Mental health consequences of the Lockerbie Disaster

Journal of Traumatic Stress, VoL 5, No. 4, 1992

Mental Health Consequences of the Lockerbie Disaster

Neil Brooks' and William McKinlay2

This paper examines mental health consequences of the Lockerbie Disaster in 66 adults claiming compensation fiom the insurers of the airline. Claimants were examined 10 to 14 months after the disaster by clinical interview and questionnaires. The most fjequent diagnoses were post-traumatic stress disorder and depression, followed by other anxiety disorders. Many were above "caseness" levels on questwnnaires, and had very high scores on intrusion and avoidance. There were no significant predictors of the presence or severity of diagnosis, but a number of predictors (age, death of fiends, exposure to unpleasant sights) of questionnaire scores. KFX WORDS disaster, post-traumatic stress disorder; DSMIII-R; depression.

INTRODUCTION

Disasters have well recognized emotional consequences for victims and others associated with the disaster (Adler, 1943; Baum et aL, 1983; Lima et al-, 1989; McFarlane, 1988a; Tichener and Kapp, 1976). The consequences include a range of affective changes which may be short lived, or cyclical, or chronic (McFarlane, 1988a). Some victims are unaffected; others have very severe and chronic emotional reactions including posttraumatic stress disorder (PTSD), depression, panic disorder, and substance abuse. Even when the victim is recovered, he/she appears to have increased

'Department of Psychological Medicine, 6 Whittingehame Gardens, Great Western Road, Glasgow, G12 OAA. Tel. No.: 041-334-9826; and Case Management Services, 5 Deanpark Brae, Edinburgh, EH14 7DZ.

'Case Management Services, 5 Deanpark Brae, Edinburgh, EH14 7DZ. Tel. No.: 031-451-5265; and ScotCare Brain Injury Unit, ScotCare Group Ltd., Murdostoun Castle, Bonkle, Newmains, Wishaw, ML2 7BY.

527

0894-!3867/9u1wO-0527SCUj.5~ 0 1992 Plenum Publishing Corporation

528 Bmoks and McKinlay

emotional vulnerability in the event of further exposure to threatening life events (McFarlane, 1988a).

Aircraft disasters are a particular type of disaster event, involving not only passengers and crew (and their relatives), and rescue, recovery, and support personnel; but also those killed or injured on the ground, or whose property is damaged by the falling aircraft. The emotional consequences for the first two groups are increasingly recognized (Bartone et aL, 1989; Duffy, 1978), but little is written about the latter group.

In December 1988, a major aircraft disaster occurred (now known as the bckerbie Disaster). On the night of the December 21, Pan Am Flight 103 outbound from London, Heathrow, exploded over Southern Scotland, following detonation of a terrorist bomb on board. The town of Lockerbie lay directly under the flight path of the aircraft, and much of the wreckage and burning aviation fuel showered onto and around the town, resulting in a massive fireball, and an enormous rain of debris including aircraft parts and whole and dismembered bodies. All the passengers and crew on the aircraft were killed, but remarkably, only 11 residents of Lockerbie were killed.

The disaster triggered an immediate massive response from civilian and military emergency and support services, and triggered the largest mur- der inquiry ever undertaken in Scotland. Shortly after the disaster, many bckerbie residents began to institute claims for financial compensation against the insurers of Pan Am, and an enormous medicolegal exercise was begun. The claims for "psychological damages" were guided initially by a coordinating group of lawyers, who contacted the first author with a request to arrange psychological examinations of claimants. It soon became obvious that the exercise was a huge one, considerably beyond the resources of any individual examiner, and a group of examiners was brought together. These were 14 (including the authors) clinical psychologists and psychiatrists who between them examined around 800 claimants. The exact figure cannot be given as examinations are still taking place. Because of the intense speed of the operation, central coordination of examinations became impossible, but two of the examiners (the authors) agreed on a specific examination format, and designed a pro forma which enabled the collection of the data to be reported in this paper.

The paper reports on the mental health consequences of the disaster in the first 66 adult claimants who were resident in Lockerbie at the time of the disaster. The aims of the paper are to identify the demographic and other features of claimants in a huge civilian air disaster; to identify the range and severity of formally diagnosed psychiatric conditions and questionnaire measures of morbidity in such claimants; and to identify possible predictors of such diagnoses and morbidity.

