Journal of Affective Disorders 147 (2013) 156163

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Journal of Affective Disorders

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Research report

Coping and PTSD symptoms in Pakistani earthquake survivors:

Purpose in life, religious coping and social support
Adriana Feder a,n,1, Samoon Ahmad b,1, Elisa J. Lee a, Julia E. Morgan a, Ritika Singh a,
Bruce W. Smith c, Steven M. Southwick d, Dennis S. Charney a
a
Mount Sinai School of Medicine, 1 Gustave L. Levy Place, NY 10029, United States
b
New York University, 50 West 4th Street, NY 10012, United States
c
University of New Mexico, 1 University Boulevard Northeast, Albuquerque, NM 87131, United States
d
Yale University School of Medicine, 153 College Street, New Haven, CT 06510, United States

a r t i c l e i n f o a b s t r a c t

Article history: Background: High rates of posttraumatic stress disorder (PTSD) and depressive symptoms have been
Received 2 October 2012 observed in earthquake survivors from less developed areas of the world. This study, conducted three
Accepted 23 October 2012 years after the 2005 Pakistan earthquake, aimed to identify potentially protective psychosocial factors
Available online 27 November 2012
associated with lower PTSD and depressive symptom levels.
Keywords: Methods: Adult earthquake survivors (N 200) were recruited from affected areas in Northwestern
Posttraumatic stress disorder Pakistan and completed self-report questionnaires measuring PTSD and depressive symptoms, positive
Earthquake and negative affect, and four psychosocial variables (purpose in life, positive and negative religious
Pakistan coping, and social support).
Purpose in life
Results: Sixty ve percent of participants met criteria for probable PTSD. Purpose in life was associated
Religious coping
with lower symptom levels and higher positive emotions. A form of negative religious coping (feeling
Social support
punished by God for ones sins or lack of spirituality) was associated with higher symptom levels and
negative emotions. Higher perceived social support was associated with higher positive emotions.
Other signicant relationships were also identied.
Limitations: Limitations include the recruitment of a sample of convenience, a modest sample size, and
the cross-sectional nature of the study.
Conclusions: Findings suggest that some psychosocial factors may be protective across cultures, and
that the use of negative religious coping is associated with poorer mental health outcomes in
earthquake survivors. This study can inform preventive and treatment interventions for earthquake
survivors in Pakistan and other less industrialized countries as they develop mental health care
services.
& 2013 Elsevier B.V. All rights reserved.

1. Introduction 2009; Naeem et al., 2011), where lack of preparation and

Earthquakes plagued mankind long before their emotional,
social and economic impact was ever studied. Over the last
decade, research has documented the heavy toll of mental illness,
in particular posttraumatic stress disorder (PTSD), in survivors of
this most devastating of natural disasters. A growing number of
studies have documented high rates of PTSD and depressive
symptoms in earthquake survivors from Pakistan and other less
developed areas of the world (Ahmad et al., 2010; Ehring et al.,
2011; Hashmi et al., 2011; Irmansyah et al., 2010; Lommen et al.,
n
Corresponding author. Tel.: 1 212 659 9145; fax: 1 212 659 9291.
E-mail address: adriana.feder@mssm.edu (A. Feder).
1
Both authors contributed equally.
resources is associated with greater risk of poor mental and
physical outcomes (Basoglu et al., 2001). Across studies, factors
that have consistently been found to increase risk for PTSD
include female gender, lower education, high exposure intensity,
and loss of close family members as a result of the earthquake
(Ahmad et al., 2010; Ali et al., 2012; Ehring et al., 2011; Irmansyah
et al., 2010; Wan Chan et al., 2011; Wang et al., 2011). Few
studies, however, have sought to identify potentially protective
psychosocial factors associated with lower symptom levels in
earthquake survivors, especially in non-Western populations,
with a few recent exceptions (Ahmad et al., 2010; Ali et al.,
2012; Ke et al., 2010; Tang, 2006).
The ability to cope with disaster is a function of numerous
genetic, neurobiological, developmental, cognitive, cultural,
psychosocial and personal factors. Signicant knowledge about

