Abstract
In December 2019, coronavirus disease 2019 (COVID-19) appeared in Wuhan (Hubei, China) and subsequently swept the globe. In addition to the risk of infection, there is a strong possibility that post-traumatic stress disorder (PTSD) may be a secondary effect of the pandemic. Health care workers (HCWs) participating in the pandemic are highly exposed to and may bear the brunt out of stressful or traumatic events. In this cross-sectional study, we assessed the morbidity and risk factors of PTSD symptoms among Chinese HCWs. A total of 457 HCWs were recruited from March 15, 2020, to Mach 22, 2020, including HCWs in Wuhan and Hubei Province (excluding Wuhan), the areas first and most seriously impacted by COVID-19. The morbidity of PTSD symptoms was assessed by the Event Scale–Revised (IES-R). The risk factors for PTSD symptoms were explored by means of logistic regression analysis. Over 40% of the respondents experienced PTSD symptoms more than one month after the COVID-19 outbreak, and this proportion increased to 57.7% in Wuhan HCWs, especially females and HCWs on the frontline. Thus, rapid mental health assessment and effective psychological interventions need to be developed for frontline HCWs to prevent long-term PTSD-related disabilities. Moreover, Negative coping style and neuroticism personality may be regarded as high risk factors for PTSD symptoms. Improving individual coping strategies to enhance resilience should be the focus of further preventive intervention strategies.
Keywords: COVID-19, PTSD, Prevalence, Risk factors, Health care workers
1. Introduction
Exposure to a catastrophic event can have a serious impact on an individual's psychosocial functioning and quality of life through a variety of psychological problems, including severe psychological distress and tremendous emotional suffering [1]. The novel COVID-19 (Corona Virus Disease 2019) is a highly infectious disease which causing an outbreak of acute infectious pneumonia [2]. To prevent virus transmission, the Chinese government has taken a series of extreme measures, including closure cities in Hubei province from January 23, and a nationwide self-quarantine. Health care workers (HCWs), as a special population, not only cannot isolate and protect themselves at home, but also must fight at the forefront of medical work. Especially during the early break, because of the surge in patients and shortage of physicians, not just physicians of infection department, but any front-line physicians had to rescue COVID-19 patients. Nurses play a critical role in patient care, during COVID-19, they will continue to be one of the most important pillars of healthcare organizations. And for laboratory physician, a total of hundreds of thousands of nucleic acid and other testings in a short period created enormous work pressure. The other hospital staffs, although not directly dealing with patients, need to properly allocate medical resources, provide sufficient logistical supports and keep the health system from collapsing in the face of such a public health event, which maintain high quality of working life for medical staffs and can relieve their psychological stress [3]. There is no doubt that they in the epicenter of the pandemic suffered unprecedented extremely stress, high work pressure and high risk of infection which brought both physically and psychologically challenge to HCWs.
Many studies have shown psychological disorders during the pandemic of COVID-19 in HCWs [[4], [5], [6]]. Apart from the fact that physical burnout caused by heavy work can in turn worsen emotional and mental health [4], HCWs were still confronting factors that directly affect mental health. Although HCWs possessed better knowledge about COVID-19 than other population [7], the poor understanding of the viruses and spreading mechanisms during the early break will undoubtedly bring great psychological stress to the Chinese HCWs who deal with COVID-19 for the first time globally. Previous studies show that psychological disorders among HCWs affect the quality, professionality and accountability negatively for the healthcare delivery which is important for cure and rehabilitation of severely and mildly infected patients [5,6]. Evidence suggests that the anxiety, depression and self-reported stress symptoms are common psychological responses to COVID-19 infection and an increase in the incidence of symptoms of post-traumatic stress disorder (PTSD) [5]. PTSD is a frequent, tenacious, and disabling psychiatric disorder related with traumatic events, often co-occurs with depression and anxiety disorder. Evidence from the past months had indicated that stressors related to COVID-19, including economic stress, impact on routine life and academic/degree delays, were associated with anxiety symptoms in Chinese college students [8]. While women, nurses and front-line healthcare staffs working in Wuhan area, were found to be at high risk of forming unhealthy mental state, which was also found in the other COVID-19 area in the world [[9], [10], [11]]. Previous studies of other pandemic infectious diseases, including severe acute respiratory syndrome (SARS) in 2003 [12,13], novel influenza A (H1N1) in 2009 [14], and Ebola virus disease (Ebola) in 2014 [15], also found a prevalence of PTSD in survivors, and the symptoms in SARS survivors can lasting for several years [16], cause catastrophic effects on individuals.
Unlike other stressful events such as wars, accidents, etc., which lead to the direct trauma, infectious diseases may cause more hidden trauma. Due to occupational characteristics, HCWs experienced some unique stressors, including witnessing the prolonged suffering and death of COVID-19 patients, working in highly infected areas with inadequate provisions, personal risk of infection or transmission of the virus, etc [5]. Although a meta-analysis study shows that the PTSD symptoms morbidity of Chinese HCWs during the pandemic is 38% (95%CI = 34%–43%, k = 2), there is a lack of relevant research compared to other mental problems like depression, anxiety and insomnia [17] and the predictors for COVID-19 related PTSD symptoms have not yet be investigated. A number of studies have concerned about medical staff's psychological health, and appealed that positive psychological intervention is necessary [11,[18], [19], [20]]. However, how to carry out effective psychological intervention is still unclear.
The purpose of the present study was to assess morbidity of PTSD symptoms in Chinese HCWs including physicians, nurses, laboratory physicians and other staffs in China, especially those in Wuhan of Hubei province. Moreover, this study also explored the associations of demographics, social support, coping styles, and personality traits with PTSD symptoms among COVID-19-exposed Chinese HCWs. It is hoped that our findings will improve understanding of the psychological effects on HCWs involved in a rapidly spreading, life-threatening outbreak, find the vulnerable characteristics and effective psychological interventions.
2. Method
2.1. Study design and participants
The study is a cross-sectional survey conducted on HCWs in Wuhan and Hubei Province (excluding Wuhan). Using the WeChat-based survey program Questionnaire Star, a self-report questionnaire was developed to survey mental health associated with the COVID-19 outbreak, online openly accessible to the medical staff. Participants can terminate the survey at any time they desired. A sample of 512 health care workers was simple random recruited from March 15, to March 22, 2020. Incomplete questionnaires, participants outside Hubei province and those with extremely short answer time (less than 7 min) or the same answers throughout the questionnaire were invalid. The sample was grouped by profession (physician, nurse, laboratory physician, other hospital staff), by age group (younger than 30, 31 to 40, and older than 40), by working locations (Wuhan and other regions inside Hubei province), by working position (quarantine, front-line, second-line), etc. This study was approved by the Ethics Committee of Sun Yat-sen University. Prior to study participation, informed consent was obtained from all participants. The procedures in this study were in accordance with the tenets of the Declaration of Helsinki for research involving human subjects.