Consequences of Lockerbie Disaster

METHOD

Procedure

529

Most examinations were carried out in the offices of lawyers in the town of Lockerbie, each examination lasting 60-90 min. Claimants all un- derwent an individual clinical examination, using a structure which allowed formal DSMIII-R diagnoses (American Psychiatric Association, 1987). In addition, the severity of formally diagnosed conditions was rated, and a checklist of specific symptornatology of PTSD was designed based on DSMIII-R criteria, and on the work of McFarlane (1988a,b). Finally, claimants completed a series of questionnaires concerning their emotional state (General Health Questionnair-28, Goldberg, 1972; Goldberg and Hillier, 1979; Leeds Scales of Anxiety and Depression, Snaith et a/., 1976; and Re- vised Impact of Events Scale, Horowitz et al., 1979).

The examinations to be reported here were conducted 10 to 14 months after the Disaster. An attempt was made to avoid the immediate anniversary period, but this was not always possible, and claimants were well aware of the closeness of the examination to the anniversary.

Subjects

The 66 subjects comprised the claimants initially referred to the two authors for medicolegal evaluation. Referrals are still being received, but those will not be dealt with in this paper. Claimants to be reported here were referred in essentially two waves, the first of which (16 people, seen within 11 months of the disaster), were people about whom the lawyer had particular anxieties because of the claimant’s level of distress. These first examinations, although obviously carried out for medicolegal purposes, also had a major clinical dimension, and 5 of these 16 claimants were referred on to appropriate mental health professionals, and of these 5 , four had requested private treatment from the authors. In fact, treatment when ar- ranged was always done through National Health Service facilities. The second wave comprised people with, in the lawyer’s view, lesser distress, although clinical examination showed that many had very considerable symptomatology.

The claims of the 66 people to be reported here have all been settled. The 66 subjects are highly selected both in terms of severity of emotional symptomatology, and geographically, in that a substantial proportion of them came from a part of the town that was destroyed or very severely dam-

530 Brooks and McKinlay

Table I. Demographic and Other Details of Lockerbie Sample

Sex N Age N Marital Status N

M 30 18-25 6 Single F 36 26-35 6 Widow/er

66 36-45 19 Divorcedheparated 46-55 11 Married/cohabiting 56-65 13

>65 fi 66

Extent of Damage to Home

None Minor-Home habitable Moderate-Inhabitable by 2 weeks Severe-Uninhabitable after 2 weeks Destroyed

10 8 4

44 66 -

N 9

18 18 11 - 10 66

Loss of Friends and Relatives

Relatives Friends

None hurtkilled 63 19 At least 1 hurt 2 1 At least 1 killed 1 45

1 Not known - 66 66

- 0

Time after Disaster when Examined

N

10-11 months 20 12 months 14

13-14 months - 32 66

aged by the immediate impact. A number of claimants had in fact had their homes destroyed (Table I).

RESULTS

The results are structured around three central questions: (1) what is the nature of the demographic and other features of this sample? (2)

Consequences of Lockerbie Disaster 53 1

what is the range and severity of formal diagnoses and questionnaire scores in this sample? (3) what factors might predict the presence and severity of formal diagnoses and the level of questionnaire scores?

(1) The Nature of the Sample (Table I )

As Table I shows, there were similar numbers of males and females, and most claimants were married. Most were aged 40 or above, with a substantial group (17%) aged 65 or above. Only 9 had suffered no damage to their homes, 10 had had their homes destroyed, and a further 11 were unable to return home for more than 2 weeks after the disaster. Only 1 claimant had had a relative killed, but 45 (68%) reported the death of a friend. This high figure reflects the nature of Lockerbie-a small town in which many people knew each other.

(2) The Nature of the Mental Health Consequences

(a) DSMII-R Diagnoses. The examiner identified symptomatology characteristic of specific DSMIII-R diagnoses, and recorded the severity of the condition (mild, in remission, moderate, severe), using DSMIII-R criteria. These were either the specific criteria (major depression and panic disorder without agoraphobia), or the more general criteria contained on page 24 of the DSMIII-R Manual.