0165-0327/$ - see front matter & 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.jad.2012.10.027
 A. Feder et al. / Journal of Affective Disorders 147 (2013) 156163
factors associated with resilience to trauma exposure has accu-
mulated in the last decade, including the potentially protective
role of positive emotions and healthy social supports (Alim et al.,
2008; Feder et al., 2009; Fredrickson, 2004; Hoge et al., 2007). Of
longstanding theoretical interest but less well-studied empirically
in trauma survivors is an individuals sense of purpose in life
(Alim et al., 2008; Feder et al., 2009; Pietrzak et al., 2010; Pietrzak
et al., 2011). The role of religious coping is also of interest in the
face of trauma, especially in the developing world where religion
is of central cultural signicance (Ali et al., 2012).
On October 8th 2005, at 8:50 am, an earthquake measuring
7.6 on the Richter scale struck the Northwestern Frontier Province in
Pakistan. The most devastating earthquake to strike the region in the
last century, according to some estimates there were more than
250,000 casualties and over 3.5 million people became homeless,
with no relief in sight and nowhere to go. The present cross-sectional
study, carried out in 2008, aimed to document the prevalence of
posttraumatic stress symptoms three years after the disaster, and to
identify psychosocial factors associated with lower PTSD and depres-
sive symptom levels in earthquake survivors.
Based on our prior ndings (Ahmad et al., 2010) and those of
others (Ali et al., 2012; Basoglu et al., 2001; Galea et al., 2005), we
hypothesized that female gender, lower education, loss of loved
ones, and closer proximity to the epicenter would be signicantly
associated with higher symptom levels. We additionally predicted
that higher purpose in life (Alim et al., 2008; Hoge et al., 2007)
and higher perceived social supports (Ali et al., 2012; Ehring et al.,
2011; Naeem et al., 2011; Zhao et al., 2009) would be signicantly
associated with lower symptom levels. While neither positive nor
negative religious coping showed any signicant associations
with symptom levels in our previous study, we re-examined the
factor in this study due to the larger and more demographically
diverse sample collected for the present study. Finally, we sought
to identify psychosocial factors associated with reported levels of
positive and negative emotions.
2. Method
2.1. Participants
Survivors of the earthquake (161 men and 39 women, mean
age37.7 years) were recruited by the principal investigator, S.A.
Participants were primarily recruited from the vicinity of Muzaf-
farabad and Balakot in Pakistan. S.A. traveled to several schools
and other institutions to recruit adult subjects who volunteered
to participate without any form of compensation. Participants
included anyone with exposure to the earthquake who consented
to participate.
2.2. Procedure
The study was approved by the Institutional Review Board of
the New York University. Informed consent was obtained from all
subjects before the self-report questionnaires were administered.
The consent forms were translated into Urdu and were read aloud
and explained to any illiterate participants before consent was
obtained. All questionnaires were also translated into Urdu and
reviewed by a consensus team before they were administered.
2.3. Materials
All constructs of interest were measured by a self-report ques-
tionnaire. The questionnaire contained demographic and trauma
exposure information as well as self-report scales to determine the
level of PTSD and depressive symptoms, positive and negative affect,
157
and four psychosocial variables (purpose in life, positive and
negative religious coping, and social support). In totaling the scores
for each scale, participants data for that variable were excluded if
20% or more of the responses for that scale were missing.
The severity of trauma symptoms was assessed using the
Traumatic Stress Symptom Checklist (TSSC; Basoglu et al., 2001) a
23-question scale designed to specically identify PTSD and depres-
sive symptoms in earthquake survivors. It was developed and
validated using non-Western populations and has an internal
consistency of.94 for all 23 items and.92 and.84 for the subscales
TSSC-PTSD and TSSC-Depression, respectively (Basoglu et al., 2001).
Seventeen questions measure severity of PTSD symptoms and the
latter six measure depressive symptoms. In scoring, each participant
received a total TSSC score as well as two subscale scores for PTSD
(TSSC-PTSD) and depression (TSSC-DEP). Responses to each question
are scaled from 0 (Not bothered at all) to 3 (Very much
bothered). A participant with a TSSC-PTSD score equal to or over
25 meets criteria for probable PTSD (Basoglu et al., 2001).
Positive and negative emotions were measured by the trait
version of the Positive and Negative Affect Schedule (Watson
et al., 1988). The schedule is comprised of 10 items to assess
positive affect (e.g., enthusiastic, proud) and 10 items to
assess negative affect (e.g., afraid, upset). Participants rated
how much they generally felt each emotion on a scale from 1 to 5.
The positive affect component has an internal consistency ranging
from.86 to.90. The negative affect component has an internal
consistency ranging from.84 to.87 (Watson et al., 1988).
Perceived social support was measured with the emotional/
informational subscale of the Medical Outcome Study (MOS)
Social Support Survey (Sherbourne and Stewart, 1991). The
subscale consists of eight questions and scored on a scale of 1
(None of the time) to 5 (All of the time). In scoring, the
responses are totaled and then multiplied by 100. A higher score
indicates a greater sense of social support. The MOS Social
Support Survey has an internal consistency of .96 (Sherbourne
and Stewart, 1991).
Purpose in life was measured with the Purpose in Life scale
(Ryff and Keyes, 1995). Each of the eight items is rated from 1
(Strongly disagree) to 6 (Strongly agree) and responses to
negatively worded items are reversed. A higher score indicates a
higher purpose in life. The scale has an internal consistency of.90
and a test-retest reliability of.82 (Ryff and Keyes, 1995).
Religious coping was measured using the 6-item RCOPE scale
(Pargament et al., 2000). The scale consists of three statements
measuring positive religious coping (RCOPE-P), and three state-
ments measuring negative religious coping (RCOPE-N). Responses
to each statement are scaled from 0 (Not at all) to 3 (A great
deal). Each set of three items are totaled separately, so each
participant receives one score for RCOPE-P and one score for
RCOPE-N. A higher score on each subscale indicates a greater use
of positive or negative religious coping. For the RCOPE-P portion of
the scale, the internal consistency ranges from.87 to.90. For the
RCOPE-N, the internal consistency ranges from.69 to.81 (Pargament
et al., 2000).
2.4. Data analysis
All analyses were performed using SPSS 19.0. Trauma severity
was estimated in the form of two variables: (a) distance to the
epicenter (in miles) and (b) death of family members. The second
variable was coded from most (3) to least (0) severe, based on the
potential impact on participants of family deaths, as follows:
3death of at least a child, grandchild or spouse; 2no deaths in
category 3, but death of at least one sibling or parent; 1 no
deaths in categories 2 or 3, but death of at least one relative in the
extended family; and 0 no deaths in the family.
158 A. Feder et al. / Journal of Affective Disorders 147 (2013) 156163

