Traumatic impact of a re disaster on survivors*A 25-year follow-up of the 1978 hotel re in Boras, Sweden

TOM LUNDIN, LENNART JANSSON

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Lundin T, Jansson L, Traumatic impact of a fire disaster on survivors*A 25-year follow-up of the 1978 hotel fire in Boras, Sweden. Nord J Psychiatry 2007;61: 479485. Oslo. ISSN 0803 9488. The objective of this study was to investigate the long-term psychological and mental health outcomes among survivors of a disastrous hotel fire. A 25-year follow-up investigation among adolescent and young adult survivors of a fire disaster was conducted in Boras, Sweden. A self evaluation questionnaire and four self-rating scales*the IES-22, PTSS-10, GHQ-28 and SoC* were sent by mail to the participants. The results from the self-reported data showed low levels of psychiatric illness. Moreover, the respondents reported a low level of traumatic stress symptoms. More than 50% of the participants stated that the fire had a determining effect on their lives. Sixteen (21.3%) respondents indicated that the fire still had an impact on their daily lives. Differences between men and women were reported in most of the self-rating scales. The results indicate that a traumatizing experience (such as a fire disaster) still had a small effect on psychological health in a long-term perspective. Bereavement, Fire disaster, Follow-up study, Post-traumatic stress disorder. Tom Lundin, M.D., Professor in Disaster Psychiatry Kunskapscentrum for katastrofpsykiatri, Department of Neuroscience, UppsalaUniversity, S-750 17 Uppsala, Sweden, E-mail: tom.lundin@neuro. uu.se; Accepted 29 November 2006.

n 9 June 1978, the spring term of all Swedish schools ended, which meant that thousands of young people between 19 and 22 years of age were celebrating their graduation. This also was the case in Boras, a town of little more than 100,000 inhabitants in the centre of the former textile industry area 60 km east of Gothenburg. On this evening, one of the main hotels in Boras, The City Hotel, had over 500 young guests in the hotels two restaurants, the nightclub and the disco. In the early morning of 10 June, at 2.35 a.m., during the last dance, a violent fire broke out in the hotel. It started with an explosion on the first floor and within a few minutes, the entire structure was like an inferno with black smoke, heat and chaos. When the fire started, over 180 persons were still in the two restaurants; 20 of these persons died, 66 were somatically injured, 85 were uninjured survivors and 17 were hotel and restaurant employees. The grief reactions following the sudden and unexpected bereavement in a 2-year follow-up have been published earlier (1). The most common somatic injuries were fractures, distortions, burn injuries, and pulmonary and other smoke injuries. In total, 55.1% of the survivors

reported the loss of a very close friend in the fire. Most survivors reported post-traumatic stress symptoms in the acute phase as well as 3 months later. Nightmares were reported by 20.1% of the surviving boys and 54.5% of the surviving girls. The most common reactions were fear, phobic symptoms, guilt feelings, numbing and a changed view of life. At a 2-year follow-up, one-third of the personally interviewed survivors felt they had got over the impact of the disaster (1). In a 10-year follow-up study (2), 20% of the survivors still experienced symptoms of post-traumatic stress disorder (PTSD), and most of the survivors felt that it had changed their view of life. Questions about the meaning, value and purpose of life had become more important, and the survivors adopted a more humble attitude toward life. In particular, the male survivors appeared to be a high-risk group for developing PTSD and pathological grief reactions.

Aims of the study

The aim of the present follow-up study is to investigate the long-term psychological and mental health outcome among survivors 25 years after the disastrous hotel fire.
DOI: 10.1080/08039480701773329

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Material and Methods

Procedure and sample
In April 2003, the complete addresses could be obtained for 111 survivors still living in Sweden after the 1978 hotel fire in Boras. A self-evaluation questionnaire and four self-administrated scales (IES-22, PTSS-10, GHQ28 and SoC-12) were sent to the home of the participants. After completion, the questionnaire and the scales were returned by mail to the principal author (TL).