As Table II shows, PTSD was the most frequently assigned diagnosis, being present to moderate or severe degree in 29 claimants (44%), and to a mild degree or in remission in a further 19 (29%). In all, 48 claimants (73%) had, or had had PTSD. However, the important obverse of this is that 18 claimants (27%) had not had PTSD at any stage after the disaster, and these 18 had no other diagnoses. There was, therefore, a sizeable mi- nority with a level of distress too low to warrant any formal diagnosis (including a diagnosis "in remission").

Table 11. DSMIII-R Axis 1 Diagnoses

Diaenosis None MildlRemission Moderate Severe Total

PTSD 18 19 18 11 66 Panic disorder (any) 56 4 5 1 66 Other anxiety disorder 58 5 2 1 66 Major depression 47 6 10 3 66

532 Brooks and McKiddy

Table 111. Comorbidity in Lockerbie Sample

Panic Disorder Other anxiety Depression

F'TSD 0 1 2 3 0 1 2 3 0 1 2 3

0 1 8 0 0 0 1 8 0 0 0 1 8 0 0 0 1 1 9 0 0 0 1 7 2 0 0 1 8 1 0 0 2 13 3 2 0 14 3 1 0 9 5 4 0 3 6 1 3 1 9 0 1 1 2 0 6 3

Code 0 = None; 1 = Mild/In remission; : 2 = Moderate; 3 = Severe

Panic Disorder Other Anxiety Other Anxiety

Depression 0 1 . 2 3 0 1 2 3 Panic 0 1 2 3

0 4 7 0 0 0 4 2 4 1 0 0 49 5 2 0 1 4 2 0 0 5 1 0 0 1 4 0 0 0 2 3 2 5 0 1 0 0 0 0 2 5 0 0 0 3 2 0 0 1 1 0 1 1 3 0 0 0 1

The presence of more than one diagnosis raises the issue of comorbidity, and this was investigated further by cross-tabulating the different diagnoses as shown in Table 111. Depression never appeared in the absence of PTSD, and this was also the case for panic disorder and other anxiety disorders. Furthermore, the 13 people with moderate-severe depression also had F E D of moderate-severe degree, and an identical relationship was found between PTSD and panic and other anxiety disorders.

The six cases with moderate-severe panic disorder also had major depression of at least moderate severity. Of the 6 with moderate-severe Panic Disorder, only one had an additional anxiety disorder (other than PTSD). There was, therefore, considerable comorbidity with a number of claimants having more than one diagnosis.

(b) Questionnaire Measures. Two of the questionnaires (GHQ28 and Leeds Scales) allow categorical use, to give an overall measure of emotional impairment ("caseness") using a cut-off score of 4/5 for the GHQ28, and 6t7 for the b e d s Scales. The GHQ also allows scoring on four individual subscales comprising anxiety/insomnia, somatic symptomatology, social dys- function, and severe depression. The Revised Impact of Events Scale gives measures of intrusion and avoidance associated with PTSD. Table IV gives summary statistics for the questionnaire measures. The mean scores on the GHQ28 and the two Leeds Scales are highly above caseness, and the two Impact of Events Scales highly above scores for normal controls reported by Horowitz et aL (1979). Inspection of the raw data showed that 42 indi-

Consequences of Lockerbie Disaster 533

Table IV. Summary Statistics for Questionnaires

GHQ LEEDS (A) LEEDS (D) IOE (I) IOE (A)

M 9.8 10.0 7.0 20.2 19.3 SD 8.6 4.8 4.4 9.6 9.4 MIN 0 0 0 0 0 MAX 26 18 16 35 34

N 62 60 60 57 57

viduals (68%) were at or above caseness on the GHQ28; 45 (75%) on the Leeds Anxiety Scale; and 32 (53%) on the Leeds Depression Scale. The predominant feature is, therefore, anxiety, but still with substantial levels of depressive symptomatology. Eighty percent of those above caseness on the GHQ28 were above on the depression scale, and 97% were above on the Anxiety scale. Individual subscale scores on the GHQ28 are shown in Table V (maximum possible for each scale is 21). This shows clearly that the primary affective presentation was in terms of anxiety and social dys- function, although there were also high levels of somatic symptomatology. Severe depressive symptomatology was much less common.