Zero-order correlations among all of the study variables were TSSC-Depressive symptom subscale scores, and PANAS-P (positive
examined. Due to the low Cronbach alpha values for positive and emotions) and PANAS-N (negative emotions) as dependent vari-
negative religious coping, each item in the R-COPE was treated as ables. For these analyses, demographic characteristics were
a separate variable for both correlations and regression analyses. entered in Step 1, followed by distance from epicenter and loss
Table 3 shows the percentage of responses for each item of the of relatives in Step 2. In Step 3, the last item in the RCOPE-N was
RCOPE. Notably, the majority of the population demonstrated entered. In step 4, the remaining psychosocial variables were
high levels of positive religious coping. Over half of the sample entered, including purpose in life, perceived social support and
agreed strongly with only one item of the RCOPE-N subscale the RCOPE-P. An alpha level of po.05 was used as the test for all
measuring negative religious coping. In preliminary analyses, of analyses.
the three items in the RCOPE_N subscale, only the last item (I feel
God is punishing me for my sins or lack of spirituality) was
signicantly associated with higher total TSSC (PTSD and depres- 3. Results
sive symptoms) score. This last item was thus included in the nal
model in lieu of the full RCOPE-N subscale. For positive religious Table 1 summarizes demographic characteristics and earth-
coping, the full RCOPE-P subscale was included in the nal model. quake exposure. Over half of the participants had some level of
Five hierarchical multivariate linear regression analyses were college education. A large majority of participants sustained home
conducted, with total TSSC symptom scale score, TSSC-PTSD and damage and became homeless as a result of the earthquake.
A third of the sample lost at least one close family member.
Table 1 Table 2 lists mean symptom scale and psychosocial scale scores.
Demographic characteristics and trauma exposure. Almost 65% of the participants met criteria for probable PTSD
(60% of male and over 80% of female participants). Table 3 shows
Variables (n 182200)a the percentage of responses for each item of the RCOPE. Notably,
Age (years), mean (SD) 37.7 (11.7)
the majority of the population demonstrated high levels of
Gender, n (%) positive religious coping. Over half of the sample agreed strongly
Male 161 (80.5%) with only the last item of the RCOPE-N subscale, mentioned above
Marital status, n (%) (I feel God is punishing me for my sins or lack of spirituality).
Married 157 (78.5%)
Table 4 shows the correlation matrix for all variables. Female
Education, n (%)
Illiterate 11 (5.5%) gender and loss of close family members were positively corre-
Below 6th grade 14 (7.0%) lated with total TSSC score, while higher education showed a
6th to 8th grade 17 (8.5%) negative correlation with total TSSC score. Further, loss of close
High school graduate 37 (18.5%) family members was also positively correlated with negative
Some college 83 (41.5%)
College graduate 38 (19.0%)
emotions, and higher education was positively correlated with
Distance from Epicenter (miles), mean (SD) 29.2 (25.6) positive emotions and negatively correlated with negative emo-
Sustained home damage, n (%) 183 (91.5%) tions. Purpose in life was negatively correlated with total TSSC
Became homeless, n (%) 163 (81.5%) score and negative emotions, and positively correlated with
Family deaths, n (%)
positive emotions. Two items of the negative religious coping
0. No relatives were lost 87 (43.5%)
1. Lost at least one relative but no deaths in categories 46 (23.0%) subscale were each signicantly positively correlated with total
2 or 3 TSSC scores: I express my anger at God and I feel God is
2. Lost at least one close relative (sister, parent) 40 (20.0%) punishing me for my sins or lack of faith. Both statements were
but no deaths in category 3 also signicantly negatively correlated with purpose in life.
3. Lost at least one very close relative (spouse, child, 27 (13.5%)
grandchild)
Higher perceived social support was positively correlated with
female gender, higher education and positive emotions, and
a
n varies due to missing data. negatively correlated with negative emotions.

Table 2
Psychometric properties for TSSC scores and psychosocial variables.

n192198a

Variables, mean (SD) Possible range M or % SD

TSSC-total score 069 38.4 15.91

TSSC-PTSD subscale score 051 29.61 11.60
Probable PTSDb 64.6%
Male 60.4%
Female 82.1%
TSSC-depression subscale score 018 8.70 5.11
PANAS-positive subscale score 1050 32.25 6.54
PANAS-negative subscale score 1050 26.76 8.43
Social support 0100 61.14 30.29
Purpose in life 848 31.33 6.51
Positive religious coping 09 8.04 1.75
Negative religious coping
I wonder whether God has abandoned me 03 .89 1.28
I express my anger at God 03 .64 1.13
I feel God is punishing me for my sins or lack of spirituality 03 1.88 1.29

a
n varies due to missing data. TSSC Traumatic Stress Symptom Checklist; PTSD posttraumatic stress disorder; PANAS Positive and negative
affect schedule.
b
Probable PTSD was assigned to any participant whose mean TSSC-PTSD subscale score was at least 25.
 A. Feder et al. / Journal of Affective Disorders 147 (2013) 156163 159

Table 3
Percentage of Responses on Items of the RCOPE (n193197)a.

Items Not at all (%) A little bit (%) Moderately (%) A great deal (%)

I work together with God as partnersb 6.6 0 1.5 91.8

I wonder whether God has abandoned mec 63.7 6.7 6.2 23.3
I look to God for strength, support, and guidanceb 5.1 0.5 3.6 90.8
I express my anger at Godc 71.9 8.9 3.1 16.1
I try to nd the lesson from Godb 17.0 1.0 8.2 73.7
I feel God is punishing me for my sins or lack of spiritualityc 25.9 11.7 10.7 51.8

a
n varies due to missing data.
b
Items in the RCOPE positive religious coping subscale.
c
Items in the RCOPE negative religious coping subscale.

Table 4
Correlation matrix between all variables.

Variables 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

1
2  .28nnn
3  .17n .50nnn
4 .12  .12  .07
5  .04  .08  .24nn .02
6 .07 .13 .10  .30nnn  .02
7 .02  .12  .04  .06 .02 .11
8 .15n  .01  .02  .11 .06 .06  .003
9 .003 .07 .06  .10 .04 .06  .08 .04
10  .01  .03 .001  .24nn .06 .13 .17n .13 .25nn
11 .004  .12 .07 .17n  .07  .13  .10  .13  .27nnn  .18n
12 .15n  .10  .04 .30nnn  .05  .13 .02  .16n  .05  .08 .13
13 .25nnn  .08  .05  .26nnn  .04 .26nnn .08 .06 .15n .22nn  .32nnn  .07
14 .28nnn  .08  .06  .24nn  .07 .25nnn .05 .06 .15n .21nn . .28nnn  .06 .98nnn
15 .14  .07  .05  .23nn .06 .26nnn .13 .08 .11 .23nn  .36nnn  .11 .88nnn .77nnn
16  .10  .02 .13 .18n .01  .02 .02  .04  .04  .17n .29nnn .30nnn  .24nn  .23nn  .24nn
17 .05  .05  .12  .40nnn .10 .19nn  .01 .07 .16n .33nnn  .35nnn  .23nn .64nnn .61nnn .61nnn  .24nn

Note. 1. Gender; 2. Age; 3. Marital Status; 4.Education; 5. Distance from epicenter; 6. Loss of close relatives; 7. RCOPE-P (positive religious coping); 8. RCOPE item 2
(I wonder whether God has abandoned me); 9. RCOPE item 4 (I express my anger at God);10. RCOPE item 6 (I feel God is punishing me for my sins or lack of spirituality); 11.
Purpose in life; 12. Medical Outcomes Study Social Support Survey; 13. Traumatic Stress Symptom Checklist (TSSC)-total; 14. TSSC-PTSD (posttraumatic stress disorder)
subscale; 15. TSSC-Depression subscale; 16. positive and negative affect schedule (PANAS)-positive; 17. PANAS-negative.
n
p o .05.
nn
p o.01.
nnn
p o.001.

