surgeons, psychiatrists, and auxiliary staff worked collaboratively as a team.

Figure 2.

Flow diagram of participant recruitment.

Thirty-minute interviews were conducted with patients included in the study. Demographic information, injury information, social support, and psychological status were recorded. Exclusion criteria included leaving the interview at any time, refusing to participate in the study, and being unable to complete the interview due to a psychiatric problem.

In the demographic evaluation, age, gender, education level, income, duration of time spent under rubble, type of injury, loss of a family member, tobacco and alcohol use, and history of psychiatric treatment were assessed. In the evaluation of injury status, previous operations, injury locations, and loss of limb function were assessed.

For psychological assessment, the Beck Anxiety–Depression, Impulsivity, and Aggression Scale and the Brief Psychiatric Symptom Inventory (BPSI) were administered in addition to a psychiatric examination^[8–10^]. A PTSD scale, the Acute Stress Disorder Short Scale, the Visual Analog Scale for Pain (VAS-P), the Impact of Event Scale, and the Dissociative Experiences Scale were administered. The Multidimensional Scale of Perceived Social Support (MSPSS) and The Self-Esteem Rating Scale (TSERS) were used to assess social status. Turkish-validated versions of all psychometric instruments were used. The validated Turkish adaptations of the Beck Depression Inventory, Beck Anxiety Inventory, Dissociative Experiences Scale, Impact of Event Scale, MSPSS, and other relevant instruments were administered. References for the validation studies have been added accordingly^[11–15^].

All data were analyzed using SPSS version 26. Due to the exploratory nature of the study and the limited sample size, no formal sample size calculation was performed. This was a cross-sectional study. Correlations among demographic characteristics, injury characteristics, and psychological and social support scale scores were evaluated using correlation analysis. Analysis of variance was used to compare more than two groups, and the t-test was used to compare parametric data between two groups. These methods were used to conduct patient assessments, with concurrent psychiatric consultation and supportive interviews.

Results

Demographic assessment

It was noted that 57.6% (n = 19) of participants had children. The mean educational attainment of the overall patient population was 11.18 ± 3.91 years. Only 21.2% (n = 7) had a high school diploma, while 48.4% (n = 16) of the patients had completed secondary education. Thirty-nine percent (n = 13) of the patients reported a middle-class income. Among those affected by the earthquake, 66.7% (n = 22) were unemployed. The proportion of smokers was 27.3% (n = 9). Among the earthquake survivors who participated in the study, 78.8% (n = 26) had lost a close family member. Three percent (n = 1) of the participants received psychiatric treatment (Table 1).

Table 1.

Demographic characteristics of the study participants (N = 33).

Characteristic	Value (mean ± SD or n [%])
Number of patients	33
Mean age (yr)	40.18 ± 16.11
Years of education	11.18 ± 3.91
Number of children	1.54 ± 1.12
Gender
Female	18	(54.5)
Male	15	(45.5)
Employment status
Employed	11	(33.3)
Unemployed	22	(66.7)
Income class
No income	5	(15.2)
Lower	11	(33.3)
Middle	13	(39.4)
Upper	4	(12.1)
Marital status
Married	15	(45.5)
Not currently married	18	(54.5)
Smoker	9	(27.3)
Alcohol user	1	(3.0)
Loss of a close family member
Yes	26	(78.8)
No	7	(21.2)
History of psychiatric treatment
Yes	1	(3.0)
No	32	(97.0)

Injury assessment

The mean duration of time patients spent under the rubble was 12 hours (range, 0–120). The mean time from the earthquake to initial hospital admission was 1.57 days (± 0.5). The mean size of the tissue defect in the injured body part was 12 cm (range, 0–50). A total of 119 wounds were recorded; 63 (52.9%) were located on the left side and 56 (47.1%) on the right side. The mean number of wounds was 2 (range, 0–7). The mean number of debridement procedures was 1 (range, 0–3). The mean number of fasciotomies was 0.87 (± 0.33) (Table 2).