2.2. Measures
2.2.1. PTSD symptomatology
The PTSD symptomatology was measured by the Impact of Event Scale-Revised (IES-R). It contains 22 items, each scoring from 0 (no problems) to 4 (frequent problems), and is divided into three subscales: intrusion, avoidance, and hyperarousal. The Higher IES-R scores indicating more severe PTSD symptoms. The cut-off score used in our study is 33 based on the values established in the literature [21]. (Cronbach's α = 0.958).
2.2.2. Psychological symptoms
The Kessler Psychological Distress Scale (K10) was used to measure psychological distress symptoms. It is a 10-item scale focusing on anxiety and depression symptoms. It is a 10-item scale focus on anxiety and depression symptoms. K10 scoring range from 10 to 50, with items rated on a five-point Likert ranging from 1 (none of the time) to 5 (all of the time), with higher scoring indicating greater stress. Respondents with a total score higher than 22 risks having a mental disorder [22]. (Cronbach's α = 0.951).
2.2.3. Stressors
Both CIVOD-19 related stressors and pre-pneumonia stressors were considered in this study.
2.2.4. COVID-19-related stressors
We developed a checklist measure to assess subjects’ experience of stressful events (stressors) associated with COVID-19. Subjects indicated whether each event happened in the previous month. The checklist consisted six categories: (a) self-related events (9 items, e.g., “You are a confirmed/suspected patient with COVID-19 pneumonia”); (b) family/friend-related events (4 items, e.g., “One of your family and friends is a confirmed/suspected patient with COVID-19 pneumonia.“); (c) information-related events (1 items, “You get a lot of pandemic information from mobile phone/Internet every day.“); (d) other COVID-19-related stressors (6 items, e.g., “You have financial difficulties during the pandemic.“).
2.2.5. Pre-pneumonia stressors
Subjects were surveyed about their history of exposure to potentially traumatic events preceding the onset of pneumonia, including suffered from a major family accident (death, serious illness, serious injuries or financial bankruptcy), seriously ill or seriously injured, waiting for employment or facing unemployment, great work pressure and stained family relationship. (Cronbach's α = 0.764).
2.2.6. Personality traits
The Eysenck Personality Questionnaire-Revised Short Scale for Chinese (EPQ-RSC), translated and revised by Qian in 2000, was used assess of personality traits. It consists of 48 items and four subscales: extraversion (E), neuroticism (N), psychoticism (P) and a lie detector inventory (L), and has been demonstrated to be reliable and valid in the general population over the age of 16, including the elderly [23]. (Cronbach's α = 0.830).
2.2.7. Social support
The Social Support Rating Scale (SSRS), a 10-item self-report scale, was used to measure social support. Three dimensions of social support were measured: subjective support (4 items), objective support (3 items), and utilization of support (3 items). The higher the score, the stronger the social support. Due to its high reliability and validity, the SSRS has been widely used in China [24]. (Cronbach's α = 0.791).
2.2.8. Coping style
Coping style was measured using the Simplified Coping Style Questionnaire (SCSQ), which is a 20-item self-report scale based on a broad coping style questionnaire and revised to fit the Chinese context. The SCSQ is composed of two subscales: positive coping (12 items) and negative coping (8 items). Each item is scored ranged from 0 to 3 (0 = never, 1 = seldom, 2 = often, 3 = always). Higher scores on each subscale are an indication of the level of coping style [25]. (Cronbach's α = 0.909).
2.3. Statistical analysis
Data analysis was performed using SPSS statistical software, version 25.0 (IBMCorp). Statistical significance was defined as a two-tailed p-value less than 0.05. The original scores obtained from the instruments tools were not normally distributed. Therefore, they are presented as medians with interquartile ranges (IQRs). Frequencies, proportions, 95% CI of proportions, as well as Chi-squared test were generated to examine the relationships between demographic variables (gender, age, marriage status, place of residence, family income, locations, etc.) and PTSD symptoms. To compare the severity of each symptom between 2 or more groups, the nonparametric Mann-Whitney U test and Kruskal-Wallis test were performed. To identify potential risk factors for PTSD symptoms among participants, multivariable logistic regression analysis was used. Associations between risk factors and outcomes are presented as odds ratios (ORs) and 95%CIs, after adjustment for confounders, including sex, age, marital status, educational level, and place of residence.
3. Results
3.1. Prevalence of PTSD symptoms among Chinese HCWs and comorbidity
This study collected a total of 425 valid questionnaires. According to the 33 cut-off of IES-R, we separated the participants into a PTSD-positive group (n = 184) and a PTSD-negative group (n = 241). And there were participants met the cut-off of K10 for psychological disorder (Fig. 1). Therefore, most participants with PTSD symptoms also experience anxiety and depression.
Fig. 1.
The morbidity of COVID-19 associated PTSD and Percentage of psychological disorder among the samples with PTSD.
3.2. Sociodemographic factors related to PTSD symptoms
The 425 valid questionnaires were from 266 females (62.6%) and 159 males (37.4%), with a mean age of 36.90 years old. Most participants were married (358 [84.2%]), had an education level of undergraduate (327 [76.9%]), lived with family (295 [69.4%]), lived in urban areas (397 [93.4%]), had annual family income between 50, 000 to 100, 000 RMB (210 [49.4%]). The subjects comprised of 163 HCWs worked (38.4%) in Wuhan, 262 (61.6%) worked in Hubei province outside Wuhan. They have different occupations, 187 (44.0%) physicians, 169 (39.8%) nurses, 40 (9.4%) laboratory physicians and 29 (6.8%) other staffs, respectively. Of the participants, 228 (53.6%) participants were frontline HCWs directly involved in diagnosis, treatment, or care of patients with or at suspicion of COVID-19 or contacting with samples of COVID-19, 143 (33.6%) participants were second-line, and other 54 (12.7%) participants were under quarantine (Table 1). Our results indicate that, PTSD symptoms was associated with sex, working location and positions among the sociodemographic factors (Table 1). In particular, more severe PTSD symptoms were reported by female, frontline workers, and those in Wuhan.
Table 1.