Six preliminary regressions were run for each item of the
RCOPE after adjusting for demographic and trauma exposure.
Only the last item of the RCOPE-N (I feel God is punishing me for
my sins or lack of spirituality) was signicantly associated with a
higher TSSC score. In the nal model predicting total TSSC score
(see Table 5), female gender, lower level of education and loss of
close family members were signicantly associated with higher
TSSC score. After adjusting for demographic characteristics, dis-
tance from the epicenter and loss of close family members, the
last item of the RCOPE-N (I feel God is punishing me for my sins or
lack of spirituality) was signicantly associated with higher TSSC
score. After adding the remaining psychosocial factors, purpose in
life was signicantly associated with lower total TSSC score; the
last item of the RCOPE-N remained associated with higher TSSC
score at the trend level. Similar predictors were associated with
higher TSSC-PTSD and TSSC-depression subscale scores, with a
few differences (see Table 5).
In analyses with self-reported positive emotions as the dependent
variable (see Table 6), higher education was signicantly associated
with higher positive emotions, while female gender was inversely
associated with positive emotions at the trend level. In the nal
model predicting self-reported positive emotions, after adjusting for
demographic characteristics, distance from epicenter and death of
family members, higher purpose in life and higher perceived social
support were signicantly associated with higher positive emotions.
Of note, these associations remained signicant even after adjusting
for total TSSC score (symptom levels) (not shown). After the addition
of all psychosocial variables, however, level of education was no
longer signicantly associated with positive emotions.
In analyses with self-reported negative emotions as the
dependent variable (see Table 6), higher education was inversely
associated with negative emotions. In the nal model, higher
education and higher purpose in life were inversely associated
with negative emotions, while a higher score on the last item of
the RCOPE-N was signicantly associated with higher negative
emotions.
4. Discussion
Over half of the participants (64.6%) met criteria for probable
PTSD three years after the event, a nding which lies on the higher
end within the range of 10% to 87% of reported PTSD prevalence
from other earthquakes (Goenjian et al., 1994; Goenjian et al., 2000;
Kessler et al., 1995; Kuo et al., 2007; McMillen et al., 2000). Findings
that female gender, lower education and loss of close family
members were associated with higher posttraumatic symptom
levels in earthquake survivors replicate previous ndings from our
work and several others (Ahmad et al., 2010; Ali et al., 2012;
Basoglu et al., 2001; Galea et al., 2005).
160 A. Feder et al. / Journal of Affective Disorders 147 (2013) 156163

Table 5
Hierarchical regression analysis for variables associated with total TSSC scores, and TSSC-PTSD and TSSC-depression subscale scores
(n 175179)a.

TSSC-total TSSC-PTSD TSSC-Depression

Modela Variable b R2 for model b R2 for model b R2 for model

1 Gender .248nn .126 .280nnn .130 .131y .074

Age .014 .043  .033
Marital status  .038  .055  .019
Education  .311nn  .291nnn  .293nnn
2 Gender .228nn .144 .258nnn .148 .119 .094
Age  .001 .034  .060
Marital status  .057  .085  .006
Education  .257nn  .239nn  .246nn
Epicenter  .031  .067 .066
Death score .172n .162n .169n
3 Gender .230nn .164 .260nnn .169 .120 .115
Age .016 .051  .036
Marital status  .067  .094  .021
Education  .214nn  .196n  .198n
Epicenter  .038  .074 .062
Death score .167n .156n .162n
R-COPE 6 .163n .163n .169n
4 Gender .220nn .205 .251nn .190 .114 .193
Age  .039 .003  .103
Marital status  .020  .056 .039
Education  .179n  .169n  .155y
Epicenter  .045  .079 .054
Death score .143n .139y .131y
R-COPE item 6 .129y .138y .122y
Purpose in life  .240nn  .195nn  .305nnn
MOS-SSS  .008  .003  .019
R-COPE Positive .023 .002 .062

a
n varies due to missing data; TSSC Traumatic Stress Symptom Checklist; PTSD posttraumatic stress disorder; RCOPE item 6 I feel
God is punishing me for my sins or lack of spirituality; MOS-SSS Medical Outcomes Study Social Support Survey, emotional/information
subscale; R-COPE positive positive religious coping.
y
p o.10.
n
po .05.
nn
p o .01.
nnn
p o .001.