Analysis
The data were analysed by comparing answers from the questionnaire with the IES-22, PTSS-10, GHQ-28 and SoC-12. A special analysis has been done concerning the variables gender, educational level, somatic injury, bereaved/non-bereaved, psychological support or treatment, psychological recovery today, if the fire had a determinative effect on the respondents life, and if the fire has an impact on the present daily life of the respondents. Chi-square statistics was used for categorical variables in testing for differences between groups. Students t-test and one-way analysis of variance (ANOVA) were performed on the continuous dependent variables. Post hoc pairwise comparisons were made using Bonferroni test statistics. The statistical software was SPSS for Windows (Statistical Package for Social Science, version 13.0.1). All reported P-values were twotailed, with P B0.05 considered statistically significant.

Instruments
A self-assessment questionnaire was designed to gain information on demographic variables, the frequency and sequel of somatic and psychic injuries, personal losses and subsequent traumatic events after the fire experience. The questionnaire is based on the social readjustment rating scale (3) and present health status. A revised version of the Impact of Event Scale, IES-22 (4), was used in the present study (IES-r). The original scale (i.e. the IES-15) has proved to have high validity (5). It included two sub-scales indicating the degree of intrusion and avoidance. The respondents are asked to score their frequency of post-traumatic stress symptoms. The revised version (i.e. the IES-22) included the 15 items of the original version plus seven additional items to assess hyperarousal symptoms; the respondents are instead asked to indicate how distressing each symptom has been during the past 7 days. The Post-Traumatic Symptom Scale, PTSS-10, was originally (6) a dichotomized questionnaire with the following items: sleep disturbances, nightmares, depressed feelings, startle reactions, isolation, irritability, instable mood, guilt feelings, fear for reminders and muscular tension. In the revised version (7) used here, the respondents are asked to indicate the frequency of the items on a 7-point scale. The General Health Questionnaire, GHQ-28 (8), is an excerpt from the GHQ-60 (9) self-rating questionnaire developed to measure four areas of health: somatic symptoms, anxiety and sleep disturbances, social dysfunction, and serious depression. The GHQ-28 contains the most significant items found after using regression analysis of the GHQ-60 questionnaire. The Sense of Coherence Scale, SoC-12 (10, 11), measures aspects of the individuals personality, which might be important for the salutogenesis (0factors promoting a good health status), i.e. how the respondent looks upon his own life regarding comprehensibility, manageability and meaningfulness. However, in the acute phase after traumatization and for persons with psychiatric disorders, the scale is more likely to measure the level of depression. The cut-off score for a high degree of coherence is 60.
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Results
After one reminder, 78 (46 males and 32 females) of the 111 survivors (70.3%) agreed to participate. Except for four, these 78 individuals were at the time of the study between 40 and 51 years of age. The four other persons, former restaurant employees, were between the 54 and 72 years old. Concerning civil status and living conditions, 78% of the respondents were married or living together. The respondents level of education was basal level (n 026), medium level (n024) or university level (n028). Basal level pertains to primary or secondary school and medium level refers to college or a comparable educational level. Educational level was more frequently higher in the male respondents (P B0.01). The majority (81%) of the respondents were working full-time and 13% part-time at the time of this study. Twenty-three (or 30%) survivors were somatically injured and 58% (n 045) had lost a very close friend in the fire. Twenty-four (31%) respondents indicated that they had developed psychological problems after the fire and 17 (22%) of these considered these problems to be caused by the fire disaster. Only five (6%) persons indicated that they had psychological problems before the tragedy. Eight persons had received some kind of treatment, such as counselling or crisis intervention. Almost all the respondents (n 072) reported full psychological recovery. Forty-one (53.2%) respondents felt that the fire had a determining effect on their lives and 16 (21.3%) indicated that the fire still had an impact on their daily life today. The degree of long-term traumatization of the respondents experience of fire was measured using the IES-22. A low level of IES scores was reported,
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indicating an overall good psychological health status 25 years after being traumatized by the hotel fire. There were significant differences between males and females, both totally and in all sub-scales (Table 1). The gender difference also explains the difference in IES scores between respondents with high and low education levels since there were significantly more males in the high education group. Respondents with somatic injuries scored significantly (P B0.01) higher on the IES scale than respondents without somatic injuries. A similar (P B0.05) difference was found between bereaved and non-bereaved respondents, i.e. the bereaved respondents scored significantly higher on the IES scale. The mean IES value for respondents who were not fully recovered psychologically (n06) was 25.7, which differed significantly (P B0.01) from the rest of the respondents. The GHQ-28 was used to measure the respondents general health status (Table 2). Scoring more than 5 on a sub-scale might indicate poor health concerning somatic symptoms, anxiety and sleep disorders, social dysfunction, or depression. The overall impression from these data is that the respondents were in good psychological health at this follow-up. There were, however, significant or near significant gender differences in all sub-scales, except somatic symptoms. Respondents who had been psychologically treated for their trauma-related symp-