Table 2.

Injuries demographics.

	Value (%)
Side of wounds
Left	63 (52.9)
Right	56 (47.1)
Under the rubble, hr (median, range)	12 (0–120)
Time from earthquake to initial hospital admission, days	1.57 ± 0.5
Defect length, cm (median, range)	12 (0–50)
Number of wounds (median, range)	2 (0–7)
Debridement (median, range)	1 (0–3)
Fasicotomy	0.87 ±0.33

Psychological assessment

In the correlation analysis related to demographic information, an inverse relationship was found between patient age and verbal aggression (r = −0.405, P = 0.019). An inverse relationship was noted between age and depressive symptoms of motor retardation (r = −0.369, P = 0.035), psychotic symptoms of uncooperativeness (r = −0.439, P = 0.011), and psychotic symptoms of unusual thinking (r = −0.391, P = 0.024). A statistically significant positive correlation (r = 0.376) was observed between the predisposition to verbal aggression and the educational level of the patients. A positive correlation (r = 0.432) was found between self-esteem reported by patients and the level of education attained by individuals. The mean time from the earthquake to referral to our Plastic and Reconstructive Surgery Department was 12 days (range, 0–16). An inverse relationship (r = −0.367) was found between the time elapsed since the earthquake and the level of anxiety reported by the patients attending our clinic. In the BPSI, psychotic symptoms of suspiciousness (r = −0.395) and emotional withdrawal (r = −0.356) were significantly reduced. A decrease in both psychotic symptoms of uncooperativeness (r = −0.365) and unusual thinking (r = −0.385) was observed as the number of wounds increased. We observed an increase in anxiety scores (r = 0.345) as the patients underwent wound debridement. The results of our study show that emotional withdrawal decreased (r = −0.386) and self-esteem increased (r = 0.384) as the time spent under the rubble increased (Table 3).

Table 3.

Correlations between demographic and injury-related variables and psychological assessment scores.

	Age		Education status		Hours under the rubble		Time from earthquake to referral		Number of wounds		Debridement
Clinical population (n) = 33	r	P	r	P	r	P	r	P	r	P	r	P
Beck Anxiety Scale	−0.168	0.349	0.129	0.473	−0.184	0.306	−0.367*	0.036	−0.218	0.223	0.345*	0.049
Buss–Perry (Verbal Aggression Scale)	−0.405*	0.019	0.376*	0.031	−0.008	0.965	0.154	0.391	−0.218	0.222	−0.155	0.39
Depressive symptom (emotional withdrawal)	−0.16	0.373	−0.091	0.614	−0.386*	0.027	−0.356*	0.042	−0.015	0.934	0.089	0.62
Symptoms of psychosis (suspiciousness)	−0.275	0.122	0.131	0.469	−0.244	0.171	−0.395*	0.023	−0.192	0.283	0.095	0.599
Depressive symptom (motor retardation)	−0.369*	0.035	0.199	0.266	−0.127	0.482	−0.187	0.298	0.155	0.39	0.197	0.273
Symptoms of psychosis (uncooperativeness)	−0.439*	0.011	0.272	0.126	−0.012	0.949	−0.161	0.369	−0.365*	0.037	0.248	0.164
Symptoms of psychosis (unusual thought)	−0.391*	0.024	0.23	0.198	−0.226	0.206	−0.313	0.076	−0.385*	0.027	0.157	0.384
TSERS	−0.017	0.924	0.432*	0.012	0.384*	0.027	0.272	0.126	0.121	0.504	−0.028	0.879

Pearson correlation.

*P < 0.05.

TSERS, The Self-Esteem Rating Scale.