Additionally, the current study found a higher purpose in life
to be associated with lower symptom levels and higher self-
reported positive emotions. A particular form of negative religious
coping, i.e., a feeling of being punished by God for ones sins or
lack of spirituality, was signicantly associated with higher
symptom levels, and this association remained at the trend level
after adjusting for purpose in life. Finally, higher perceived social
support, while not associated with symptom levels, was asso-
ciated with higher self-reported positive emotions. Associations
with negative emotions generally paralleled those of posttrau-
matic symptom levels.
The high prevalence of probable PTSD compared to that in
other studies of disaster survivors (Neria et al., 2008) may relate
to the lack of preparation and resources, as well as to the high
percentage of survivors in our sample who lost their homes
during the earthquake. As hypothesized, female gender is sig-
nicantly associated with higher trauma symptom levels in the
current study. This result supports similar ndings from previous
studies done on this population (Ahmad et al., 2010; Niaz et al.,
2007; Suhail et al., 2009) as well as earthquake studies done on
both non-Western (Basoglu et al., 2001; Karanci and Rustemli,
1995) and Western (Benight et al., 1999) populations. Lower
education and death of close family members were both signi-
cantly associated with higher symptom levels, consistent with
ndings of previous earthquake studies (Priebe et al., 2009; Wan
Chan et al., 2011; Wang et al., 2011; Xu and Song, 2011). Unlike in
the previous waves of this study, further distance from the
epicenter was not signicantly associated with lower symptom
levels.
4.1. Purpose in life
A higher sense of purpose in life was associated with both
lower PTSD and depressive symptom levels in this sample. Closely
related to having a sense of purpose is the concept of nding
meaning in life, which has been theorized to be important in
resilience after signicant adversity, beginning with the writings
of Viktor Frankl (1959), a concentration camp survivor. Traumatic
experiences directly and often violently confront an individuals
worldview and assumptions about life (Janoff-Bulman, 1992). It is
thought that successful recovery from trauma involves integrat-
ing the traumatic experience into their worldview, thus main-
taining or regaining a sense of purpose in life.
While nding meaning or purpose after severe trauma has
been an important concept in the clinical and theoretical litera-
ture, little empirical research has been done on the subject. In our
previous study of African Americans with high levels of trauma
exposure, a higher sense of purpose in life was the psychosocial
factor that most strongly differentiated the resilient and currently
psychiatrically ill groups, and also signicantly differentiated the
recovered from the currently ill groups (Alim et al., 2008). The
present study demonstrates a similar association between a sense
of purpose and lower symptom levels in trauma survivors from a
very different culture, suggesting that this potentially protective
factor may be universal. Suhail et al., 2009 found in their sample
of the Pakistan earthquake survivors a high percentage of those
suffering from PTSD symptoms as well as a general reported
mood of purposeless, no hope for the future, and the emptiness
of life.
 A. Feder et al. / Journal of Affective Disorders 147 (2013) 156163 161

Table 6 religious coping that was signicantly associated with higher

Linear regression analysis for variables associated with PANAS positive and posttraumatic symptom levels. In nal regression models, feeling
negative scales (n 178) a.
punished by God due to personal guilt remained signicantly
PANAS-P PANAS-N associated with higher negative emotions and marginally signi-
cantly associated with higher symptom levels.
Modela Variable b R2 for model b R2 for model Religion is a central cultural component in Pakistan, where an
estimated 97% of the population is Muslim (U.S. Department of
1 Age  .109 .044 .029 .186
Gender  .116 .064
State, 2006). Traditionally, the traumatized and mentally ill have
Marital status .152y  .145y sought help from faith healers and religious leaders (Mubbashar
Education .198nn  .438nnn and Saeed, 2001). In the stress literature, negative religious
2 Age  .122 .040 .009 .189 coping has been linked to higher levels of anxiety, depression
Gender  .123 .061
and posttraumatic stress symptoms in diverse populations (Ano
Marital status .156y  .119
Education .221nn  .421nnn and Vasconcelles, 2005; McConnell et al., 2006). Further, associa-
Epicenter .024 .090 tions between negative religious coping and psychopathology
Death score .083 .071 appear to be stronger in the setting of recent stress or injury
3 Age  .132 .049 .030 .246 (McConnell et al., 2006). Findings in our sample suggest that a
Gender  .125 .064
Marital status .162y  .131
particular form of negative religious coping represents a distinct
Education .192n  .360nnn vulnerability for earthquake survivors in Pakistan, which goes
Epicenter .029 .080 beyond simple spiritual discontent (abandonment by God, anger
Death score .087 .062 at God). Of interest is a related nding by Suhail et al., 2009, who
R  COPE 6  .124 .253nnn
studied a sample of 125 earthquake survivors admitted to six
4 Age  .074 .159  .026 .288
Gender  .137y .060 Lahore city hospitals shortly after the earthquake. The authors
Marital status .125  .092 found that 72% of participants reported coping by requesting
Education .084  .305nnn God to forgive their sins. By contrast, the authors note that only
Epicenter .058 .064 5% or fewer respondents reported using more adaptive strategies
Death score .126y .038
R-COPE 6  .083 .223nn
such as talking with others or future planning.
Purpose in life .249nn  .209nn The collective idea that natural disasters constitute a punishment
MOS-TOT .260nn  .101 from God for personal sins might be a fairly widespread belief in
R-COPE P .049  .072 Pakistani culture. As mentioned by Niaz (2006) referring to the
a aftermath of the 2005 earthquake in Pakistan, ysome of the nave
n varies due to missing data; PANAS-P positive and negative affect
schedule-positive affect subscale; PANAS-N positive and negative affect sche- religious leaders inadvertently said that the earthquake was to teach
dule-negative affect subscale; R-COPE item 6 I feel God is punishing me for my the evil a lesson and it was the wrath of God that led to the disaster.
sins or lack of spirituality; MOS-SSS Medical Outcomes Study Social Support Other studies in earthquake survivors, however, suggest that these
Survey, emotional/information subscale; R-COPE Positive positive religious beliefs may be more widespread across cultures. In Salvadoran
coping.
y
p o .10.
earthquake survivors, attributing the earthquake to Gods punish-
n
p o .05. ment of Mans evil behavior, violence, or lack of prayers and respect
nn
p o.01. was the most common explanation (57.3% of their sample),
nnn
p o.001. although the authors did not measure its relationship to PTSD
symptom levels (Vazquez et al., 2005). In a general population study
Further, in our sample a higher sense of purpose was sig- of predominantly Catholic earthquake survivors in LAquila, Italy,
nicantly associated with higher self-reported positive emotions, negative religious coping (including religious conict and doubt, and
even in the presence of posttraumatic symptoms. A study of a feeling of being punished or abandoned by God) was found to be
earthquake survivors in El Salvador found positive emotions to be signicantly correlated with self-reported PTSD symptom severity
as prevalent as negative emotions (Vazquez et al., 2005). Positive (Stratta et al., 2012). A clear implication from our and others
emotions are known to be associated with better physical and ndings is the need to incorporate regional religious beliefs into
mental health, and promote more adaptive and effective coping psychological interventions for earthquake survivors, including
(Cohn et al., 2009; Folkman, 2008; Ong et al., 2006). In empirical education about the natural causes of earthquakes and involvement
studies, positive emotions were found to foster efcient emotion of religious leaders.
regulation and faster physiological recovery from stress (Tugade In the current study, none of the items in the positive religious
and Fredrickson, 2004). In stressful situations, the ability to coping subscale of the RCOPE were found to be associated with
experience positive alongside negative emotions is thus thought symptom levels. While reports in the literature on positive
to serve a protective function. Further, Fredrickson (2001) postu- religious coping and mental health have been less consistent
lated a relationship between positive emotions and nding (Witvliet et al., 2004), positive religious coping has generally been
positive meaning after life events. In a study of veterans living associated with healthier adjustment to stress and lower depres-
with spinal cord injury, purpose in life was not only signicantly sion levels (Ano and Vasconcelles, 2005; Koenig, 2009; Smith
associated with but also accounted for a large portion of the et al., 2003). In our sample, the majority of participants reported
variance in psychological wellbeing (deRoon-Cassini et al., 2009). uniformly high levels of positive religious coping. This narrow
variability might account for the lack of association between
4.2. Religious coping positive religious coping and symptom levels.