(c) DSMII-R Diagnoses and Questionnaire Measures. The relationship between clinical and questionnaire measures of morbidity was examined. As PTSD and Depression were the most frequent diagnoses, the analysis concentrated solely on identifying the relationship between questionnaire measures and PTSD and Depression. Multiple regression was used to identify any linear relationship between the presence and severity of PTSD (coded as non, mild, moderate, or severe), as the dependent variable, and the five questionnaire measures. Using stepwise entry, the first variable en- tered into the equation was the Leeds Depression score (multiple R2 = 0.54), and the second was the intrusion subscale of the Impact of Events Scale (multiple R2 = 0.59), explaining only an additional 4% of variance.

Table V. Summary Statistics for GHQ28 Subscales

Scale

Sev. Somatic M n s o m n i a Social Depression

M 8.8 10.2 10.5 3.7 SD 10.2 6.4 4.3 5.0 MIN 1 0 5 0

N 62 62 62 62

MAX 21 21 21 18


Inspection of the residuals showed only one particular outlier (with a formal diagnosis but a low score on questionnaires), otherwise the normal probability plot of standardized residuals was near to a straight line. As far as depression is concerned, the only predictor was the score on the Leeds Depression Scale (I?* = 0.42).

Claimants were then subdivided into those with no diagnosis of F’TSD or depression, and those with a diagnosis at moderate or severe level. Cross-tabulation identified the relationship between the two levels of each diagnosis, and caseness on the b e d s Depression Scale. Of the 26 claimants with moderate-severe PTSD, 23 (88%) were above caseness on depression, and of those with lesser degrees of PTSD or none, 9 (22%) were above caseness (Chi square = 20.3, p < 0.001). On the depression diagnosis, of the 10 with moderate-severe depression, all were above caseness on the depression scale, although 22 of the 32 claimants above caseness did not have moderate-severe depression (Chi square = 8.4, p c 0.01). The sensitivity of the Leeds Depression Scale as an index of moderate-severe PTSD was, therefore, 88%, although its specificity was only 26%. The sensitivity of the depression scale as a predictor of moderate-severe depression was loo%, with 44% specificity. Inspection of the distribution of Leeds Depres- sion scores of claimants with and without moderate-severe levels of FTSD or depression, showed that no change in caseness criterion on the Leeds Scale would increase sensitivity or specificity. A high score on the Leeds Scale while indicating psychological morbidity, does not guarantee a clinical diagnosis of depression.

(3) Prediction of Presence and Severity of Morbidity.

Many potential predictors of morbidity appear in the literature (see Gibbs, 1989, for a summary), including demographic (age and gender), intra-individual (habitual coping responses, previous psychological morbidity), and disaster experience such as nature of involvement, loss or damage to one’s home, death or injury of relative or friends, etc. These potential predictors were investigated as follows:

(a) Demographic. The major variables examined were age, gender, and marital status. To investigate any effect of gender or marital status on morbidity, cross-tabulations were performed to examine the distribution of diagnoses of FTSD and depression as a function of gender and marital status. The Chi square values were all nonsignificant, and there was no evidence of any relationship between these potential predictors, and the presence or severity of either diagnosis. The possible effects of age were investigated by using one way analyses of variance to compare the mean

Consequences of Loekerbie Disaster 535

age of claimants in the four different levels of the two primary diagnoses. The F ratios were both nonsignificant, and inspection of raw data gave no indication of any consistent age trends.

On questionnaire measures, there was no relationship between gender and scores on any of the questionnaires, although there was a relationship with age. When product moment correlation coefficients were calculated between age and questionnaire scores, there was one correlation significant (Leeds Anxiety Scale, r = +0.35,p < 0.01). Scores on this scale are known to be correlated with age, and an age correction factor has been incorpo- rated by the authors of the scale into the scoring system. Even after this age correction, patients with higher anxiety scores were older. The use of correlation assumes a linear and continuous relationship between age and morbidity. The GHQ and Leeds Scales, while allowing a continuous score, also function as diagnostic instruments via caseness cut-off. The effects of age were, therefore, investigated further, by using one-tailed T tests to compare the mean ages of those below, and at or above caseness on these scales. In view of the number of separate t tests being computed (9, a cautious criterion of significance was used (p < 0.01) in this and all other sets o f t tests. There was no significant difference in age on the GHQ or Leeds Depression Scale, but there was on the Anxiety Scale, with the mean age of "cases" being 48.7 (SD = 14.3), and of noncases 37.5 (SD = 14.3); t = 2 . 2 , ~ < 0.01. furthermore, when scores of the oldest people were examined (age 65 or above) the lowest Leeds Anxiety score obtained was 10, which is well above caseness. The minimum score of those age 45 to 64 was 1, and for those below 45 it was 0.