toms (n 08) reported significantly (P B0.05) poorer health status as compared with untreated respondents, suggesting that only survivors with health problems had been given treatment. Eight respondents who had been given psychological treatment or support reported lower scores on the SoC-12 scale (mean score050.9); all other respondents reported scores higher than 60 (Table 3). Male survivors scored significantly higher than female survivors (P B0.001) on the SoC. There were also significant differences between respondents on the comprehensibility, manageability and meaningfulness sub-scales. Respondents who reported that the fire had a determining effect on their lives scored slightly but significantly (P B0.05) lower on the SoC. When using the PTSS-10 self-evaluation scale, significant differences were observed in six of the eight variables, the exceptions being educational level and personal losses in the fire (bereavement) (Table 4). Several respondents reported several traumatic life events many years after the fire (Table 5). The majority (n069) of respondents reported between three and six traumatic events. Finally, there were significant differences between respondents with high stress and low stress load on the IES, GHQ and PTSS scales (Table 6).

Table 1. Self-evaluation for some subgroups of survivors by help of the Revised Impact of Events Scale (IES-22; mean values).
n Total Gender Men Women Educational level Basal level Medium level University level Somatic injured Somatic uninjured Bereaved Non-bereaved Psychological support/treatment With Without Fully psychological recovery today Yes No Fire had a determining effect on my life Yes No Present impact if the disaster experience in daily life Yes No 78 46 32 26 24 28 23 55 45 32 8 16 72 6 41 36 16 59 IES-i 4.9 3.9 6.6** 6.2 5.6 3.2 4.9 5.0 6.1* 3.6 11.4** 6.3 4.4 11.8** 6.2** 3.4 8.5*** 3.7 IES-a 3.5 2.1 5.9*** 4.2 3.4 3.0 4.4* 3.3 4.5* 2.6 10.9 5.3 3.4 6.8** 5.0* 2.0 5.8 2.8 IES-h 2.9 1.7 4.6** 4.0 3.0 1.8 3.8** 2.5 3.3 2.3 11.0*** 4.0 2.5 7.0* 3.6 2.0 4.6** 2.1 IES-total 11.3 7.7 17.1*** 14.4 12.0 8.0 13.1** 10.9 13.9* 8.5 33.3* 15.6 10.4 25.7** 14.8* 7.4 18.9** 8.6