Of the three aspects of negative religious coping measured in
this sample, feeling abandoned by God, expressing anger at God,
and a feeling of being punished by God for ones sins or lack of
spirituality, the third item was endorsed by over half of the
respondents. After adjusting for demographic characteristics and
trauma severity, it was only this particular form of negative
4.3. Social support
While perceived social support was not signicantly asso-
ciated with PTSD symptom levels, it was signicantly associated
with self-reported positive emotions. Social support has been
linked to better wellbeing and health in a range of populations,
162 A. Feder et al. / Journal of Affective Disorders 147 (2013) 156163
and has been found to foster adaptive coping (Charuvastra and
Cloitre, 2008; Southwick et al., 2005). In prior studies of earth-
quake survivors, social support was associated with positive
adjustment, better quality of life and more adaptive coping
strategies (Ke et al., 2010; Tang, 2006; Wang et al., 2011) and
lower PTSD symptom levels in several studies of earthquake
survivors in Pakistan (Ali et al., 2012; Ehring et al., 2011;
Naeem et al., 2011) and other countries (Altindag et al., 2005;
Benight et al., 1999; Xu and Song, 2011), but not all studies of
earthquake survivors (Klc- et al., 2006). A study that examined a
non-traumatized Pakistani population found social support to be
a strong predictor of subjective wellbeing in this culture (Suhail
and Chaudhry, 2004).
This study investigated risk and potentially protective factors
for PTSD and depressive symptoms in Pakistani earthquake
survivors with no or limited access to mental health intervention.
Limitations include the recruitment of a sample of convenience, a
modest sample size, and the cross-sectional nature of the study.
Future longitudinal studies should be conducted to clarify causal
relationships.
Our study adds to the growing number of studies conducted in
survivors of the 2005 earthquake in Pakistan, and to the literature
on earthquake survivors in general. We show a high prevalence of
PTSD symptoms three years after the earthquake, and extend
prior ndings on risk factors to this population. Some potentially
protective factors, such as a sense of purpose in life and perceived
social support, appear to be protective across a wide range of
traumatic events and cultures. Our ndings also suggest that
PTSD symptom levels and negative emotions are linked to the use
of a particular form of negative religious coping, a nding that has
begun to emerge in earthquake survivors from populations and
countries where religion is central to the culture. Findings from
our study and others can inform the development of preventive
and treatment interventions for earthquake survivors, as Pakistan
continues to move forward in developing its mental health care
services.
Role of funding source
There was no funding source for this study (funded by investigators
themselves).
Conict of interest
The authors have no conicts of interest to report.
Acknowledgements
The authors wish to thank the following individuals in Pakistan whose
contributions helped us with data collection and recruitment logistics: Shahid-
Ghafoor, MBBS, Khalid Hussain, and Nisar Ahmad. Special thanks to RiffatAra
Ahmad, MBBS, AamirSajjadHaider, and SahidGhafoor, MBBS, for assistance with
translation services. We also thank William Taboas, MA, and Gerardo Acosta for
assisting with data entry and verication.
References
Ahmad, S., Feder, A., Lee, E.J., Wang, Y., Southwick, S.M., Schlackman, E., Buchholz,
K., Alonso, A., Charney, D.S., 2010. Earthquake impact in a remote South Asian
population: psychosocial factors and posttraumatic symptoms. Journal of
Traumatic Stress 23, 408412.
Ali, M., Farooq, N., Bhatti, M.A., Kuroiwa, C., 2012. Assessment of prevalence and
determinants of posttraumatic stress disorder in survivors of earthquake in
Pakistan using Davidson Trauma Scale. Journal of Affective Disorders 136,
238243.
Alim, T.N., Feder, A., Graves, R.E., Wang, Y., Weaver, J., Westphal, M., Alonso, A.,
Aigbogun, N.U., Smith, B.W., Doucette, J.T., Mellman, T.A., Lawson, W.B.,
Charney, D.S., 2008. Trauma, resilience, and recovery in a high-risk African
American population. American Journal of Psychiatry 165, 15661575.
Altindag, A., Ozen, S., Sir, A., 2005. One-year follow-up study of posttraumatic
stress disorder among earthquake survivors in Turkey. Comprehensive Psy-
chiatry 46, 328333.
Ano, G.G., Vasconcelles, E.B., 2005. Religious coping and psychological adjustment
to stress: a meta-analysis. Journal of Clinical Psychology 61, 461480.
Basoglu, M., Salcioglu, E., Livanou, M., Ozeren, M., Aker, T., Kilic, C., Mestcioglu, O.,
2001. A study of the validity of a screening instrument for traumatic stress in
earthquake survivors in Turkey. Journal of Traumatic Stress 14, 491509.
Benight, C.C., Swift, E., Sanger, J., Smith, A., Zeppelin, D., 1999. Coping self-efcacy