The VAS-P showed a positive correlation with impulsivity (r = 0.379) and the attention scale (r = 0.454). A positive correlation was found between the Disabilities of the Arm, Shoulder, and Hand questionnaire and TSERS (r = 0.407, P = 0.019). The Dissociative Questionnaire showed a significant positive correlation with the hostility scale (r = 0.468), the depression scale (r = 0.377), and the anxiety scale (r = 0.419) was found. The Impact of Event Scale-Revised showed a significant positive correlation with the depression scale (r = 0.400) and the anxiety scale (r = 0.347) (Table 4).

Table 4.

Correlations between psychological, pain, and functional assessment scores.

Clinical population (n) = 33	DIS-Q		IES-R		VAS-P		Quick DASH
	r	P	r	P	r	P	r	P
Beck Anxiety Scale	0.419*	0.015	0.347*	0.048	0.246	0.168	0.164	0.361
Beck Depression Scale	0.377*	0.031	0.400*	0.021	0.272	0.125	0.244	0.171
Baratt No Plan Scale	0.275	0.121	0.025	0.892	0.379*	0.03	−0.054	0.767
Baratt Attention Scale	0.289	0.103	−0.031	0.863	0.454**	0.008	−0.274	0.123
Buss–Perry Hostility Scale	0.468**	0.006	0.232	0.194	0.197	0.272	−0.015	0.935
TSERS	0.041	0.822	0.132	0.462	0.196	0.275	0.407*	0.019

Pearson correlation.

*P < 0.05.

^***P < 0.01.

TSERS, The Self-Esteem Rating Scale; DIS-Q, Dissociation Questionnaire; IES-R, Impact of Event Scale-Revised; VAS-P, Visual Analog Scale for Pain; Quick DASH: Disabilities of the Arm, Shoulder, and Hand.

Assessment of social support

Comparison of the data obtained revealed that men had higher rates of physical aggression [P = 0.04], irritability [P = 0.04], verbal aggression [P = 0.048], and depression [P = 0.025]. A significant relationship was found between the social support score and the number of children, and a decrease in the number of children was associated with an increase in the social support score [P = 0.038; mean rank = 69 (60–72)]. In the BPSI, suspiciousness [P = 0.025; mean rank = 0 (0–0)] and motor retardation [P = 0.031; mean rank = 0 (0–0.5)] were more common among low-income individuals (Table 5). Acute stress scores differed significantly according to the loss of a close family member (P = 0.003), whereas the difference in attention scores did not reach statistical significance (P = 0.06) (Table 6).

Table 5.

Comparison of psychological and social support scores according to gender, number of children, and income status.

Clinical population (n) = 33	Gender			Number of children			Income status
	Female (n = 18) Median (range %25–75)	Male (n = 15) Median (range %25–75)	P value	None (n = 14) Median (range %25–75)	>1 (n = 19) Median (range %25–75)	P-value	Lower (n = 16) Median (range %25–75)	Higher (n = 17) Median (range %25–75)	P-value
Buss–Perry Anger Scale	6.5 (4–8)	11 (7–14)	0.04*	7 (4.75–12.5)	8 (5–10)	0.99	7 (5–10.75)	8 (4.5–12)	0.87
Buss–Perry Physical Aggression Scale	3.5 (0–7.25)	8 (4–13)	0.04*	7 (0–13)	6 (2–8)	0.71	6.5 (3.25–8)	4 (0.5–12)	0.68
Buss–Perry Verbal Aggression Scale	2 (0–4.5)	4 (2–8)	0.048*	5.5 (0.75–7.25)	3 (1–4)	0.23	4 (2–6)	4 (1–6)	0.63
Depression Mood in the BPSI	0 (0–1)	1 (0–3)	0.03*	0 (0–1.25)	0 (0–2)	0.79	0.5 (0–2)	0 (0–1)	0.61
Suspiciousness in the BPSI	0 (0–1)	0 (0–2)	0.96	0 (0–1)	0 (0–1)	0.90	1 (0–2)	0 (0–0)	0.03*
Motor Retardation in the BPSI	1 (0–2)	0 (0–1)	0.51	0 (0–1.25)	1 (0–1)	0.51	1 (0–2)	0 (0–0.5)	0.03*
MSPSS	60 (38–69)	62.5 (51–72)	0.53	69 (60–72)	54 (48–64)	0.04*	58. (47.75–64.5)	68 (53.5–72)	0.1

*P < 0.05.

