Journal of Traumatic Stress. Vol. 14, No. 3.

2001

The Effect of Relocation After a Natural Disaster

Louis M. Najarian,'~~
Amen K. Goenjian? David Pelcovitz,'
Francine Mandel,' and Berj Najarian'

Twenty-five women remaining in a city devastated by an earthquake were compared with 24 relocated survivors and 25 comparison women. The women were
administered a structured PTSD interview, the Hamilton Depression Scale, and
SCL-90-R. The women in both exposedgroups showed significantly more symptoms
of avoidance, arousal, and total PTSD than the comparison group. The women in
the relocated city had significantly higher depression scores than the women in the
earthquake city. On the SCL-90-R, relocated women were most symptomatic and
comparison group women were least symptomatic. Relocarion after a disaster appears to be associated more with risk for depression than with PTSD in situations
where recovery is delayed following the trauma.
KEY WORDS: disaster, posttraumatic stress disorder; depression.

A devastating earthquake with a magnitude of 6.9 on the Richter scale struck

Armenia on December 7, 1988, killing approximately 25,000 people according to
Soviet reports and 100,OOO people according to other reports (Poghosyan, 1989;
Ryan, 1989). Previous reports have documented high rates of posttraumatic stress
disorder (PTSD)reactions in children (Pynoos et al., 1993) and adults (Goenjian
et al., 1994) in the earthquake zone in Armenia. Immediately after the earthquake,
many survivors were relocated and placed in hotels, sanitariums, and government
residences in distant cities that were minimally damaged.
Relocation has been noted to be a factor in coping with stress of a natural
disaster. Milne (1977) noted that children relocated after a cyclone in Australia
experienced more academic difficulties than those remaining at home and Maj
'Division of Child and Adolescent Psychiatry, Department of Psychiatry, North Shore University
Hospital NYU School of Medicine, Manhasset, New York.
'UCLA Trauma Psychiatry Program,Department of Psychiatry and Biobehavioral Sciences, UCLA
School of Medicine, Los Angeles. California.
3T0 whom correspondence should be addressed at 324 Park Avenue, Manhasset, New York 11030.

511
0894-9867/01107000511519.W0110 2001 International Society forliaumatic Stms Studies

512

Najarian, Gwnjian, Pelcovitz, Mandel, and Najarian

et al. (1 989) found victims of an earthquake, both relocated and those remaining
in the devastated area, to have high prevalence of psychiatric disorders. Structured
interviews or measures of PTSD were not used in either study. Steinglass and
Gemty (1990) compared two communities requiring massive relocation, one due
to a tornado and one due to a flood; PTSD diminished over time but the effect
of relocation could not be assessed because all individuals had returned to their
homes at the time of the study and there was no comparison group.
The wars and genocidal events in Southeast Asia during the last 25 years have
offered further understanding of the traumatic effect of war, relocation, and life
stressors on the victims. Studies of Cambodian victims traumatized during the Pol
Pot regime now living in the United States several years after the trauma continue
to reveal high levels of PTSD (Hubbard, Realmuto, Northwood, & Masters, 1995;
Kinzie, Sack, Angell, Clarke, & Ben, 1989; Kinzie, Sack, Angell, Manson, &Ben,
1986; Sack et al., 1993; Sack, Clarke, & Seely, 1996). Epidemiological studies on
Cambodian refugees identified PTSD and depression to exist across two generations of adolescents and one or both of their parents (Sack et al:, 1993, 1996;
Sack, Clarke, & Seely, 1995). An early study by Beiser (1988) on refugees from
many Southeast Asian countries dispersed throughout Canada demonstrated that
depression declined over time but some groups were still highly depressed 2 years
after resettling in Canada. A study of Bosnian adolescents several months after
relocation to the United States indicate that 25% met criteria for PTSD and 17% for
depression (Weine et al., 1995). The main focus in the studies of adolescents and
young adults from Cambodia and Bosnia was the continued presence and severity
of PTSD symptoms and depression years after the trauma. Savin, Sack, Clarke,
Meas, and Richard (1996) examined PTSD and depression in Cambodian young
adult trauma victims living in a Thailand refugee camp, but waiting to return to
Cambodia. That study found rates of both PTSD and depression similar to a comparable group of Cambodian victims that were relocated to the United States. The
sample in the refugee camp appeared more psychologically ill than traumatized
victims living in the United States. This finding was similar to that of the earthquake victims in Armenia (Najarian, Goenjian, Pelcovitz, Mandel, & Najarian,
1996) where the exposed victims remaining in the disaster zone appeared to be
more psychologically ill than the victims relocated to an intact city although both
traumatized samples met criteria for PTSD and depression. Although these studies
of Asian refugees provide important information on the effect of war trauma and
subsequent resettlement, they differ in that our investigation examines a relocated
population that remained in their country and did not experience the same cultural
loss attending the resettled Asian refugees. The current study is investigating the
psychiatric outcomes of relocation in a situation where the cultural milieu remains
constant.
Most studies of the impact of relocation are hampered by a number of methodological flaws. Failure to use comparison groups or standardized trauma-specific