as a mediator of distress following a natural disaster. Journal of Applied Social
Psychology 29, 24432464.
Charuvastra, A., Cloitre, M., 2008. Social bonds and posttraumatic stress disorder.
Annual Review of Psychology 59, 301328.
Cohn, M.A., Fredrickson, B.L., Brown, S.L., Mikels, J.A., Conway, A.M., 2009.
Happiness unpacked: positive emotions increase life satisfaction by building
resilience. Emotion 9, 361368.
deRoon-Cassini, T.A., de, S., Valvano, A., Hastings, J., Horn, P., 2009. Psychological
well-being after spinal cord injury: perception of loss and meaning making.
Rehabilitation Psychology 54, 306314.
Ehring, T., Razik, S., Emmelkamp, P.M., 2011. Prevalence and predictors of
posttraumatic stress disorder, anxiety, depression, and burnout in Pakistani
earthquake recovery workers. Psychiatry Research 185, 161166.
Feder, A., Nestler, E.J., Charney, D.S., 2009. Psychobiology and molecular genetics of
resilience. Nature Reviews Neuroscience 10, 446457.
Folkman, S., 2008. The case for positive emotions in the stress process. Anxiety,
Stress & Coping 21, 314.
Frankl, V.E., 1959. Mans Search for Meaning. Beacon Press, Boston, MA.
Fredrickson, B.L., 2001. The role of positive emotions in positive psychology: the
broaden-and-build theory of positive emotions. American Psychologist 56,
218226.
Fredrickson, B.L., 2004. The broaden-and-build theory of positive emotions.
Philosophical Transactions of the Royal Society B: Biological Sciences 359,
13671377.
Galea, S., Nandi, A., Vlahov, D., 2005. The epidemiology of post-traumatic stress
disorder after disasters. Epidemiologic Reviews 27, 7891.
Goenjian, A.K., Najarian, L.M., Pynoos, R.S., Steinberg, A.M., et al., 1994. Posttrau-
matic stress disorder in elderly and younger adults after the 1988 earthquake
in Armenia. American Journal of Psychiatry 151, 895901.
Goenjian, A.K., Steinberg, A.M., Najarian, L.M., Fairbanks, L.A., Tashjian, M., Pynoos,
R.S., 2000. Prospective study of posttraumatic stress, anxiety, and depressive
reactions after earthquake and political violence. American Journal of Psy-
chiatry 157, 911916.
Hashmi, S., Petraro, P., Rizzo, T., Nawaz, H., Choudhary, R., Tessier-Sherman, B.,
Kasl, S., Nawaz, H., 2011. Symptoms of anxiety, depression, and posttraumatic
stress among survivors of the 2005 Pakistani earthquake. Disaster Medicine
and Public Health Preparedness 5, 293299.
Hoge, E.A., Austin, E.D., Pollack, M.H., 2007. Resilience: research evidence and
conceptual considerations for posttraumatic stress disorder. Depression and
Anxiety 24, 139152.
Irmansyah, I., Dharmono, S., Maramis, A., Minas, H., 2010. Determinants of
psychological morbidity in survivors of the earthquake and tsunami in Aceh
and Nias. International Journal of Mental Health Systems 4, 110.
Janoff-Bulman, R., 1992. Shattered Assumptions: Towards a New Psychology of
Trauma. Free Press, New York.
Karanci, A.N., Rustemli, A., 1995. Psychological consequences of the 1992 Erzincan
(Turkey) earthquake. Disasters 19, 818.
Ke, X., Liu, C., Li, N., 2010. Social support and quality of life: a cross-sectional study
on survivors eight months after the 2008 Wenchuan earthquake. BMC Public
Health 10 573-573.
Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., et al., 1995. Posttraumatic stress
disorder in the National Comorbidity Survey. Archives of General Psychiatry
52, 10481060.
Klc- , C., Aydn, _I., Tas-kntuna, N., Ozc- urumez, G., Kurt, G., Eren, E., Lale, T., Ozel, S.,
Zileli, L., 2006. Predictors of psychological distress in survivors of the 1999
earthquakes in Turkey: effects of relocation after the disaster. Acta Psychia-
trica Scandinavica 114, 194202.
Koenig, H.G., 2009. Research on religion, spirituality, and mental health: a review.
Canadian Journal of Psychiatry 54, 283291.
Kuo, H.W., Wu, S.J., Ma, T.C., Chiu, M., Chou, S., 2007. Posttraumatic symptoms
were worst among quake victims with injuries following the Chi-chi quake in
Taiwan. Journal of Psychosomatic Research 62, 495500.
Lommen, M.J., Sanders, A.J., Buck, N., Arntz, A., 2009. Psychosocial predictors of
chronic post-traumatic stress disorder in Sri Lankan tsunami survivors.
Behaviour Research and Therapy 47, 6065.
McConnell, K.M., Pargament, K.I., Ellison, C.G., Flannelly, K.J., 2006. Examining the
links between spiritual struggles and symptoms of psychopathology in a
national sample. Journal of Clinical Psychology 62, 14691484.
McMillen, J., North, C.S., Smith, E.M., 2000. What parts of PTSD are normal:
intrusion, avoidance, or arousal? Data from the Northridge, California, earth-
quake. Journal of Traumatic Stress 13, 5775.
Mubbashar, M.H., Saeed, K., 2001. Development of mental health services in
Pakistan. Eastern Mediterranean Health Journal 7, 392396.
Naeem, F., Ayub, M., Masood, K., Gul, H., Khalid, M., Farrukh, A., Shaheen, A.,
Waheed, W., Chaudhry, H.R., 2011. Prevalence and psychosocial risk factors of
PTSD: 18 months after Kashmir earthquake in Pakistan. Journal of Affective
Disorders 130, 268274.
Neria, Y., Nandi, A., Galea, S., 2008. Post-traumatic stress disorder following