MSPSS, Multidimensional Scale of Perceived Social Support.

BPSI, Brief Psychiatric Symptom Inventory.

Table 6.

Comparison of attention and acute stress scores according to time spent under the rubble and loss of a close family member.

Clinical population (n) = 33	Hours under dent			Loss of close family member
	<12 hour (n = 14)	>12 hour (n = 19)		Loss or None (n = 7)	>1 (n = 26)
	Median (range %25–75)	Median (range %25–75)	P-value	Median (range %25–75)	Median (range %25–75)	P-value
Baratt Attention Scale	7.5 (4–9.75)	6 (4–8)	0.51	3 (0–8)	7 (4.75–9)	0.06
NSESSS	30 (12.25–50)	32 (7–84)	0.82	84 (48–84)	26 (7–48.25)	0.001

NSESSS, National Stressful Events Survey Acute Stress Disorder Short Scale.

Discussion

The present study evaluated the psychological status of earthquake survivors with crush injuries who required treatment and follow-up in a plastic surgery service. Unlike many previous studies focusing on community-based earthquake populations, our cohort consisted of severely injured patients who experienced prolonged hospitalization, repeated surgical interventions, extensive soft-tissue defects, and, in some cases, functional impairment. These unique clinical characteristics provide valuable insight into the psychological burden carried by reconstructive surgery patients after major disasters.

Our findings suggest that demographic, social, and injury-related factors may influence psychological outcomes following earthquake-related crush injuries. Younger age was associated with higher levels of verbal aggression, depressive symptoms, and certain psychotic symptom dimensions. Similar findings have been reported in previous disaster studies, in which younger individuals were found to be more vulnerable to psychological distress and emotional dysregulation following traumatic events[16]. Younger survivors may possess fewer coping resources and less life experience when dealing with catastrophic stressors, potentially contributing to increased psychological vulnerability.

Educational attainment demonstrated a positive association with self-esteem and verbal aggression scores. Although higher educational levels are generally associated with better coping abilities, the observed increase in verbal aggression may reflect a greater tendency among educated individuals to express emotional distress verbally rather than physically[17].

Given the exploratory nature of this study, these findings should be interpreted cautiously and require confirmation in larger populations.

Male participants demonstrated significantly higher levels of depression, irritability, and both verbal and physical aggression compared with female participants. Although Previous disaster literature consistently reports increased susceptibility to anxiety and depressive symptoms among women following traumatic events. Biological, psychological, and social factors may contribute to these differences^[18,19^]. Given the small sample size and exploratory design of the present study, this sex-related finding should be interpreted cautiously and requires confirmation in larger cohorts.

The time elapsed between the earthquake and referral to our Plastic and Reconstructive Surgery Department was inversely associated with anxiety and several psychotic symptom dimensions. This observation may reflect gradual psychological adaptation and recovery over time. However, because the present study used a cross-sectional design, causal relationships cannot be established[20]. Longitudinal studies are necessary to better characterize the temporal evolution of psychological symptoms among earthquake survivors undergoing reconstructive treatment.

Medical factors also appeared to influence psychological outcomes. Increased numbers of debridement procedures were associated with higher anxiety scores. Repeated surgical interventions may contribute to uncertainty, pain, prolonged hospitalization, and concerns regarding future functional outcomes[21]. These findings highlight the importance of incorporating psychological support into the multidisciplinary management of patients requiring repeated reconstructive procedures.

Pain severity demonstrated a positive correlation with impulsivity and attention-related symptoms. Previous studies have established close relationships between pain, anxiety, depression, and psychological distress[22]. Effective pain control may, therefore, play an important role not only in physical recovery but also in psychological well-being.