Demographic characteristics and relation to PTSD symptoms morbidity.
| Characteristic | Total | No. (%) |
χ2 | P | |
|---|---|---|---|---|---|
| PTSD-negative | PTSD-positive | ||||
| Overall | |||||
| Gender | |||||
| Men | 159 (37.4) | 100 (62.9) | 59 (37.1) | 3.961 | 0.047 |
| Women | 266 (62.6) | 141 (53.0) | 125 (47.0) | ||
| Age | |||||
| ≤30 | 114 (26.8) | 72 (63.2) | 42 (36.8) | 3.366 | 0.186 |
| 31-40 | 168 (39.5) | 95 (56.5) | 73 (43.5) | ||
| ＞40 | 143 (33.6) | 74 (51.7) | 69 (48.3) | ||
| Marriage status | |||||
| Unmarried | 67 (15.8) | 45 (67.2) | 22 (32.8) | 3.544 | 0.060 |
| Married | 358 (84.2) | 196 (54.7) | 162 (45.3) | ||
| Education level | |||||
| High school | 28 (6.6) | 15 (53.6) | 13 (46.4) | 0.171 | 0.918 |
| Undergraduate | 327 (76.9) | 187 (57.2) | 140 (42.8) | ||
| Postgraduate | 70 (16.5) | 39 (55.7) | 31 (44.3) | ||
| Residence | |||||
| Urban | 397 (93.4) | 224 (56.4) | 173 (43.6) | 0.196 | 0.658 |
| Rural | 28 (6.6) | 17 (60.7) | 11 (39.3) | ||
| Living arrangement | |||||
| Living alone | 84 (19.8) | 46 (54.8) | 38 (45.2) | 0.211 | 0.900 |
| Living with family | 295 (69.4) | 168 (56.9) | 127 (43.1) | ||
| Others | 46 (10.8) | 27 (58.7) | 19 (41.3) | ||
| Annual family income | |||||
| ≤50, 000 RMB | 86 (20.2) | 52 (60.5) | 34 (39.5) | 1.854 | 0.603 |
| 50, 000–100,000 RMB | 210 (49.4) | 120 (57.1) | 90 (42.9) | ||
| 100, 000–200,000 RMB | 93 (21.9) | 52 (55.9) | 41 (44.1) | ||
| ＞200,000 RMB | 36 (8.5) | 17 (47.2) | 19 (52.8) | ||
| Working location | |||||
| Wuhan | 163 (38.4) | 69 (42.3) | 94 (57.7) | 22.254 | <0.001 |
| Huber province (excluding Wuhan) | 262 (61.6) | 172 (65.6) | 90 (34.4) | ||
| Occupation | |||||
| Physician | 187 (44.0) | 106 (56.7) | 81 (43.3) | 0.471 | 0.925 |
| Nurse | 169 (39.8) | 96 (56.8) | 73 (43.2) | ||
| laboratory physician | 40 (9.4) | 24 (60.0) | 16 (40.0) | ||
| Others | 29 (6.8) | 17 (54.8) | 14 (45.2) | ||
| Working position | |||||
| Front line | 228 (53.6) | 118 (51.8)a | 110 (48.2)a | 8.307 | 0.016 |
| Second-line | 143 (33.6) | 95 (66.4)b | 48 (33.6)b | ||
| Quarantine | 54 (12.7) | 28 (51.9)a,b | 26 (48.1)a,b | ||
3.3. Stressful events associated with COVID-19 related PTSD symptoms
Among the 425 HCWs, about 96.0% reported getting a lot of pandemic information from mobile phone/Internet every day (Table 2). A considerable proportion of participants reported suffering work-related stresses (e.g. over 80.0% reported that their work during pandemic was related to fighting the pandemic and that they were at risk of infection from this, high work pressure (69.9%), have met confirmed/suspected patients with COVID-19 pneumonia (68.9%)). Other stressors more than half participants reported included life pattern changed (70.1%), separation from family (lover) (67.1%), and met with confirmed/suspected patients (52.2%). Regarding event exposures, work exposure, and relatives or friends got pneumonia were all strongly associated with high PTSD symptoms. In detail, respondents who had experience high work pressure or lost family or friends due to COVID-19 pneumonia were especially more likely to report PTSD symptoms (OR = 4.46, 95%CI 2.74–7.26, P < 0.001; OR = 4.31, 95%CI 1.79–10.37, P < 0.001). The experience of front-line work including met/close contact with confirmed/suspected patients was more likely to report PTSD symptoms (OR = 1.93, 95%CI 1.30–2.85, P = 0.001, OR = 2.17, 95%CI 1.43–3.28, P < 0.001). Those participants reported changed life pattern showed higher PTSD symptoms than those who did not (OR = 2.77, 95%CI 1.76–4.36, P < 0.001). Participants under great pressure to work before the pandemic were more tend to report PTSD symptoms (OR = 2.22, 95%CI 1.48–3.29, P < 0.001).
Table 2.
Influence of stressful events on COVID-19 related PTSD symptoms morbidity.
| No. (%) |
OR (95%CI) | P | |||
|---|---|---|---|---|---|
| Response Yes | PTSD-negative | PTSD-positive | |||
| CIVOD-19 related stressors | |||||
| You get a lot of epidemic information from mobile phone/Internet every day. | |||||
| Yes | 408 (96.0) | 229 (56.1) | 179 (43.9) | 1.88 (0.65–5.42) | 0.238 |
| No | 12 (70.6) | 5 (29.4) | |||
| Your work during the epidemic is related to fighting the epidemic. | |||||
| Yes | 366 (86.1) | 207 (56.6) | 159 (43.4) | 1.05 (0.60–1.82) | 0.878 |
| No | 34 (57.6) | 25 (42.4) | |||
| You are at risk of getting infected because of your work during the epidemic. | |||||
| Yes | 353 (83.1) | 199 (56.4) | 154 (43.6) | 1.09 (0.65–1.81) | 0.760 |
| No | 42 (58.3) | 30 (41.7) | |||
| Your life pattern has changed significantly during the epidemic. | |||||
| Yes | 298 (70.1) | 148 (49.7) | 150 (50.3) | 2.77 (1.76–4.36) | <0.001 |
| No | 93 (73.2) | 34 (26.8) | |||
| Your work pressure during the epidemic is very high. | |||||
| Yes | 297 (69.9) | 139 (46.8) | 158 (53.2) | 4.46 (2.74–7.26) | <0.001 |
| No | 102 (79.7) | 26 (20.3) | |||
| You may have met confirmed/suspected patients with COVID-19 pneumonia. | |||||
| Yes | 293 (68.9) | 155 (52.9) | 138 (47.1) | 1.67 (11.09–2.55) | 0.018 |