disasters: a systematic review. Psychological Medicine 38, 467480.
 A. Feder et al. / Journal of Affective Disorders 147 (2013) 156163
Niaz, U., 2006. Role of faith and resilience in recovery from psychotrauma.
Pakistan Journal of Medical 22, 204207.
Niaz, U., Hassan, S., Hassan, M., 2007. Post-traumatic stress disorder (PTSD),
depression, fear and avoidance in destitute women, earthquake survivors of
NWFP, Pakistan. Journal of Pakistan Psychiatric Society 4, 4449.
Ong, A.D., Bergeman, C., Bisconti, T.L., Wallace, K.A., 2006. Psychological resilience,
positive emotions, and successful adaptation to stress in later life. Journal of
Personality and Social Psychology 91, 730749.
Pargament, K.I., Koenig, H.G., Perez, L.M., 2000. The many methods of religious
coping: development and initial validation of the RCOPE. Journal of Clinical
Psychology 56, 519543.
Pietrzak, R.H., Goldstein, M.B., Malley, J.C., Rivers, A.J., Johnson, D.C., Morgan III,
C.A., Southwick, S.M., 2010. Posttraumatic growth in veterans of Operations
Enduring Freedom and Iraqi Freedom. Journal of Affective Disorders 126,
230235.
Pietrzak, R.H., Russo, A.R., Ling, Q., Southwick, S.M., 2011. Suicidal ideation in
treatment-seeking Veterans of Operations Enduring Freedom and Iraqi Free-
dom: the role of coping strategies, resilience, and social support. Journal of
Psychiatric Research 45, 720726.
Priebe, S., Grappasonni, I., Mari, M., Dewey, M., Petrelli, F., Costa, A., 2009.
Posttraumatic stress disorder six months after an earthquake: ndings from
a community sample in a rural region in Italy. Social Psychiatry and
Psychiatric Epidemiology 44, 393397.
Ryff, C.D., Keyes, C.L.M., 1995. The structure of psychological well-being revisited.
Journal of Personality and Social Psychology 69, 719727.
Sherbourne, C.D., Stewart, A.L., 1991. The MOS social support survey. Social
Science & Medicine 32, 705714.
Smith, T.B., McCullough, M.E., Poll, J., 2003. Religiousness and depression:
evidence for a main effect and the moderating inuence of stressful life
events. Psychological Bulletin 129, 614636.
Southwick, S.M., Vythilingam, M., Charney, D.S., 2005. The psychobiology of
depression and resilience to stress: implications for prevention and treatment.
Annual Review of Clinical Psychology 1, 255291.
Stratta, P., Capanna, C., Riccardi, I., Carmassi, C., Piccinni, A., DellOsso, L., Rossi, A.,
2012. Suicidal intention and negative spiritual coping one year after the
earthquake of LAquila (Italy). Journal of Affective Disorders 136, 12271231.
163
Suhail, K., Chaudhry, H.R., 2004. Predictors of subjective well-being in an Eastern
Muslim culture. Journal of Social and Clinical Psychology 23, 359376.
Suhail, K., Malik, F., Mir, I.A., Hasan, S.S., Sarwar, A., Tanveer, S., 2009. Psychological
health of earthquake survivors in Pakistan. Psychology and Developing
Societies 21, 183207.
Tang, C.S., 2006. Positive and negative postdisaster psychological adjustment
among adult survivors of the Southeast Asian earthquake-tsunami. Journal
of Psychosomatic Research 61, 699705.
Tugade, M.M., Fredrickson, B.L., 2004. Resilient individuals use positive emotions
to bounce back from negative emotional experiences. Journal of Personality
and Social Psychology 86, 320333.
U.S. Department of State, Bureau of Democracy, Human Rights and Labor , 2006.
International Religious Freedom Report.
Vazquez, C., Cervellon, P., Perez-Sales, P., Vidales, D., Gaborit, M., 2005. Positive
emotions in earthquake survivors in El Salvador (2001). Journal of Anxiety
Disorders 19, 313328.
Wan Chan, C.L., Wang, C., Qu, Z., Lu, B.Q., Ran, M., Yan Ho, A.H., Yuan, Y., Zhang,
B.Q., Wang, X., Zhang, X., 2011. Posttraumatic stress disorder symptoms
among adult survivors of the 2008 Sichuan earthquake in China. Journal of
Traumatic Stress 24, 295302.
Wang, B., Ni, C., Chen, J., Liu, X., Wang, A., Shao, Z., Xiao, D., Cheng, H., Jiang, J., Yan,
Y., 2011. Posttraumatic stress disorder 1 month after 2008 earthquake in
China: Wenchuan earthquake survey. Psychiatric Research 187, 392396.
Watson, D., Clark, L.A., Tellegen, A., 1988. Development and validation of brief
measures of positive and negative affect: the PANAS scales. Journal of
Personality and Social Psychology 54, 10631070.
Witvliet, C., Phipps, K., Feldman, M., Beckham, J., 2004. Posttraumatic mental and
physical health correlates of forgiveness and religious coping in military
veterans. Journal of Traumatic Stress 17, 269273.
Xu, J., Song, X., 2011. Posttraumatic stress disorder among survivors of the
Wenchuan earthquake 1 year after: prevalence and risk factors. Comprehen-
sive Psychiatry 52, 431437.
Zhao, G., Yang, Y., Zhang, Q., Zhang, S., Deng, H., Zhu, Y., Ren, Z., Lan, K., Liu, C., Tao,
Q., Wang, M., Liu, S., Zhang, Z., Chen, Y., Li, H., Geng, T., Liu, Y., Zhang, W., Sun,
X., 2009. Prevalence and related factors for PTSD in community residents after
the Wenchuan earthquake. Chinese Mental Health Journal 23, 478489.