The effects of marital status on questionnaire measures were examined by using t tests to compare scores of the 44 married people with those of the remaining claimants. It was expected that scores would be lower in married people because of mutual support, but the married group scored consistently higher on all measures of psychological morbidity. While the difference was significant, it was not interpreted as its direction was con- trary to the hypothesis.

(b) Intra-Individual Factors. No information was collected about habitual coping style, so this could not be evaluated. However, information was collected from each claimant's general practitioner (all of whom sup- plied a report about pre- and post-disaster consultations), and from the claimants about the predisaster medical and psychologicaVpsychiatric history. In one case where there was some doubt about the predisaster history, a close relative of the claimant was also interviewed. Original clinical re- cords were not scrutinized, so it is very likely that the incidence of predisaster psychological morbidity is underestimated. Using these sources, predisaster psychological/psychiatric history was categorized as non (N =


Table VI. Mean Scores on Questionnaires as a Function of Marital Status (Married or Not)

GHQ LEEDS (A) LEEDS (D) IOE (A) IOE (I)

Status N M SD N M SD N M SD N M SD N M SD

Married 44 10.7 9.1 43 10.5 4.6 43 7.6 4.6 42 21.1 8.6 42 22.1 8.8 Not 18 7.4 6.9 17 8.8 5.0 17 5.4 3.6 15 14.2 9.9 15 14.7 10.0

r 1.4 NS 1.3 NS 1.7 NS 2 . 6 ~ = 0.01 2 . 7 ~ = 0.01

49); one isolated episode warranting treatment (N = 7); more than one episode (N = 3); and a history of prolonged treated psychiatric disorder (N = 7). For purposes of analysis, those with no history were compared (via Chi square) with the 10 (7 + 3) with the more significant histories, on the distribution of diagnoses of PTSD and depression. The two Chi square values were nonsignificant. t tests were then used to compare the mean questionnaire scores of those with no predisaster history, and those with a significant history (Table VII). None of the t values were significant although the mean score was higher on every measure in those in the "history" group. However, missing data resulted in only 5 cases in that group, so these results must be treated with extreme caution.

(c) Disaster Related Factors. A number of factors associated with the disaster were potential predictors of morbidity. The most obvious ones include the nature of the losses of an individual (whether physical in terms of property, or personal in terms of friends or family), and whether or not an individual had been exposed to particularly unpleasant sights. The effects of losses incurred were examined first, followed by an examination of the effects of exposure to human remains.

The relationship between damage to the claimant's property and diagnosis was estimated using cross tabulations (Table VIII). The Chi square statistic was not significant for PTSD, but was for depression. Three of the

Table VII. Mean Scores on Questionnaire Measures as a Function of Previous Psychiatric History


History N M SD N M SD N M SD N M SD N M SD

None 46 9.0 8.4 45 9.7 4.7 45 6.6 4.3 42 19.8 10.0 42 20.1 9.5 Sigruficant 6 15.3 11.1 5 14.0 3.1 5 10.1 6.0 5 121.6 7.2 5 25.0 9.3

I 1.7 NS 2.0 NS 1.6 NS 0.4 NS 1.1 NS

Consequences of Loekerbie Disaster 537

Table VIII. PTSD and Depression as a Function of Damage to Property

PTSD Depression

Mild/ Mild/ Damage None Remission Moderate Severe None Remission Moderate Severe

A' 1 1 3 4 4 1 1 3 Bb 7 5 4 2 15 1 2 0 c 4 5 7 2 12 2 4 0 D d 5 5 1 0 10 1 0 0 F 1 3 3 3 6 1 3 0

~ ' ( d f 12) = 16.7 NS x z = 25.5 p c 0.01

'No damage bMinor damage but habitable. 'Bamage but habitable within 2 weeks. dDamaged, and not habitable for over 2 weeks. 'Destroyed.

nine who had suffered no damage to their property had a severe level of Depression, whereas none of the 10 whose property had been destroyed had severe Depression. This is a counter-intuitive result, and it was not replicated in an analysis of questionnaire measures, which showed that the mean questionnaire scores in the five subgroups identified in Table VIII did not differ significantly among themselves, although the scores were consistently highest in the claimants who had suffered no property damage.