| No | 86 (65.2) | 46 (34.8) | |||
| You cannot be reunited with your family (lover) during the epidemic | |||||
| Yes | 285 (67.1) | 158 (55.4) | 127 (44.6) | 1.17 (0.78–1.76) | 0.452 |
| No | 83 (59.3) | 57 (40.7) | |||
| You have met confirmed/suspected patients with COVID-19 pneumonia. | |||||
| Yes | 222 (52.2) | 109 (49.1) | 113 (50.9) | 1.93 (1.30–2.85) | 0.001 |
| No | 132 (65.0) | 71 (35.0) | |||
| You have financial difficulties during the epidemic. | |||||
| Yes | 136 (32.0) | 65 (47.8) | 71 (52.2) | 1.70 (1.13–2.51) | 0.011 |
| No | 176 (60.9) | 113 (39.1) | |||
| You are a close contact of patients with COVID-19 pneumonia. | |||||
| Yes | 139 (32.7) | 61 (43.9) | 78 (56.1) | 2.17 (1.43–3.28) | <0.001 |
| No | 180 (62.9) | 106 (37.1) | |||
| Your relatives and friends are informed to forced home stay/designated place isolation observation. | |||||
| Yes | 118 (27.8) | 52 (44.1) | 66 (55.9) | 2.03 (1.32–3.13) | 0.001 |
| No | 189 (61.6) | 118 (38.4) | |||
| Someone of your family and friends are confirmed/suspected patient with COVID-19 pneumonia. | |||||
| Yes | 88 (20.7) | 35 (39.8) | 53 (60.2) | 2.38 (1.47–3.85) | <0.001 |
| No | 206 (61.1) | 131 (38.9) | |||
| You have been informed of forced home stay/designated place isolation observation. | |||||
| Yes | 71 (16.7) | 35 (49.3) | 36 (50.7) | 1.43 (0.86–2.38) | 0.167 |
| No | 206 (58.2) | 148 (41.8) | |||
| Your relationship with your family was strained during the epidemic. | |||||
| Yes | 64 (15.1) | 25 (39.1) | 39 (60.9) | 2.32 (1.35–4.01) | 0.002 |
| No | 216 (59.8) | 145 (40.2) | |||
| You experienced fever, cough and other COVID-19 pneumonia symptoms during the epidemic. | |||||
| Yes | 55 (12.9) | 20 (36.4) | 35 (63.6) | 2.60 (1.44–4.67) | 0.001 |
| No | 221 (59.7) | 149 (40.3) | |||
| Someone in your family or friends died of COVID-19 pneumonia | |||||
| Yes | 28 (6.6) | 7 (25.0) | 21 (75.0) | 4.31 (1.79–10.37) | <0.001 |
| No | 234 (58.9) | 163 (41.1) | |||
| You are a confirmed/suspected patient with COVID-19 pneumonia. | |||||
| Yes | 17 (4.0) | 6 (35.3) | 11 (64.7) | 2.49 (0.90–6.86) | 0.069 |
| No | 235 (57.6) | 173 (42.4) | |||
| You are waiting for employment during the epidemic. | |||||
| Yes | 8 (1.9) | 3 (37.5) | 5 (62.5) | 2.22 (0.52–9.40) | 0.455 |
| No | 238 (57.1) | 179 (42.9) | |||
| Someone in your family or friends suffered serious injuries, natural disasters and other accidents. | |||||
| Yes | 8 (1.9) | 3 (37.5) | 5 (62.5) | 2.22 (0.52–9.40) | 0.455 |
| No | 238 (57.1) | 179 (42.9) | |||
| Pre-CIVOD-19 stressors | |||||
| You were under great pressure to work before the epidemic. | |||||
| Yes | 165 (38.8) | 74 (44.8) | 91 (55.2) | 2.21 (1.48–3.29) | <0.001 |
| No | 187 (64.2) | 93 (35.8) | |||
| You suffered a major family accident (death, serious illness, serious injuries or financial bankruptcy) before the epidemic. | |||||
| Yes | 34 (8.0) | 15 (44.1) | 19 (55.9) | 1.74 (0.86–3.52) | 0.122 |
| No | 226 (57.8) | 165 (42.2) | |||
| Your relationship with your family was strained before the epidemic. | |||||
| Yes | 20 (4.7) | 11 (55.0) | 9 (45.0) | 1.08 (0.44–2.65) | 0.875 |
| No | 230 (56.8) | 175 (43.2) | |||
| You were seriously ill or seriously injured before the epidemic. | |||||
| Yes | 9 (2.1) | 2 (22.2) | 7 (77.8) | 4.73 (0.97–23.02) | 0.077 |
| No | 239 (57.5) | 177 (42.5) | |||
| You were waiting for employment or facing unemployment before the epidemic. | |||||
| Yes | 8 (1.9) | 4 (50.0) | 4 (50.0) | 1.32 (0.33–5.34) | 0.979 |
| No | 237 (56.8) | 180 (43.2) | |||
3.4. Risk factors of COVID-19 related PTSD symptoms
No significant difference in social support was found between PTSD-positive and -negative participants, no matter subjective support, objective support or utilization of support. In coping behaviors, those PTSD positive respondents reported more negative coping and positive coping style (Z = 8.705, 3.837, P < 0.001). And the neuroticism personality traits in PTSD-positive respondents were higher than PTSD-negative respondents (Z = 7.120, P < 0.001) (Table 3).
Table 3.
Social support, coping style and personality in participants.
| PTSD-negative |
PTSD-positive |
|||||
|---|---|---|---|---|---|---|
| Median | P25, P75 | Median | P25, P75 | Z | P | |
| SSRS total score | 38.0 | 34.0, 44.0 | 37.5 | 34.0, 42.0 | −0.951 | 0.342 |
| Subjective support | 22.0 | 18.0, 25.0 | 22.0 | 19.0, 24.0 | −0.016 | 0.987 |
| Objective support | 9.0 | 7.0, 12.0 | 9.0 | 6.0, 11.0 | −1.524 | 0.128 |
| Utilization of support | 8.0 | 7.0, 9.0 | 7.0 | 6.0, 9.0 | −1.080 | 0.280 |
| Positive coping style | 22.0 | 15.0, 27.0 | 24.0 | 19.0, 29.0 | 3.837 | <0.001 |
| Negative coping style | 7.0 | 4.0, 10.5 | 12.0 | 8.25, 16.0 | 8.705 | <0.001 |
| Extraversion | 50.67 | 42.48, 58.42 | 49.48 | 41.29, 58.42 | −0.840 | 0.401 |
| Neuroticism | 48.85 | 42.07, 58.69 | 62.07 | 51.76, 69.07 | 7.120 | <0.001 |
| Psychoticism | 46.26 | 42.09, 51.76 | 46.26 | 40.78, 51.91 | −0.280 | 0.780 |
Data was shown as median with interquartile range and tested by Mann-Whitney U test.