RelocationAfter a Natural Disaster

513

measures have limited the generalizability of these findings. There are few studies
that systematically assess whether relocation facilitates the process of psychological recovery from the trauma of disaster. In one of the earliest studies designed
to examine the effect of relocation, Laor et al. (1996, 1997) systematically investigated the effects of relocation on victims of SCUD attacks in Israel. The initial
study (Laor et al., 1996) and 30-month follow-up study (Laor et al., 1997) examined three groups of preschool children and their mothers exposed to SCUD
missile attacks during the Persian Gulf War. The displaced group whose homes
were destroyed showed highest stress symptoms.

Present Study
During 1989 and 1990, the senior author provided crisis intervention to the
traumatized victims exposed to the earthquake in Gumri (formerly Lenninakan),
the major city devastated by the earthquake, and those exposed victims relocated
to Yerevan, the capital of Armenia where there was minimal damage by the earthquake. Gumri is the second largest city in Armenia, with a population of 280,000
located about 20 miles from the epicenter of the earthquake. Fifty percent of Gumri
was destroyed and 90% substantially damaged (Goenjian, 1993; Ryan, 1988).Although all exposed victims met criteria for PTSD, those individuals who relocated
to the intact capital city did not appear as psychologically ill as those remaining
in the earthquake city. Previous studies have suggested that victims of a natural
disaster should remain in the area to maintain cohesion in the family (Galante &
Foa, 1986) and in a psychological community to contribute to a recovery environment (Erikson, 1976) until reconstruction to normal predisaster conditions is
completed. The design for this study was generated from the clinical observation
that relocated victims of the earthquake did not appear as psychologically ill as
those victims remaining in the devastated city.
The following clinical cases illustrate the basis for this study. These vignettes
illustrate the difficult environment in which the survivors who remained in the
earthquake city had to cope, as compared to the relocated victims. In contrast
to the relocated victims, those remaining in the earthquake city were constantly
reminded of the reality of the earthquake which transformed their lives. All names
and identifying information were changed to ensure confidentiality.
Vignette 1: Relocated Participant
Gayane is a 40-year-old school teacher, mother of two children ages 14 and
12 who relocated to a hotel in Yerevan immediately after the earthquake because
her private home was destroyed in Gumri. She lived in two rooms with her two
children and 65-year-old mother. Her husband was killed in the earthquake. She