The effects of loss of friends or relatives were then analyzed. Of the 65 claimants with complete data here, 19 reported having no friends hurt or killed, one had a friend hurt, but 45 reported having had at least one friend killed, reflecting the close-knit nature of the Lockerbie community. Sixty three had had no relatives hurt or killed, two had at least one relative hurt, and one had had a relative killed. Happily, so few of the claimants had had relatives hurt or killed that this variable could not be examined further. In order to examine the effects of loss of a friend, cross tabulations were used to compare the distribution of PTSD and depression as a function of injury to or loss of a friend, but neither Chi square ratio was significant, showing no impact of loss of friends on the presence or severity of clinical diagnosis. This was not the case, however, when questionnaire measures were examined by means of t tests to compare the mean level of questionnaire scores in those who had had no friends killed or hurt, and those who had had at least one killed or hurt (Table IX). The t ratios were significant on the GHQ28 and Leeds Depression Scale, and on all measures, those with friends killed or hurt scored at a higher mean level. Indeed, the difference on the GHQ28 was very substantial, and there was, therefore, clear evidence that respondents who had had

538 B m k s and McKinlay

Table IX. Questionnaire Measures as a Function of Loss or Death of a Friend


N M SD M SD M SD M SD M SD

At least one 45 11.6 9.1 10.5 4.9 7.7 4.6 20.4 9.6 21.5 9.6

None 16 5.1 4.6 8.4 4.1 4.8 2.7 15.7 8.3 16.3 8.8 killedhurt

r = 3 . 7 ~ < 0.01 1.5 NS 2 . 9 ~ < 0.01 1.6 NS 1.8 p < 0.04

killedhurt

friends hurt or killed had significantly higher psychological morbidity on questionnaire measures.

The next factor to be studied was the effects on psychological morbidity of exposure to unpleasant sights, particularly dead bodies. Exposure was categorized as follows: 20 claimants reported no unpleasant sights; 10 reported seeing bodies under sheets or similar covering; 9 had seen uncov- ered bodies; and 27 had seen dismembered bodies or body parts. The dis- tributions of depression and PTSD in these 4 groups were compared by cross tabulation, and neither of the Chi square ratios were significant. The analysis of predictors then continued by using one way analyses of variance to compare mean questionnaire scores in the four "exposure" groups (Table X). On each scale, those exposed to dismembered bodies had the highest scores, although this only reached significance (using a conservative alpha o f p < 0.01) on the Impact of Events Intrusion Scale. It just failed to reach significance on the Avoidance Scale, and Scheffk testing showed that the significance arose from the difference between those who had seen no bodies, and those who had seen dismembered bodies.

DISCUSSION

The paper aimed to identify the nature, severity, and predictors of psychological morbidity in a large sample of adults, all of whom were claiming financial compensation for "psychological damage" in the Lockerbie Disaster. The sample cannot be considered representative of the whole community of Lockerbie, as the factors that led to a claim were not identified, other than observing that a large number of claimants had property destroyed or damaged, and a large number had had friends killed or injured. Few, however, had been bereaved.

The main diagnoses assigned were PTSD and depression, followed by other anxiety disorders. The primacy of PTSD and depression (particu-


Table X. Questionnaire Measures as a Function of Exposure to Distressing Sights

GHQ LEEDS (A) LEEDS (D) IOE (A) IOE (I) N M SD M SD M SD M SD M SD

None 18 8.8 8.6 9.1 4.8 6.5 4.7 14.7 9.9 153 10.9 Mild 8 7.9 7.8 9.1 5.1 5.5 3.7 15.7 4.5 18.0 8.3 Moderate 9 5.7 4.1 9.2 4.3 5.0 3.2 18.9 7.0 15.9 7.4 Body parts 27 12.4 9.4 11.2 4.8 8.4 4.5 23.4 9.6 25.3 7.6

F 1.8 NS 0.9 NS 2.0 NS 3.5 p = 0.02 5.3 p < 0.01

larly the former) are well recognized (Lima et af., 1989); McFarlane. 1988a; Oliver0 and Fero, 1990). Given that this is a sample of claimants, one might have expected uniformly high levels of morbidity, but this was not the case. Although 48 had or had had FTSD, 18 had never had it. Nineteen had had depression, but 47 had never had it. There was a substantial degree of comorbidity, with 14 having more than one diagnosis, and one having 4 diagnoses. However, 18 had no diagnoses, and did not report symptomatology of a nature or level that would have warranted a diagnosis at any time since the disaster. In this situation, the search for predictors of current morbidity is mandatory.