To further elucidate the relation among sociodemographic factors, social support, coping strategies, personality and PTSD symptom levels, logistic regression analyses were performed (Table 4). Coping style was added into the regression equation, avoidant coping predicted PTSD symptoms (OR = 1.209, 95%CI 1.154–1.267, P＜0.001) in model 1. In model 2, personality was added in, and neuroticism was found to be another risk factor related to PTSD symptoms (OR = 1.045, 95%CI 1.024–1.066, P＜0.001). In model 3, working location was added in and working in Hubei province outside Wuhan was related to a lower risk of PTSD symptoms than working in Wuhan (OR = 0.426, 95%CI 0.271–0.669, P＜0.001). Among these risk factors, working location and neuroticism belong to pre-trauma factor, while avoidant coping style belongs to post-trauma factors.
Table 4.
Logistic regression analysis of the morbidity of COVID-19 related PTSD symptoms among Chinese health care workersa.
| Model 1 | Model 2 | Model 3 | |
|---|---|---|---|
| Factors | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) |
| Negative coping style | 1.209 (1.154–1.267)b | 1.173 (1.117–1.233)b | 1.165 (1.109–1.225)b |
| Neuroticism | N/A | 1.045 (1.024–1.066)b | 1.046 (1.025–1.067)b |
| Working location | N/A | N/A | 0.426 (0.271–0.669)b |
Univariate binary logistic regression (α = 0.10) was used to exclude the education level, occupation, place of residence, living arrangement, subjective support, family income, psychoticism, extraversion, objective support and utilization of support. Factors to enter to stepwise forward binary logistic regression include gender, age, marriage status, working location, working position, neuroticism, positive coping style and negative coping style.
P < 0.001.
4. Discussion
This study evaluated 425 HCWs inside Wuhan and Hubei province excluding Wuhan one month after the outbreak of novel coronavirus pneumonia. Previous studies about COVID-19 mostly focused on participants' emotion problems such as anxiety and depression [8,10], because to diagnose PTSD symptoms, patients must have experienced re-experiencing, avoidance and arousal symptoms for at least 1 month, and their study sampled from January 29, 2020, to February 3, 2020, which was early in the pneumonia outbreak and people were still in the acute stress response stage. Our research revealed that nearly 43.3% participants reported suffering tremendous psychological stress, may even meet PTSD symptoms. The ratio was much higher than the earthquake-associated PTSD (from 15.6% to 24.2%) [26,27] and flood-associated PTSD (15.4%) [28]. Stressful events like earthquakes and floods were often happened unexpectedly, and much more devastating and destructive than infectious diseases. But the trauma caused by infectious is much more unpredictable, which might bring more damage to one's psychology.
Our results also suggested that female, frontline worker, and those in Wuhan were related to PTSD symptoms, acted as the strongest predictor of PTSD. Working in Wuhan was found to be associated with a higher risk of PTSD symptoms in multivariable logistic regression analysis. There is no doubt that HCWs in the epicenter of the pandemic suffered more stress, particularly those who directly contact with COVID-19 patients, and was at especially high risk for infection, their mental health may require special attention. It seems women are much more likely to develop PTSD symptoms, not only in our health care worker samples, evidences were also found from a subsample of the National Comorbidity Survey [29], Italy sample [30], SARS survivors [16] and even rodent studies which showed higher proportions of hippocampal oligodendrocytes with sex difference in rat model of PTSD [31]. The underlying mechanism may involve biochemical and hormonal alterations related to gender. Corticosteroid-induced activation of the HPA axis and production of proinflammatory cytokines were found to differ by sex when people were exposed to stress [32]. Also, higher estrogen levels were associated with negative memories in women [33], while lower testosterone might predict the development of PTSD [34]. Therefore, we need to pay more attention to female, frontline HCWs in Wuhan, and preventive and therapeutic strategies of PTSD symptoms are needed to take into account.
Our findings indicate that exposure to the pandemic outbreak at work, work pressure, and relative or friend got pneumonia were all strongly associated with high PTSD symptoms. In particular, the experiences of high work pressure/lost family or friends due to COVID-19 pneumonia contributed extraordinarily to developing PTSD symptoms, consistent with one previous SARS study [35]. Other work exposure events related to morbidity of PTSD symptoms including met/close contact with confirmed/suspected patients. In addition, changed life pattern was another event related with PTSD symptoms, a relatively fixed lifestyle provides comfort and security, while a changed life pattern generates anxiety and fear. On the other hand, media exposure was reported especially common in our study, but seems unrelated to PTSD symptoms, which is contrary to previous finding [36]. Besides the COVID-19 related events, one event related to COVID-19 is work pressure. Maternal deprivation improves contextual fear memory in adulthood, this phenomenon was found in our previous study. Maternal deprivation is the first stress, and contextual shock is considered as a second-hit stress. The enhanced contextual fear memory showed that second-hit stress enhances the susceptibility of PTSD [27]. The enhanced contextual fear memory showed that second-hit stress enhances the susceptibility of PTSD [37]. Over one third of participant reported under great pressure to work prior to the pandemic, and this proportion increased to two thirds during pandemic. High work pressure and high risk of infection brought both physically and psychologically challenge to HCWs. They deserve to be treated gently by the world.
Social support, generally defined as the belief that someone is cared about, loved, esteemed and has available assistance, has been found to have the ability to reduce stress and depression and improve health, and is therefore understood to be a protective factor for individuals who have experienced trauma [38]. While poor social support maybe a robust predictor of psychiatric morbidity following trauma exposure, including PTSD [39], depression [40] and anxiety disorders [41]. Numerous studies had emphasized the role of social support in the development of PTSD, most of them suggested that social support and PTSD are negatively related, that is, increased social support might result in lower PTSD symptomatology, while decreased social support might result in higher PTSD symptoms following trauma [42]. The assessment of the nursers in emergency room, intensive care unit, and general ward has reported that the social support plays an important part in coping with work-related stress [43]. However, this study failed to find any significant differences between PTSD-negative and PTSD-positive group, no matter in SSRS total score, subjective support, objective support or utilization of support. And none of them was entered into the regression equation either. One possible reason is that at the early stage of the outbreak, medical staffs faced great pressure, but also received an unprecedented number of social recognition and support at the same time. Since PTSD symptoms and social support may interact over time [44], the severe PTSD symptoms found in our study may decrease social support in future, which could further increase PTSD symptoms. Thus, the pneumonia pandemic of people is coming to an end, but the psychological pandemic of medical workers may just begin. We hope that the love for the medical staff will go on.