Dissociative symptoms were positively associated with hostility, depression, and anxiety. Major traumatic experiences, such as earthquakes, frequently trigger dissociative responses, particularly among individuals exposed to severe injury or loss[23]. Monitoring dissociative symptoms may help identify patients at increased risk of developing persistent psychological disorders.

Patients with lower income levels demonstrated higher levels of depressive and psychotic symptom dimensions. Socioeconomic disadvantage may reduce access to psychological resources, social support, and adaptive coping strategies. Previous studies have similarly demonstrated that financial hardship is associated with increased psychological distress following disasters^[24,25^]. These findings emphasize the need for psychosocial interventions that consider socioeconomic vulnerability.

Acute stress scores differed significantly according to the loss of a close family member (P = 0.003), whereas the difference in attention scores did not reach statistical significance (P = 0.06). Given the small and unequal group sizes, particularly the limited number of participants without family loss, these findings should be interpreted cautiously.

Social support remains one of the most important protective factors following traumatic events. Consistent with previous literature, individuals reporting stronger social support generally demonstrated better psychological outcomes. Recent evidence has further emphasized the importance of coping strategies, resilience, and social integration in reducing the psychological consequences of severe stress and trauma. Psychological self-efficacy, resilience mechanisms, and culturally sensitive psychosocial interventions may contribute substantially to recovery among disaster survivors^[26–31^]. A similar pattern was observed among our patients, in which young adults without children and those who perceived greater family support experienced less anxiety and depression.

Our findings also align with recent conceptual models emphasizing the integration of mental health services into surgical and trauma care pathways. Hsu et al suggested that psychological assessment should be incorporated into routine surgical care, while Naeim and colleagues highlighted the importance of culturally adapted mental health interventions in regions affected by large-scale traumatic events. Similarly, multigenerational resilience frameworks have proposed that social support, cultural identity, and community resilience may influence psychological adaptation following disasters. These perspectives may help explain some of the associations observed in our cohort.

The present study has several limitations. First, the sample size was relatively small, which may have limited statistical power and increased the risk of Type I and Type II errors. Second, the study was conducted at a single center and included only patients referred to a plastic surgery service, potentially limiting generalizability. Third, the cross-sectional design precludes determination of causality or long-term psychological trajectories. Finally, psychological assessments were performed during a specific period of recovery and may not fully reflect long-term outcomes.

Despite these limitations, this study provides valuable preliminary evidence regarding the psychological characteristics of earthquake survivors with crush injuries undergoing reconstructive treatment. Future multicenter studies with larger sample sizes and longitudinal follow-up are needed to validate these findings and better understand the long-term psychological consequences of severe earthquake-related injuries.

Conclusion

Earthquake survivors with crush injuries treated in plastic surgery departments may experience substantial psychological distress in addition to their physical injuries. Younger age, lower socioeconomic status, loss of family members, and repeated surgical interventions appeared to be associated with less favorable psychological outcomes in this cohort. These findings should be interpreted cautiously due to the exploratory nature and limited sample size of the study. Nevertheless, they suggest that early psychological assessment and multidisciplinary psychosocial support may be beneficial components of post-disaster reconstructive care. Further large-scale prospective studies are required to confirm these observations and guide evidence-based interventions.

Ethical approval

Ankara Bilkent City Hospital Ethics Committee approved our study number E1-23-3372.

Consent

All participants were provided informed consent.

Sources of funding

None.

Author contributions

O.O.: Wrote the paper, performed the analysis; O.B.Y.: Data collection; D.T.: Data collection; B.Y.: Contributed data/analysis tools; H.M.E.: Contributed data/analysis tools; and R.E.U.: Contributed data/analysis tools.

Conflicts of interest disclosure

The authors declare that they have no commercial associations or financial interests that may pose or create a conflict of interest regarding this article.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Ozer Ozmut.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Presented at (if applicable)

None.