514

Najarian, Goenjian, Pelcovitz, Mandel, and Najarian

was attractive, well groomed, articulate, and met DSM-Ill-R criteria for PTSD and
depression. During brief psychotherapy (six visits), she expressed survivors guilt
for the first time. She had encouraged her husband to stay home from work because
he was ill on the day of the earthquake while she and the children were at school. He
was killed at home when the house was destroyed. She secured voluntary work in
the school her children attended next to the hotel. She organized an arts and craft
program for children in the hotel in which she resided because many relocated
families lived there. As her mood and PTSD symptoms improved, she became
more involved with her children and they began to attend concerts, museums, and
theater in Yerevan as they had done in Gumri prior to the earthquake. During the
summer 1989, she volunteered to help in a summer camp program and secured a
place for her children. The PTSD and depression improved as she continued to
live in the hotel indefinitely while waiting for repair of her damaged house.
Kgnette 2: Participant Remaining in Earthquake Cify
Aram is a 38-year-old engineer living in a tent in Gumri since the earthquake,
with his 38-year-old wife, a music teacher; three children ages 12, 10,s; and both
his parents ages 63. He worked in a large clothing factory where 200 people died
during the earthquakebecause of poor construction of the building. He was outside
the building at the time of the earthquake but assisted victims, includingthe removal
of corpses. Although no one in his immediate family died, he mourned with his
best friend as they both walked daily to the cemetery where his best friends wife
and two children were buried. It was a common practice in the earthquake zone
for families of victims of the earthquake to visit the cemetery daily and cry at the
grave of their lost ones, even 6 months after the earthquake.
Aram spoke cautiously in a sad, suspicious manner about his life with no
hope for the future. He was dressed in shabby clothes and indicated proudly with a
disgusted spirit, these were his only clothes and it was difficult to keep them clean
when living in a dusty tent. He was diagnosed with PTSD and reluctantly agreed
to meet regularly in brief psychotherapy. When the concept of confidentiality was
explained a second time after the initial consultation, there was a dramatic change
in his mood and affect, as he openly attacked the government for failure to provide
more adequate housing and employment. He blamed Gorbachev for the earthquake
as did 30% of the residents of the city, because they suspected a bomb caused it
because there was a large Soviet army post located in Gumri along the Turkish
border. As his mood improved, he was encouraged to stop visiting the cemetery,
which he did. On his own, he moved the tent where he lived with his family, away
from the grounds of the factory where he assisted so many victims. This provided
only mild help because there was no place to avoid reminders because 90% of the
city was damaged. Both he and his wife were cultured, as they enjoyed attending
concerts and the theater but the buildings were destroyed and this activity was

Relocation After a Natural Disaster

515

no longer available. Their recreation was limited to watching television, listening

to cassettes, and visiting with friends. He changed some of his daily routine and
PTSD symptoms diminished while his mood improved as he continued to express
anger at the government. Aram began to attend church regularly and spoke proudly
about the heritage of Armenia, it being the oldest Christian nation. At the end of
treatment, his mood was improved but he still experienced mild PTSD symptoms
as he and his family continued to live in a tent while waiting for repair to their
damaged apartment building.
The present study focused on exploring the association between relocation
and PTSD symptomatology on children and their mothers. This study was based
on interviews with 25 mothers and their children. The initial study focused on
the relative adjustment of children who remained in the earthquake city compared
with those who were relocated (Najarian et al., 1996).
To date, there have been no studies of adults, using structured measures of
PTSD and depression, which have examined the differential impact of remaining
in an earthquake city where there has been no repair to the damage contrasted with
relocation to an intact city. This study was designed to test the hypothesisthat adults
who were exposed to the earthquake and relocated to an intact city where there
was no damage would show significantly lower levels of PTSD and depression
than a comparison group of earthquake victims who had similar exposure and
remained in the earthquake city and a comparable group who did not experience
the earthquake.

Method
Participants

The families witnessing the earthquake were selected from Gumri. This
study was based on interviews with 74 mothers and their children. The first group
of women (n = 25) remained in Gumri after the earthquake and lived with their
families, initially in tents and later trailers or reconstructed homes. The second
group consisted of relocated women (n = 24) who left Gumri immediately after
the earthquake because their homes were destroyed. They moved with their families to hotels and sanitariumsthat were emptied to receive the homeless in Yerevan.
Yerevan is the capital of Armenia with a population of 1.3 million people. The
damage was mild in Yerevan and there were no deaths from the earthquake. The
relocated families lived in their new residences from the time immediately following the earthquake until the time of this study, 2'/2 years after the earthquake. The
third group of women (n = 25) evaluated were those who lived in Yerevan at the
time of the earthquake; they were the comparison group.
Table 1 shows the demographics of the sample. There were no significant
differences in the distribution of ages, level of education, or the occupations of the

Najarian, Goenjian, Pelcovitz, Mandel, and Najarian

516

Table 1. Demographic Characteristicsof Mothers by Location

Variable

Earthquake
(n = 25)

Average age
Level of education
Graduate school
College
Trade school
High school
Employed
Professional (physician,
lawyer, accountant)
Teacher
Trade (factory worker,
seamstress, cashier)

36

Relocated
(n = 24)

38

Comparison
(n = 25)

38

Nore. Values in parentheses are percentages.