Coping behaviors can be categorized into positive coping and negative coping, with high levels of positive coping typically associated with less psychological distress, conversely, high levels of negative coping typically associated with greater psychological distress and depressive symptoms [45]. One study about Chinese healthcare workers exposed to physical violence showed that the coping styles influenced the development of PTSD symptoms [46]. Other studies have found that negative coping styles are associated with mental health problems, including a recent article on the impact of COVID-19 on adolescents [47,48]. Specifically, negative, avoidance-focused coping was a predictor of tendency to PTSD symptoms [49], while positive coping strategies are positively associated with resiliency [50]. In the present research, coping style is an important mediating factor between the stress associated with COVID-19 and the symptoms of PTSD, especially the negative coping style. Thus, strengthening individual coping strategies to enhance resilience should be a focus of further prevention and intervention strategies.
Another risk factor for PTSD symptoms found in this study is neuroticism, one of the major temperamental basic personality traits, characterized by a negative emotional response to threat or negative affectivity. Personality may directly and indirectly impact responses to external stimuli through coping strategies, cognitive and social support processes [51]. And neuroticism and introversion are more likely to lead to PTSD as reported in earthquake student survivors and fire fighters [[51], [52], [53]]. Our results were consistent with many other studies in various contexts such as road traffic accidents, former peacekeepers and earthquake survivors, which suggested that personality characteristics, especially neuroticism, positively associated with the prevalence of PTSD symptoms [54,55]. Studies focusing on the relationship of personality traits and coping processes has indicted that neuroticism are positively associated with avoidance coping [56]. Neurotic people may tend to view the COVID-19 outbreak as occurring more negatively and threateningly, report more worries and stressors in their daily routine, decrease mental resilience, and have more trouble coping with stressful situations [57]. So it is necessary to attach more importance to these neurotic medical staff.
4.1. Advantages and limitations
The strengths of our study is our systematically consideration about risk factors for PTSD symptoms, including sociodemographic factors, pre-COVID-19 stressful events, COVID-19 related stressful events, social support, coping strategies, and personality. Limitations are our small sample and online self-report questionnaires design, and follow-up studies are needed.
5. Conclusions
In sum, this study suggests that after experiencing COVID-19 the incidence of PTSD symptoms among HCWs is 43.3%, especially for those women, worked in Wuhan and front-line. According to the intangible and long-lasting stress characteristics associated with the COVID-19 pandemic, rapid mental health assessment and effective psychological interventions need to be developed for those HCWs with vulnerable characteristics and key stressors to improve individual coping strategies. We suggest that more social support should be provided and particular attention should be paid to HCWs to prevent long-term PTSD-related disabilities.
Author contribution statement
Li Xue: Conceived and designed the experiments; Contributed reagents, materials, analysis tools or data; Wrote the paper.
Qi Li; Wei Liu; Jie-Yu Wang: Performed the experiments; Analyzed and interpreted the data; Wrote the paper.
Xiao-Guang Wang; Xi Deng: Analyzed and interpreted the data.
Bo Hao; Yu-Bo Hu; Lu Liu: Performed the experiments.
Hu Zhao; Yan-Wei Shi: Conceived and designed the experiments; Contributed reagents, materials, analysis tools or data.
Funding statement
This work was supported by National Natural Science Foundation of China [81601652, 81530061].
Data availability statement
Data included in article/supplementary material/referenced in article.
Declaration of interest’s statement
The authors declare no conflict of interest.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.heliyon.2023.e14415.
Contributor Information
Hu Zhao, Email: zhaohu3@mail.sysu.edu.cn.
Yan-Wei Shi, Email: shiyanw@mail.sysu.edu.cn.
Li Xue, Email: xueli6@smu.edu.cn.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
References
- 1.McMillan K.A., Asmundson G.J., Sareen J. Comorbid PTSD and social anxiety disorder: associations with quality of life and suicide attempts. J. Nerv. Ment. Dis. 2017;205:732–737. doi: 10.1097/NMD.0000000000000704. [DOI] [PubMed] [Google Scholar]
- 2.Bao Y., Sun Y., Meng S., Shi J., Lu L. 2019-nCoV epidemic: address mental health care to empower society. Lancet. 2020;395(10224):e37–e38. doi: 10.1016/S0140-6736(20)30309-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Aminizadeh M., Saberinia A., Salahi S., et al. Quality of working life and organizational commitment of Iranian pre-hospital paramedic employees during the 2019 novel coronavirus outbreak. Int. J. Healthc. Manag. 2021;15(1):36–44. [Google Scholar]
- 4.Jamebozorgi M.H., Karamoozian A., Bardsiri T.I., et al. Nurses burnout, resilience, and its association with socio-demographic factors during COVID-19 pandemic. Front. Psychiatr. 2022;12 doi: 10.3389/fpsyt.2021.803506. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Sahebi a, Yousefi a, Abdi k, et al. The prevalence of post-traumatic stress disorder among health care workers during the COVID-19 pandemic: an umbrella review and meta-analysis. Front. Psychiatr. 2021;12 doi: 10.3389/fpsyt.2021.764738. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Sheikhbardsiri H., Doustmohammadi M.M., Afshar P.J., et al. Anxiety, stress and depression levels among nurses of educational hospitals in Iran: time of performing nursing care for suspected and confirmed COVID-19 patients. J. Educ. Health Promot. 2021;10:447. doi: 10.4103/jehp.jehp_1319_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Sahebi A., Golitaleb M., Aliakbari F., et al. The knowledge, attitudes, and practice (KAP) of the Iranian public towards COVID-19: a systematic review. Disaster Emerg. Med. J. 2021;6(4):186–193. [Google Scholar]