IES-22 and its subscales: IES-i, intrusion; IES-a, avoidance; IES-h, hyperarousal. Differences between subgroups: *PB0.05, **PB0.01 and ***P B0.001.
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Table 2. Self-evaluation for some subgroups of survivors by help of the General Health Questionnaire (GHQ-28; mean values).
Subscales n Total Gender Men Women Educational level Basal level Medium level University level Somatic injured Somatic uninjured Bereaved Non-bereaved Psychological support/treatment With Without Fully psychological recovery today Yes No Fire had a determining effect on my life Yes No 78 46 32 26 24 28 23 55 45 32 8 16 72 6 41 36 Som 4.6 4.1 5.3 4.5 4.3 4.9 5.5 4.2 4.3 4.9 8.3 5.6 4.6 4.8 5.1 4.1 6.3 4.0 Anx 5.4 5.2 5.8 4.7 6.2 5.4 6.7 4.9 5.1 5.8 10.6* 5.6 5.3 7.0 6.0 4.9 7.6 4.8 Soc 7.0 6.7 7.5 7.2 6.5 7.3 7.8 6.7 6.7 7.5 9.3 6.6 7.1 6.2 7.2 6.9 7.3 6.9 Dep 1.8 1.4 2.3* 1.8 1.8 1.9 2.2 1.6 1.7 1.8 7.5** 1.6 1.8 2.2 2.3* 1.3 2.9* 1.4 Total 18.8 17.4 21.2* 18.2 18.8 19.5 22.3 17.6 18.0 20.1 35.6* 19.4 18.9 20.2 20.8 17.2 24.1 17.3

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Present impact if the disaster experience in daily life Yes 16 No 59

GHQ-28 with subscales; Som, Somatic symptoms; Anx, Anxiety and sleep disorders; Soc, Social dysfunction; Dep, Serious depression. Range 021 for each subscale. Differences between subgroups: *PB0.05, **PB0.01 and P B0.001.

Discussion
Very few long-term follow-up studies of disaster survivors have been published as scientific reports. One of the most notable reasons for so few studies is the lack of national registers of personal code numbers. Such registers, which are available primarily in the Nordic countries, are necessary for tracing persons after several years have passed. The first Scandinavian long-term follow-up study of disaster survivors was published by Holen (12). In March 1980, the oilrig Alexander L. Kielland capsized following extremely bad weather conditions. Of the 212 men on board at the time, only 89 survived; 75 of these lived in Norway and therefore could be followed-up in a longer-term perspective. In a 9-year follow-up, 33.5% of the survivors had developed psychiatric problems corresponding to PTSD. Another oil platform disaster was the capsizing of Piper Alpha in July 1988, resulting in the deaths of 167 men and leaving 59 survivors. Forty-six of the survivors were located for a 10-year follow-up, of whom 72% (n033) agreed to be interviewed. The diagnostic criteria for PTSD were met by 21% of the survivors (13).

In February 1972, the Buffalo Creek Dam collapsed causing over 600 persons to claim some kind of intervention by mental health professionals. A 14-year follow-up study in 1986 showed that 120 adult survivors had a PTSD rate of 28% as compared with a rate of 44% in 1974, i.e. 2 years after the collapse of the dam (14). In a 17-year follow-up study, 99 of 207 child survivors (age 215 years at the time of the disaster) from floods were evaluated by self-rating scales (15). The rate of disaster-related PTSD was 7%, which should be compared with the immediate post-flood rate of 32%. There were no age differences though female survivors had more PTSD-related symptoms than male survivors. The authors concluded that the survivors seemed to have recovered from the event. In our 25-year follow-up data, 21.3% of the respondents reported that the fire still had a significant effect on their present daily lives. The self-evaluation of traumatic stress symptoms using the IES-r indicated low scores except for the six non-treated respondents who reported persisting psychological problems because of their personal experiences of the fire. The medium score for this group was 25.7. Eight respondents who had received psychological treatment for their
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Table 3. Self-evaluation for some subgroups of survivors by help of Sense of Coherence Scale and its subscales (SoC-12; mean values).
Subscales n Total Gender Men Women Educational level Basal level Medium level University level 78 46 32 26 24 28 23 55 45 32 8 16 72 6 41* 36 16 59 Com 20.2 20.8** 18.5 19.0 19.8 20.7 20.0 19.9 20.1 19.5 15.9 17.6 20.3 14.7 19.1 21.0 17.2 20.9 Man 21.1 22.3*** 19.4 20.6 21.0 21.6 20.6 21.4 20.7 21.8 16.6 19.5 21.4 17.5 20.3 22.5 18.9 22.2 Mean 22.7 23.6* 21.4 23.2 22.5 22.4 22.1 22.9 22.8 22.5 19.0 20.9 22.5 24.7 22.4 23.3** 23.3 22.8 Total 64.0 66.7** 59.3 62.8 63.3 64.7 62.7 64.1 63.6 63.9 50.9 58.0 64.3 56.8 61.7 66.8* 59.3 65.9