women in the three groups. There was a significant difference in the employment
of the three groups (p < .001). Sixty percent of the women in the comparison group
were employed at the time of the study, whereas 36% of the mothers remaining
in the ekhquake city were employed as compared with none of the relocated.
There was also a significantdifference in the prevalence of loss in the three groups
(p c .01). Loss was measured by using a structured questionnaire that asked the
adult who in their immediate family (mother, father, children. grandparents) was
killed in the earthquake-for the purpose of this study, the definition of loss did
not include aunts, uncles, cousins, or friends. Fifty percent of the relocated adults
experienced a loss in the immediate family, whereas 20% of the adults in the
earthquake city and no one in the comparison city experienced a loss.
The degree of trauma exposure in this sample was extreme. Exposure to horrifying sights continued for days following the earthquake in Gumri. Throughout
the city, people heard screams from those who had been injured, burned, or trapped
under collapsed buildings, or they saw mutilated corpses exposed on the sidewalks
and bodies hanging from buildings.
Procedure

The principal of each school selected the children. They were asked to select
25 children from the same grade, ages 11 through 13 years, to participate in the
study. The principals were told to chose the students randomly without any bias.
Because we were concerned that they may have viewed the research interview
as a chance to get help for their more troubled students, they were specifically
instructed not to choose students based on psychological need. They were also
asked not to bias their selection by choosing problem-free students. At the time

Relocation After a Natural Disaster

517

of the study, in May 1991, Armenia was a republic in the Soviet Union. In the
communist system, school principals were extremely powerful, therefore, when a
student was identified to participate in the study, all mothers complied without any
challenge to the principals authority. However, when the mothers convened at the
school to begin the study, the principal investigator made it clear to all the women
that if they were not comfortableparticipating in the study, they were free to refuse
without any consequences. In keeping with research standards in Armenia at the
time of the study (10 years ago) verbal consent was obtained from all subjects. The
children and their mothers were interviewed in the school in May 1991,2/2 years
after the earthquake. No one in the sample had received prior treatment.
All self-report measures were administered to the women in a classroom adjacent the childs classroom while the children were examined. Four local Armenian
psychologists who had extensive mental health experience, including test administration, supervised the administration of .the measures. All instruments were
translated into the Armenian version following previously published guidelines,
including the use of independent back-translation and administration to bilingual
participants (Brislin, 1976). Ten bilingual participants in Armenia were interviewed with both the English and Armenian versions. The correlation between
scores for the two versions was .95.
Measures

The PTSD section of the third revised edition of the Diagnostic and Statistical
Manual (DSM-111-R:American Psychiatric Association, 1987) was administered
to each woman. Because there were no available interviews in the Armenian language to measure PTSD in adults, the DSM-111-R PTSD section was translated
into the Armenian language and administered in a structured interview format that
systematically asked participants about each of the 17 DSM-111-R symptoms.
The Hamilton Depression Scale (HDS:Hamilton, 1960), a widely used measure of adult depression, was administered to all participants. The HDS is a21-item
self-report questionnaire, which measures depression in adults.
The Symptom Checklist-90-R (SCL-90-R: Derogatis, 1983) was also administered to all participants. The SCL-90-R is a 90-item self-report symptom
inventory developed to reflect primarily symptom patterns of psychiatric patients.
Each of the 90 items of the inventory is rated on a 5-point scale of distress (W),
ranging from not at all to extremely. The 90 items are scored and interpreted in
terms of nine primary symptom dimensions and three global indices of distress.
Statistical Analysis

Comparisons of the three groups on response to items or endorsement of

PTSD symptoms were made using chi-square tests for proportions followed by

Najarian, Goenjian, Pelcovitz, Mandel, and Najarian

518

Boneferroni adjusted pairwise comparisons. An analysis of variance was used to

determine whether the proportion of items endorsed is equal for each subscale
in each location. Student-Newman-Keuls tests were used to determine which
location differed within each subscale if there was a significant difference in the
three locations on that subscale.
Comparisons of the mean scores of the three groups on the Hamilton Depression score and the SCL-90-R scores were made using analysis of variance
followed by post hoc comparisons using Student-Newman-Keuls tests. The level
of depression of those who lost family in the earthquake was compared with the
level of depression of those who did not lose family in the earthquake using an
independent samples t test. Additionally, an analysis of variance was used in order
to compare the locations and presence of loss as an indicator of level of depression
in the women.