- 8.Cao W., Fang Z., Hou G., Han M., Xu X., Dong J., Zheng J. The psychological impact of the COVID-19 epidemic on college students in China. Psychiatr. Res. 2020;287 doi: 10.1016/j.psychres.2020.112934. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Heidarijamebozorgi M., Jafari H., Sadeghi R., et al. The prevalence of depression, anxiety, and stress among nurses during the coronavirus disease 2019: a comparison between nurses in the frontline and the second line of care delivery. Nur. Midwif. Stud. 2021;10(3):188–193. [Google Scholar]
- 10.Lai J., Ma S., Wang Y., Cai Z., Hu J., Wei N., et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw. Open. 2020;3(3) doi: 10.1001/jamanetworkopen.2020.3976. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Wu W., Zhang Y., Wang P., Zhang L., Wang G., Lei G., et al. Psychological stress of medical staffs during outbreak of COVID-19 and adjustment strategy. J. Med. Virol. 2020 doi: 10.1002/jmv.25914. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Lee A.M., Wong J.G., McAlonan G.M., Cheung V., Cheung C., Sham P.C., et al. Stress and psychological distress among SARS survivors 1 year after the outbreak. Can. J. Psychiatr. 2007;52:233–240. doi: 10.1177/070674370705200405. [DOI] [PubMed] [Google Scholar]
- 13.Wu K.K., Chan S.K., Ma T.M. Posttraumatic stress after SARS. Emerg. Infect. Dis. 2005;11(8):1297–1300. doi: 10.3201/eid1108.041083. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Yeung N.C.Y., Lau J.T.F., Choi K.C., Griffiths S. Population responses during the pandemic phase of the influenza A (H1N1) pdm09 Epidemic, Hong Kong, China. Emerg. Infect. Dis. 2017;23:813–815. doi: 10.3201/eid2305.160768. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Keita M.M., Taverne B., Sy Savané S., March L., Doukoure M., Sow M.S., et al. Depressive symptoms among survivors of Ebola virus disease in Conakry (Guinea): preliminary results of the PostEboGui cohort. BMC Psychiatr. 2017;17(1):127. doi: 10.1186/s12888-017-1280-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Mak I.W.C., Chu C.M., Pan P.C., Yiu M.G., Ho S.C., Chan V.L. Risk factors for chronic post-traumatic stress disorder (PTSD) in SARS survivors. Gen. Hosp. Psychiatr. 2010;(6):590–598. doi: 10.1016/j.genhosppsych.2010.07.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Yan H., Ding Y., Guo W. Mental health of medical staff during the coronavirus disease 2019 pandemic: a systematic review and meta-analysis. Psychosom. Med. 2021;83(4):387–396. doi: 10.1097/PSY.0000000000000922. [DOI] [PubMed] [Google Scholar]
- 18.Chew N.W.S., Lee G.K.H., Tan B.Y.Q., Jing M., Goh Y., Ngiam N.J.H., et al. A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak. Brain Behav. Immun. 2020 doi: 10.1016/j.bbi.2020.04.049. S0889–1591(20)30523-30527. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Wu K., Wei X. Analysis of psychological and sleep status and exercise rehabilitation of front-line clinical staff in the fight against COVID-19 in China. Med. Sci. Monit. Basic Res. 2020;26 doi: 10.12659/MSMBR.924085. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Jin Y.H., Huang Q., Wang Y.Y., Zeng X.T., Luo L.S., Pan Z.Y., et al. Perceived infection transmission routes, infection control practices, psychosocial changes, and management of COVID-19 infected healthcare workers in a tertiary acute care hospital in Wuhan: a cross-sectional survey. Mil. Med. Res. 2020;7(1):24. doi: 10.1186/s40779-020-00254-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Creamer M., Bell R., Failla S. Psychometric properties of the impact of event scale-revised. Behav. Res. Ther. 2003;41(12):1489–1496. doi: 10.1016/j.brat.2003.07.010. [DOI] [PubMed] [Google Scholar]
- 22.Andrews G., Slade T. Interpreting scores on the kessler psychological distress scale (K10) Aust. N. Z. J. Publ. Health. 2001;25(6):494–497. doi: 10.1111/j.1467-842x.2001.tb00310.x. [DOI] [PubMed] [Google Scholar]
- 23.Qian M., Wu G., Zhu R., Zhang S. A revised version of Eysenck personality questionnaire short form scale Chinese version (EPQRSC) Acta Psychol. Sin. 2000;32:317–323. (in Chinese) [Google Scholar]
- 24.Xiao S., Yang D. The effect of social support on physical and psychological health. J. Chin. Psych. 1987;1:183–187. (in Chinese) [Google Scholar]
- 25.Sun P., Sun Y., Jiang H. Gratitude and problem behaviors in adolescents: the mediating roles of positive and negative coping styles. Front. Psychol. 2019;10:1547. doi: 10.3389/fpsyg.2019.01547. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Wang X., Gao L., Shinfuku N., Zhang H., Zhao C., ShenY Longitudinal study of earthquake-related PTSD in a randomly selected community sample in north China. Am. J. Psychiatr. 2000;157:1260–1266. doi: 10.1176/appi.ajp.157.8.1260. [DOI] [PubMed] [Google Scholar]
- 27.Zhou X., Kang L., Sun X., Song H., Mao W., Huang X., et al. Prevalence and risk factors of post-traumatic stress disorder among adult survivors six months after the Wenchuan earthquake. Compr. Psychiatr. 2013;54:493–499. doi: 10.1016/j.comppsych.2012.12.010. [DOI] [PubMed] [Google Scholar]
- 28.Hu S., Tan H., Cofie R., Zhou J., Yang T., Tang X., et al. Recovery from posttraumatic stress disorder after a flood in China: a 13-year follow-up and its prediction by degree of collective action. BMC Publ. Health. 2015;15:615. doi: 10.1186/s12889-015-2009-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Kessler R.C., Sonnega A., Bromet E., Hughes M., Nelson C.B. Posttraumatic stress disorder in the national comorbidity survey. Arch. Gen. Psychiatr. 1995;52(12):1048–1060. doi: 10.1001/archpsyc.1995.03950240066012. [DOI] [PubMed] [Google Scholar]
- 30.Carmassi C., Dell'Osso L., Manni C., Candini V., Dagani J., Iozzino L., et al. Frequency of trauma exposure and post-traumatic stress disorder in Italy: analysis from the World Mental Health Survey Initiative. J. Psychiatr. Res. 2014;59:77–84. doi: 10.1016/j.jpsychires.2014.09.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Kim G.S., Uddin M. Sex-specific and shared expression profiles of vulnerability and resilience to trauma in brain and blood. Biol. Sex Differ. 2020;11(1):13. doi: 10.1186/s13293-020-00288-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Mendoza C., Barreto G.E., Ávila-Rodriguez M., Echeverria V. Role of neuroinflammation and sex hormones in war-related PTSD. Mol. Cell. Endocrinol. 2016;434:266–277. doi: 10.1016/j.mce.2016.05.016. [DOI] [PubMed] [Google Scholar]
- 33.Cheung J., Chervonsky L., Felmingham K.L., Bryant R.A. The role of estrogen in intrusive memories. Neurobiol. Learn. Mem. 2013;106:87–94. doi: 10.1016/j.nlm.2013.07.005. [DOI] [PubMed] [Google Scholar]