Potential predictors included those within the individual (demographic and personal history), and those related to the Disaster (damage to home, loss of friends or relatives, exposure to unpleasant sights, etc.) (Gibbs, 1989; Logue et aL, 1981). A further potential predictor relates to the legal process itself. It is natural to wonder if some of the claimants were exaggerating or manufacturing symptomatology, but this did not seem to be the case clinically, and using criteria suggested by Resnick (1988), there was no evidence for manufacturing symptomatology, although Resnick’s model is based on military personnel rather than civilian victims.

In the analysis of predictors, demographic factors were of some im- portance in that those scoring at or above caseness on questionnaire measures appeared to be older, but there were no significant age differences in those with and without a moderate to severe PTSD or depression. In the literature, effects of age are not consistent, with some studies reporting that greater distress is found in older victims, and some that it is found in younger (Gibbs, 1989). One problem is that it is difficult to construct a coherent model of the effects of age. Gibbs points out that older people have increased exposure to emotional stress, and, therefore, might be expected to be more vulnerable. Yet, they have had more experience in coping (and might, therefore, be expected to be better at it), although this


assumption only holds if the coping experiences were successful. In this study, increasing age was not convincingly associated with an increasing rate of diagnosis, nor was there any relationship between diagnosis and gender, despite suggestions that women are more affected by disasters than men (Gibbs, 1989; Maj et aL, 1989). On questionnaire measures, there were significant relationships between increasing age and increasing psychopathology. So, on a threshold model of psychopathology (illhot ill) age is not a significant factor, but on a distributional model it certainly is, particularly for anxiety and the general impact of a disaster.

Marital status might be expected to be an important factor, with married people coping better than single individuals, because of the mutual support available within a marital or similar relationship. Indeed, a recent study (Lima et al, 1989) showed that emotional distress 2 months after a major earthquake in Equador was higher in those who were single, sepa- rated, or widowed, than in those who were mamed. In the Lockerbie claimants, married people did not have a lower rate or severity of diagnosis of FISD or Depression, and they had consistently higher scores than single claimants on the questionnaire measures, particularly the Impact of Events Scale. Had it been just the intrusion score of this scale that was different, one might have hypothesized post hoc that the difference came from the fact that mamed individuals talked to each other about the disaster and its consequences, thereby reinforcing intrusive phenomena. However, married claimants were also significantly higher on avoidance, so a simple cog- nitive rehearsal explanation is not sufficient, and the clinical significance (if any) of this result remains obscure.

An obvious potential predictor of post-disaster coping is the claimant’s personal resources, whether defined as an enduring personality characteristic or coping style, or in some other way. While no attempt was made to assess individual coping, premorbid psychopathology was assessed, although this was not done exhaustively. Premorbid history has already been indicated as a possible predictor of current distress by McFarlane (1988b), who found that firefighters who showed chronically high levels of distress after a major Australian bush fire were more likely to admit to previous psychological disorder. In the current study, the rates of PTSD and depression did not differ between those with no premorbid psychological history, and those with a highly significant history, nor were there significant differences on questionnaire scores. One factor to bear in mind is that two of the seven claimants with a substantial and chronic history had a considerable degree of social blunting resulting from a long- standing (and still present) serious psychiatric condition rather than the Disaster, and neither of these individuals had PTSD or depression. It may well be that the exact nature of the previous psychiatric history is


an important factor (schizophrenia versus alcohol abuse versus long-term coping difficulties, etc.), and attempts at making global inferences about relationships between previous history and current symptomatology are too simplistic.