Results
Table 2 shows the rate of endorsement for each of the 17 items, three PTSD
clusters and PTSD. The women in the three cities were significantly different in
Table 2. Comparison of PTSD Symptoms by Location
Eanhquake
Criterion

PTSD Summary
Criterion B: Reexperiencing
Intrusive thoughts
Bad dreams
Fears recurrence
Distress at reminders
Criterion C: Avoidance
Avoid thoughts
Avoid activities
Memory loss
Diminished interests
Detached
Restricted affect
Foreshonened future
Criterion D: Arousal
Sleep disturbance
Irritable
Concentration
Hypervigilance
Startle
Physiologic reactivity

23
24
22
9
21
21
25
22
20
21
20
14
18
18

24
17
11
17
12
8
19

Relocated

Comparison

9%

xz(df=2)

92
96
88
69
88
84
100
88
83
84
87
58
82
75
96
71
50
78

16
18
17
12
16
17
17
16
17
10

89

3
22
5
1
17
12
6
10
9

12
85
19

42.7"'
4.4
36.0.'.
16.5"'
5. I
13.8"'
42.7***
17.8***
20.4*"
33.8"'
30.4"'
2 I .2***
21.2***
25.9***
39. I ***
23.5*'*
1 1.2"
3 1.8*"
20.9***
18.5"'
29.9***

50

32
76

10

14
9
14

16
15
7
11
12
11
15

100

94
80
89
94
94
89
94
56
56
78
50
78
89
83
41
61
67
65
83

2
3
4
3
5
4
2
0
1
1

8
65
48
23
40
36
4
8
12
15

12
19
16
8
0
4
4
12

Nore. Both the earthquake and relocated groups differed from the comparison group except for

Criterion B (fears recurrence),on which there were no differences, and for restricted affect, on which
only the earthquake group differed from the comparison group.
**p c .01. ***p < .001.

RelocationAfter a Natural Disaster

519

Table 3. Average Number and Percentage of PTSD Items Endorsed by Location

Earthquake(n = 25)

Subscale

Reexperiencing
Avoidance
Arousal

2.92
5.40
4.20

0.95
1.26
1.53

Relocated (n = 24)

0.73
0.77
0.70

3.44
5.00
4.61

D
0.78
1.75
1.75

Comparison (n = 25)

0.86
0.71
0.77

1.35
1.42
0.69

0.98
1.47
1.01

%
0.34

0.20
0.12

their meeting criteria for the PTSD of arousal and avoidance symptoms clusters, as
well as for PTSD. Pairwise comparisons showed that the women in the earthquake
and relocated cities did not differ in experiencing PTSD. There was a significant
difference in the rate of PTSD for the avoidance and arousal cluster between
the earthquake and comparison cities. Similarly, there were the same differences
between the women in the relocated and comparison cities. However, there was
no significant difference in their scores on the reexperiencing criterion.
Table 3 shows the average number of symptoms and percentage of items endorsed by each group of the three PTSD symptom clusters. There was a significant
location effect on the PTSD symptom categories ( p < .001). Pairwise comparisons
showed the earthquake and relocated groups having significantly higher scores on
each of the symptom clusters.
The three groups had significantly different average Hamilton Depression
scores, F( 1,64) = 2 6 . 6 3 , ~< .OO1. This result was significantly different between
each of the cities. Those participants in the relocation city had a mean score of
3 1.7 (SD= 7.0). women in the earthquake city had a mean score 24.8 (SD= 8.9).
and women in the comparison city had a mean score of 17.1 (SD= 5.7).
There were significant differences among groups in responses to the question
about diurnal mood, x2(4, N = 64) = 39.9, p < .001. Pairwise comparisonsshowed
that each of the three groups was significantly different from the other two groups.
Almost three quarters of those in the earthquake city (7 1.4%) answered that their
mood was a little worse in the morning or night or at both times. In contrast,
the women in the relocated city were more evenly distributed between those who
answered little worse in the morning or night or at both times (55.6%) and those
who indicated diurnal mood variation occurred very much (44.4%). Conversely,
80% of the women in the comparison city said that they experienced no diurnal
mood variation.
There were also significant differences among groups on Hamilton items relating to experiences of derealizatioddepersonalization, x2(8, N = 65) = 46.9,
p c .OO 1. pairwise comparisons showed that each of the groups was significantly
different from the other two groups. Over 90% of the women in the earthquake city
reported that they did not experience significant derealizatioddepersonalization
(39% did not experience, and 52.2% experienced this symptom only a little).
In contrast, 44% of the women in the relocated city reported difficulties with