- 34.Reijnen A., Geuze E., Vermetten E. The effect of deployment to a combat zone on testosterone levels and the association with the development of posttraumatic stress symptoms: a longitudinal prospective Dutch military cohort study. Psychoneuroendocrinology. 2015;51:525–533. doi: 10.1016/j.psyneuen.2014.07.017. [DOI] [PubMed] [Google Scholar]
- 35.Wu P., Fang Y., Guan Z., Fan B., Kong J., Yao Z., et al. The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk. Can. J. Psychiatr. 2009;54(5):302–311. doi: 10.1177/070674370905400504. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Collimore K.C., McCabe R.E., Carleton R.N., Asmundson G.J. Media exposure and dimensions of anxiety sensitivity: differential associations with PTSD symptom clusters. J. Anxiety Disord. 2008;22(6):1021–1028. doi: 10.1016/j.janxdis.2007.11.002. [DOI] [PubMed] [Google Scholar]
- 37.Wang R.H., Chen Y.F., Chen S., Hao B., Xue L., Wang X.G., et al. Maternal deprivation enhances contextual fear memory via epigenetically programming second-hit stress-induced Reelin expression in adult rats. Int. J. Neuropsychopharmacol. 2018;21(11):1037–1048. doi: 10.1093/ijnp/pyy078. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Neria Y., Suh E.J., Marshall R.D. In: The Professional Response to the Aftermath of September 11, 2001, in New York City: Lessons Learned from Treating Victims of the World Trade Center Attacks, in Early Intervention for Trauma and Traumatic Loss. Litz B.T., editor. Guilford Press; New York (NY): 2004. [Google Scholar]
- 39.Evans S.E., Steel A.L., DiLillo D. Child maltreatment severity and adult trauma symptoms: does perceived social support play a buffering role? Child Abuse Negl. 2013;37:934–943. doi: 10.1016/j.chiabu.2013.03.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Lin J., Su Y., Lv X., Liu Q., Wang G., Wei J., et al. Perceived stressfulness mediates the effects of subjective social support and negative coping style on suicide risk in Chinese patients with major depressive disorder. J. Affect. Disord. 2020;265:32–38. doi: 10.1016/j.jad.2020.01.026. [DOI] [PubMed] [Google Scholar]
- 41.Wang J., Mann F., Lloyd-Evans B., Ma R., Johnson S. Associations between loneliness and perceived social support and outcomes of mental health problems: a systematic review. BMC Psychiatr. 2018;18(1):156. doi: 10.1186/s12888-018-1736-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Dworkin E.R., Ullman S.E., Stappenbeck C., Brill C.D., Kaysen D. Proximal relationships between social support and PTSD symptom severity: a daily diary study of sexual assault survivors. Depress. Anxiety. 2018;35(1):43–49. doi: 10.1002/da.22679. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.Kerasiotis B., Motta R.W. Assessment of PTSD symptoms in emergency room, intensive care unit, and general floor nurses. Int. J. Emerg. Ment. Health. 2004;6:121–133. [PubMed] [Google Scholar]
- 44.Shallcross S.L., Arbisi P.A., Polusny M.A., Kramer M.D., Erbes C.R. Social causation versus social erosion: comparisons of causal models for relations between support and PTSD symptoms. J. Trauma Stress. 2016;29:75–82. doi: 10.1002/jts.22086. [DOI] [PubMed] [Google Scholar]
- 45.Compas B.E., Connor-Smith J.K., Saltzman H., Thomsen A.H., Wadsworth M.E. Coping with stress during childhood and adolescence: problems, progress, and potential in theory and research. Sychol Bull. 2001;127(1):87–127. [PubMed] [Google Scholar]
- 46.Shi L., Wang L., Jia X., Li Z., Mu H., Liu X., et al. Prevalence and correlates of symptoms of post-traumatic stress disorder among Chinese healthcare workers exposed to physical violence: a cross-sectional study. BMJ Open. 2017;7(7) doi: 10.1136/bmjopen-2017-016810. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47.Wright M., Banerjee R., Hoek W. Depression and social anxiety in children:differential links with coping strategies. J. Abnorm. Child Psychol. 2010;38:405–1942. doi: 10.1007/s10802-009-9375-4. [DOI] [PubMed] [Google Scholar]
- 48.Liang L., Ren H., Cao R., Hu Y., Qin Z., Li C., et al. The effect of COVID-19 on youth mental health. Psychiatr. Q. 2020;91(3):841–852. doi: 10.1007/s11126-020-09744-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.Pina A.A., Villalta I.K., Ortiz C.D., Gottschall A.C., Costa N.M., Weems C.F. Social support, discrimination, and coping as predictors of posttraumatic stress reactions in youth survivors of hurricane Katrina. J. Clin. Child Adoles. 2008;37:564–574. doi: 10.1080/15374410802148228. [DOI] [PubMed] [Google Scholar]
- 50.Howe T., Davidson B., Worrall L., Hersh D., Ferguson A., Sherratt S., et al. 'You needed to rehab … families as well': family members' own goals for aphasia rehabilitation. Int. J. Lang. Commun. Disord. 2012;47(5):511–521. doi: 10.1111/j.1460-6984.2012.00159.x. [DOI] [PubMed] [Google Scholar]
- 51.Yin Q., Wu L., Yu X., Liu W. Neuroticism predicts a long-term PTSD after earthquake trauma: the moderating effects of personality. Front. Psychiatr. 2019;10:657. doi: 10.3389/fpsyt.2019.00657. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52.Wen J., Shi Y.K., Li Y.P., Yuan P., Wang F. Quality of life, physical diseases, and psychological impairment among survivors 3 years after Wenchuan earthquake: a population based survey. PLoS One. 2012;7:43–81. doi: 10.1371/journal.pone.0043081. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 53.McFarlane A.C. The longitudinal course of posttraumatic morbidity. The range of outcomes and their predictors. J. Nerv. Ment. Dis. 1988;176:30–39. doi: 10.1097/00005053-198801000-00004. [DOI] [PubMed] [Google Scholar]
- 54.Bramsen I., Dirkzwager A.J.E., van der Ploeg H.M. Predeployment personality traits and exposure to trauma as predictors of posttraumatic stress symptoms: a prospective study of former peacekeepers. Am. J. Psychiatr. 2000;157:1115–1119. doi: 10.1176/appi.ajp.157.7.1115. [DOI] [PubMed] [Google Scholar]
- 55.Vassiliki H., Nicholas T. Personality and peritraumatic dissociation in the prediction of PTSD in victims of road traffic accidents. J. Psychosom. Res. 2001;51:687–692. doi: 10.1016/s0022-3999(01)00256-2. [DOI] [PubMed] [Google Scholar]
- 56.Afshar H., Roohafza H.R., Keshteli A.H., Mazaheri M., Feizi A., Adibi P. The association of personality traits and coping styles according to stress level. J. Res. Med. Sci. 2015;20(4):353–358. [PMC free article] [PubMed] [Google Scholar]
- 57.Frazier P.A., Gavian M., Hirai R., Park C., Tennen H., Tomich P., et al. Prospective predictors of post-traumatic stress disorder symptoms: direct and mediated relations. Psych. Trauma. 2011;3:27–36. [Google Scholar]
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