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Somatic injured Somatic uninjured Bereaved Non-bereaved Psychological support/treatment With Without Fully psychological recovery today Yes No Fire had a determining effect on my life Yes No Present impact if the disaster experience in daily life Yes No

Sense of Coherence and its subscales; Com, Comprehensibility; Man, Manageability; Mean, Meaningfulness. Cut-off score for a high degree of coherence is 60. Differences between subgroups: *PB0.05, **PB0.01 and ***P B0.001.

symptoms, which they correlated to the trauma experience, had an IES-r score of 33.3, a score that might indicate PTSD. However, no personal interviews have been carried out to confirm the PTSD diagnosis. If we assume that eight of 78 respondents have long-term PTSD, the morbidity rate would be 10.3%, which could be compared with the 28% found in the 14-year followup after the Buffalo Creek flood disaster (14). Traumatic events (such as the Boras hotel fire) in the post-disaster period might have a significant impact on present mental health. Thus, such events must be considered when assessing the self-evaluation scores. If we assume that up to four stressful life events during a 25-year period are what could be expected and that between five and seven events represent a high stress load, then this might have strongly influenced both the IES and the GHQ scores. However, in the IES instrument, the respondents were asked to evaluate their stress symptoms with reference to their experience of the fire. Although the scores were very low, significant differences were found between men and women on general health status as measured by the GHQ scale. The cluster
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of symptoms reflecting social dysfunction was the only area of health in the GHQ with a clinically significant level (5). The extremely low scoring in depressive symptoms was also evident in the SoC. This scale apparently reflects degree of depression as well as sense of coherence. Differences in SoC scores between men and women were significant, both totally and in the three sub-scales, but still on a high level. The survivors in this study were socially well adjusted with a low unemployment rate (6%) and almost 80% were either married or living together (partner). This fact might explain why the sense of coherence was, overall, relatively high. The significant difference between men and women on level of education might explain the seemingly, but non-significant, difference in IES scores for respondents of varying educational levels. The PTSS-10 self-rating scale has been used for nearly 30 years to assess the most prominent traumatic stress symptoms. Thus, the instrument is likely to be as well validated as the IES-r. Comparing PTSS-10 and IES-r in regard to the significant differences in all eight variables, the results

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Table 4. Self-evaluation for some subgroups of survivors by help of the Post-Traumatic Symptom Scale, PTSS-10.
n Total Gender Men Women Educational level Basal level Medium level University level Somatic injured Somatic uninjured Bereaved Non-bereaved Psychological support/treatment With Without Fully psychological recovery today Yes No 78 46 32 26 24 28 23 55 45 32 8 16 72 6 15.3 20.6** 17.4 17.4 17.6 21.6*** 15.8 18.0 17.2 35.3** 20.1 16.5 29.5** 19.9** 14.7 22.0** 15.9 Mean

Table 6. The effects of exposure for stressful life events during the post-disaster period (25 years).
Normal strain (n046) IES-i IES-a IES-h IES Total GHQ-Som GHQ-Anx GHQ-Soc GHQ-Dep GHQ-Total SoC-Com SoC-Man SoC-Mean SoC Total PTSS-10 4.2 4.7 2.4 11.7 4.0 4.5 6.7 1.1 16.4 20.5 21.6 22.8 64.9 16.1 High stress load (n032) 6.2 6.1 3.5 18.1 5.5 6.8 7.5 2.8 22.5 18.9 20.5 22.6 62.1 19.4 Sign 0.05 n.s. 0.05 0.05 n.s. n.s. n.s. 0.001 0.05 n.s. n.s. n.s. n.s. 0.01

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Fire had a determining effect on my life Yes 41 No 36 Present impact if the disaster experience in daily life Yes 16 No 59

Differences between subgroups: *P B0.05, **P B0.01 and ***P B0.001.