520

Najarian, Goenjian, Pelcovitz, Mandel, and Najarian

derealizatioddepersonalization (33.3% much; 11.1% very much); 16.7% did

nor experience depersonalizatiodderealization; 16.7% experienced this symptom a lirrle, and 22.2% rated themselves in the middle range on derealizatiod
depersonalization.The women in the comparison city almost exclusively answered
that they had no experience of derealizatioddepersonalization.
The participants answered the paranoid scale significantly differently in the
three cities, x2(6, N = 67) = 18.7, p < .01. Pairwise comparisons determined
that the women in the earthquake city were significantly different from the women
in the comparison city. The response of women in the earthquake city was as
follows: none (44%).paranoid (32%). and thinks people talk about them (24%).
The women in the relocated city replied none (55.6%), paranoid (16.7%), rhinks
people ralk about them (26.7%). and thinks people follow them (1 1.1 %); and the
women in the comparison city replied almost exclusively none (91.7%).
The participants answered the obsessivekompulsive question significantly
~ .01. Pairwise comparisons
differently in the three cities, x2(4,N = 63) = 1 3 . 8 , <
showed that each of the groups was significantly different from the other two
groups. The response of the women in the earthquake city was as follows: none
(52.4%), little (33.3%), and much (14.3%); the women in the relocated city replied
none (55.6%), little (22.2%), and much (22.2%); and the women in the comparison
city replied almost exclusively none (95.9%).
The womens answer regarding whether they have more fights after the earthquake was significantly different in the three cities, x 2 ( 8 , N = 66) = 30.3, p <
,001. Pairwise comparisons showed that the women differed significantly between
the comparison and the other two cities. The response of the women in the earthquake city was as follows: none (29.2%), lirtle (16.7%). and occasionally (25%),
a lot (20.8%), and always (8.3%); the women in the relocated city replied none
(27.8%), a lirtle (17.8%), occasionally (1 1.1%), and a lor (33.3%); and the women
in the comparison city replied almost exclusively none (9 1.7%).
There was no significant difference in the levels of depression expressed by
those women who had lost members of their immediate families as compared with
those who did not lose members of their immediate families. Further, when the
location of the participants was controlled for, there was no relationship between
location and loss in relation to depression, F(2,38) = 2.22, ns.
Table 4 shows the SCL-90-Rscores for the participants in the three cities.
There were significant differences between groups on the following scales: somatization, obsessivekompulsive, depression, anxiety, phobia, paranoid, and the
global seventy index. In each case, those in the relocated city were most symptomatic and those in the comparison city were least symptomatic. For all scales
on which there were group differences, the relocated women were significantly
different than comparison women. The earthquake city mothers exhibited significantly greater symptoms than the comparison mothers on the following scales:
somatization, obsessivekompulsive, depression, anxiety, and the global severity

Relocation After a Natural Disaster

521

Table 4. SCL-90-R Scores by Location

~~

Sornatization
Obsessive/compulsive
Interpersonal sensitivity
Depression
Anxiety
Hostility
Phobia
Paranoid
Psychoticism
Global seventy index

Earthquake

Relocated

SD

SD

SD

58.9
55.2
50.9
54.9
59.5
47.1
61.6
50.2
52.0
55.5

9.0
9.7
9.3
7.8
7.3

63.5
56.1
49.2
59.2
63.1
45.2
62.3
53.2
54.8
58.3

12.0
11.7
10.0
8.1
11.2
9.0
8.3
8.2
10.0
9.4

48.9
45.8
45.7
46.7
49.7
44.3
54.2
44.3
49.5
45.5

16.6
12.0
11.3
9.4
14.9
11.3
12.2
11.0
11.8
15.3

8.8

8.8
10.4
11.7
10.0

Comparison

F(2.66)
7.1"
5.8**

1.6
1.9.'.
7.8***
0.5
4.4'
4.2'
1.1

6.8'

' p c .05. '*p c .01.'"p < .001.

index. There was no significant differences between the symptoms of the women
in the relocated and earthquake cities.

Discussion
Relocation did not diminish the prevalence of PTSD in the adults who witnessed the earthquake and were displaced to Yerevan. Presumably, the severity
of the trauma outweighed the benefit of living in an intact city. Contrary to those
who suggest remaining in the disaster area minimizes PTSD symptomatology, the
women who relocated were no worse than those who remained in the disaster city.
Our hypothesis that the adults who relocated would be less symptomaticthan those
who remained in the earthquakecity was not substantiated.The finding that 92% of
the women remaining in the earthquake city and 89% of the relocated women met
criteria for PTSD 2'/2 years after the disaster is not surprising in light of the trauma
suffered in the earthquake. It is now well known that natural disasters that involve
threat to one's life, and the lives of family members, are associated with very high
risk for PTSD (Pynoos et al., 1987; Vogel & Vernberg, 1993). The finding that in
both cities only approximately 10%of the women were not diagnosed with PTSD
testifies to the extremely high risk women face for experiencingthis disorder when
they do not receive treatment after a disaster of such magnitude. Galante suggests
that remaining at the site of the disaster is associated with quicker recovery and
healing (Galante & Foa, 1986), but our finding that 92% of the women who remained in Gumri continued to have PTSD,highlights the difficulty of recovering
from the effects of a trauma when a city remains in disrepair, and no psychiatric
treatment for the effects of the trauma is available.
The high rate of women endorsing avoidance (100% in earthquake city,
94% in relocated city) was in contrast to their children (Najarian et al., 1996)

522

Najarian, Goenjian, Pelcovik, Mandel, and Najarian

who were less likely to avoid reminders of the earthquake (32% in earthquakecity,
28% relocated city). This is similar to the findings of Laor et al. (1997) who also
reported that in response to SCUD attacks in Israel, mothers were more likely to
endorse avoidance symptoms than were their children. A possible explanation of
higher avoidance rates in the mothers in our study is that, unlike their children,
who attended school, most of the mothers in both cities remained unemployed
after the earthquake. The conditions in Armenia, at the time of this study made
it virtually impossible for most of the parents to find employment outside of the
home. Remaining in their home may have perpetuated PTSD related avoidance,
because they were not forced to extinguish their fears by venturing outside. In
contrast, their children attended school on a regular basis, in effect forcing them
to overcome avoidant behaviors.
A surprising finding was that 85% of the participants in the comparison group
reported reexperiencing. This finding is consistent with the report in children who
lived in the capital city. All 25 (100%) of the children in our previous report
endorsed reexperiencing symptoms (Najarian et al., 1996).This may be explained
by the fact that television coverage of the earthquake continued on a daily basis
in the entire country for several months and there is only one television station in
Armenia. The entire population was overwhelmed with a daily visual stimulation of
the devastation.Television coverage of a traumatic event has proven to contribute to
mass reaction to the trauma (Kiser et al., 1993).Also, many adults in the comparison
city had relatives in the earthquake city or traveled to the earthquakecity to offer aid.
Finally, the severity of the earthquake and related experiences may have fostered
development of memories that recurred with a multiplicity of cues.
The SCL-90-R results suggest that the women in the earthquake samples had
general distress in addition to their PTSD symptoms. Specifically, both groups
of exposed adults had significantly higher scores on the global severity index, as
well as in the specific areas reflecting difficulties with somatization, obsessivecompulsive symptoms,depression, and anxiety. Somatizationis a common cluster
of symptoms seen in survivors of trauma (Van der Kolk et al., 1996).In the presence
of total environmental chaos, an increase in obsessive-compulsive symptomatology might be seen as an adaptive manner of organizing ones life. In a large
community survey of traumatized victims, Saunders found a higher incidence of
obsessive-compulsive disorder in traumatized individuals than nontraumatized
persons (Saunders, Villeponteaux, Lipovsky, Kilpatrick, & Veronen, 1992).
The strikingly high number of responses to questions relating to paranoia
on both the HDS and the SCL-90-R warrants elaboration. Although the relocated
women clearly showed more evidence of global depression and mood instability, a
different clinical picture emerges in the two exposed groups when paranoid symptoms and aggression are examined. Although paranoid symptoms were statistically
greater in women who remained in the earthquake city as compared with the comparison group, no such significant differences were found when relocated women