Normal strain (04) and high stress load (57). The Revised Impact of Events Scale, IES-r (range 088), and its subscales: IES-i, intrusion; IES-a, avoidance; IES-h, hyperarousal. The General Health Questionnaire, GHQ-28, with its subscales: GHQSom, Somatic symptoms; GHQ-Anx, Anxiety and sleep disorders; GHQ-Soc, Social dysfunction; GHQ-Dep, Serious depression; range 021 for each subscale. Sense of Coherence Scale, SoC, and its subscales: SoC-Com, Comprehensibility; SoC-Man, Manageability; SoC-Mean, Meaningfulness. Cut-off score for a high degree of coherence is 60. The Post-Traumatic Symptom Scale, PTSS-10: range 17 for each item: total maximum 70.

are of equal significance except for bereavement. The IES scale seems to be more reasonable than the PTSS scale in assessing long-term traumatic grief symptoms. The only high-scoring group for all the scales was the group that had been psychologically treated for traumatic stress symptoms directly after the disaster (n 08). This finding only reflects the fact that these survivors were those who were the most traumatized ones. It has been assumed in the past that there is little or no change in the frequency of PTSD in survivors 18 months after a major disaster. According to two of the Buffalo
Table 5. Subsequent stressful life events in the post-disaster period.
Type of event Raising a family Death of other close relative First-time parenthood Close relatives serious illness Other type of separation than divorce Fired/dismissed Somatic injury/illness Divorce Retired Death of a spouse Imprisonment n 67 62 56 41 28 25 24 12 4 1 1

Creek studies (14, 15) and the present study, it is reasonable to assume that the incidence of PTSD, or at least traumatic stress reactions, decreased over the years: 44% after 2 years, 28% after 14 years, 7% after 17 years (only children), and about 10% in our study. It is somewhat difficult and uncertain to even compare flood survivors with fire disaster victims, however.

Conclusions
The results of our 25-year follow-up of young students who had survived a serious fire disaster show a low level of psychiatric illness. Traumatic stress symptoms were reported on a low level. More than 50% stated that the fire had a determining effect on their lives, but the fire had only for 21% a present impact on daily life. The disaster seems thus to have had an important impact, maybe with a new view of life and a change in social functioning, but without an increased psychiatric morbidity.
Acknowledgements*We will thank Ewa Johansson and Lena Tillander for skilful administrative support during all phases of this study. Many thanks also to Lars Weisaeth for inspiring me (TL) in this long-term follow-up.

References
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11. Antonovsky A. Unravelling the mystery of health. How people manage stress and stay well. San Francisco, CA: Jossey-Bass; 1987. 12. Holen A. A long-term outcome study of survivors from a disaster. The Alexander L. Kielland disaster in perspective. Dissertation, Oslo University; 1990. 13. Hull AM, Alexander DA, Klein S. Survivors of the Piper Alpha oil platform disaster: Long-term follow-up study. Br J Psychiatry 2002;181:4338. 14. Green BL, Lindy JD, Grace MC, Gleser GC, Leonard AC, Korol M, et al. Buffalo Creek survivors in the second decade: Stability of stress symptoms. Am J Orthopsychiat 1990;60:4354. 15. Green BL, Garce MC, Vary MG, Kramer TL, Gleser GC, Leonard AC. Children of disaster in the second decade: A 17-year follow-up of the Buffalo Creek survivors. J Am Acad Child Adolesc Psychiatry 1994;33:719.
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Tom Lundin, M.D. Ph.D., Department of Neuroscience, Psychiatry, University of Uppsala, Sweden., and National Center for Disaster Psychiatry, University of Uppsala, Sweden. Lennart Jansson, Ph.D., Department of Neuroscience, Psychiatry, University of Uppsala, Sweden.

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