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523

were compared with the comparison group. These findings raise the intriguing possibility that women who remained in the earthquake city, when confronted with
extreme hardships had to worry about how to meet basic needs for themselves and
their families. This pressure might have contributed to increased suspiciousnessof
the government for not allocating them housing and resources. Also, individuals
often were perceived as opportunist taking advantage of others. In comparison,
although the relocated women had to struggle with a sense of loss of community,
they were living in an environment that was physically more comfortable and basic
needs such as heat, water, and electricity were more readily available.
Adults with a paranoid disorder have a higher incidence of childhood trauma
such as abuse or a chronic illness (Blum, 1968, 1974). Rangell, in an essay on
the course of psychic trauma, stresses the importance of attachment to ground
as a prerequisite for the maintenance of psychic equilibrium (Rangell. 1976). He
elaborates further on how the loss of confidence in this attachment results in basic
anxiety with the threat of total annihilation of the self and this relationship extends
from the ground beneath one to the space around ones self, including people,
institutions, and culture. When the devastation is so severe as it was in Armenia
with delay in the reconstruction, one can appreciate how a primitive anxiety may
evolve to a lack of faith and mistrust of others. The presence of a high degree of
paranoia in the women also supports Colbys homeostatic theory of paranoia in
which the phenomenon results from attempts of the organism to pursue internal
equilibrium (Colby, 1977). Any threat, whether internal or external, to restoring
this equilibrium may be transformed into the belief that others threaten me.
Our results regarding the differential levels of depression in the three cities
consistently indicate that the relocated women were experiencing significantly
higher levels of depression. This was the case in terms of total depression scores.
Although almost three quarters of the women who remained in the earthquake city
reported only relatively minor symptoms of depression, almost half of the women
who were relocated, reported significant difficulty with depression. Similarly,
44% of the relocated women reported serious difficulty with feelings of unreality as compared with 10% of the mothers who remained in the earthquake city.
One can speculate that relocated women had particular difficulties with their sense
of connectedness to their environment, that is they felt unreal in relation to the
outside world, or experienced unstable moods as their day progressed. Although
they lived in neighborhoods, which were physically intact, their internal mood did
not reflect a sense of stability and reality. Perhaps their primary sense of connection and sense of community was so compromised by the move that they were
not able to regain a sense of equilibrium and integration, even 2/2 years after the
earthquake. Another possible contribution to this lack of connectedness is unemployment. As noted in Table 1, in contrast to the earthquake city group where 36%
of the women were employed, none of the women in the relocated group were employed. This may also have played a role in their higher levels of depression. Our

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findings that depression was still significant relative to the comparison groups in
both exposed groups is consistent with the research of others in which depression
is a persistent problem in survivors of trauma (Beiser, 1988; Goenjian et al., 1995;
Sack et al., 1994, 1996; Westermeyer, Nerder, & Callies, 1989).
There is much information about the effect of relocation of war refugees
to different countries that necessitate acculturation and learning a new language
(Beiser, 1988; Westermyer et al., 1989). This study examined the effect of relocation within the same country, which avoids the need for cultural and language
adaptation. It allows for a more precise examination of the effect of relocation. In
light of our finding that the relocated women were more symptomatic, our results
suggest that policy should direct all humanitarian aid to maintaining victims in
the disaster area. Considering the amount of financial and material aid donated to
Armenia from the entire world, more effort should have been directed to the reconstruction of the earthquake zone and this would have avoided victims remaining
in relocated areas 2'/2 year after the earthquake.
There are some limitations in the design of this study. We did not measure
severity of exposure, nor did we assess perceived life-threat or percentage of
participants who lost extended family members. The relatively small number of
participants points to the need for replication of our findings with a much larger
sample. Another limitation was the nature of participant selection. As noted earlier,
the principals were asked not to choose students on the basis of who they felt needed
help. This limits the generalizability of our results in that we could not control any
bias, which may have subtly affected the principals' choice of participants. Future
research should also be conducted assessing these variables, using a longitudinal
design.
Our study is consistent with previous research that finds a high risk for PTSD
and depression for survivors of a natural disaster. Because of the extensive damage
by recent natural disasters, such as earthquakes, floods, avalanches,and tornadoes,
many victims are relocated to intact communities. Relocated adults are at particularly high risk for depression in addition to PTSD and a variety of other psychiatric
symptoms. This study was generated by the clinical observation that relocated victims appeared less psychologically ill than those victims remaining in the disaster
zone. When studied statistically, this fact was not substantiated. More research is
needed before definitiveconclusions informing public policy are drawn. However,
our results suggest the need to direct aid, including medical, psychological, food,
and shelter, to maintain victims in their natural environment and to expedite the
reconstruction process.

Acknowledgments
The authors wish to thank the Psychiatric Outreach Program of the Armenian
Relief Society, Western Region, in Glendale California for their support of the

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525

clinical work, which made this study possible and Dr.Victor Labruna for his
editorial assistance.

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