As far as Disaster experiences are concerned, the results in the literature are rather conflicting. McFarlane (1988b) in his study of firefighters found that the key factor in current symptomatology was the distressing nature of the experience, rather than the actual physical losses suffered. Green et a,! (1989) in a study of Vietnam veterans showed that the nature of military experience was a very important predictor of current PTSD and other associated diagnoses, and in a very recent study, exposure to "heavy combat" more than doubled a Vietnam veteran's risk of reporting a substance abuse postdischarge (Fischer, 1991). In the Green et QL study, injury alone did not simply predict current PTSD, but the patient who had had experience of infantry patrols was much more likely to have F'TSD. In that study, and in the study by Breslau and Davis (1987), the most potent predictor of PTSD in combination with an anxiety disorder was exposure to the grotesque, including mutilation and participating in or observing abu- sive violence. In such situations, multiple diagnoses were much more likely.

In the Lockerbie sample, loss or damage to the family home bore no relationship to diagnosis or questionnaire scores. Loss of friends was not an important predictor of diagnosis, but was related to the questionnaire levels with significant effects on the GHQ28, and Leeds Depression Scale. Furthermore, on clinical examination it was striking how many claimants spontaneously reported distress occasioned by the death of friends or ac- quaintances.

Exposure to grotesque sights was not a significant predictor of formal diagnoses, in contrast to the study by Green et ~ l . (1989), which found that exposure to the grotesque specifically predicted PTSD and associated comorbidity. In the Lockerbie sample, such exposure was consistently associated with higher levels of questionnaire morbidity, with those exposed to dismembered bodies having the highest scores on all questionnaire measures, the effect reaching significance on the Impact of Events Scales.

Time after disaster at which the claimants were examined was a highly significant predictor of diagnoses and questionnaire morbidity, but these figures bear no relationship to natural history of morbidity: they relate solely to the referral pattern, in that the lawyers referred those with (in the lawyers' view) the greatest distress.

In conclusion, the current study found high levels of formal diagnoses and associated comorbidity, and high scores on questionnaire measures as- sessing various aspects of psychological morbidity. Substantial numbers of claimants had more than one diagnosis, and some had three or more. No


unequivocal predictor of the presence or severity of DSMITI-R diagnoses was found. Possible reasons for this include the nature of the population (claimants with unknown selection biases), the time after the Disaster at which the examinations were cam'ed out (two "waves," but all seen rather close to the anniversary), and the nature of the examination (medicolegal rather than clinical). Furthermore, symptomatology in individuals after a disaster is far from static. Certainly a number of claimants had already shown substantial recovery (evidenced by a diagnosis "in remission"), yet others may still present with new symptoms of a level to warrant a formal diagnosis. Indeed, since the examinations reported here were camed out, new claimants have come fonvard, some of whom are reporting symptoms appearing de novo well over a year after the disaster. While there were few predictors of diagnosis, this was not the case for questionnaire measures, the levels of which were related to age and Disaster experience. The scores also related to marital status, but in a counter-intuitive way, and no clear explanation for this could be found.

Other work in this population demands a long-term follow-up, and examination of the demographics of the town of Lockerbie, to identify individuals who had similar experiences to those reported in this paper, but who do not make a claim for compensation. The examination of such individuals as compared with those reported here could give crucial information about the factors which lead individuals to instigate compensation claims after a major civilian disaster, and would help in understanding the natural history and predictability of postdisaster morbidity.

REFERENCES

Adler, A.. (1943). Neuropsychiatric complications in victims of Boston's Cocoanut Grove disaster. 1A.M.A. 123: 1098-1111.

American Psychiatric Association (1987). DSM-111-R Diagnosric and Sfafistical Manual of Mental Dkorden (third edition, revised), APA. Washington, DC.

Bartone, P. T., Ursano, R. J., Wright, K. M., and Ingraham, L. H., (1989). The impact of a military air disaster on the health of assistance workers. J. New. Ment. Dic. 177: 317-328.

Baum, A., Fleming, R., and Davidson, L. M. (1983). National disaster and technological catastrophe. Environ. Behau. 15: 333-354.

Breslau, N., and Davis, G. (1987). Posttraumatic stress disorder: The etiologic specifity of wartime stressors. Am. 1 Psychintry 144: 578-583.

Duffy, J. C.. (1978). Emergency mental health services during and after a major aircraft accident. A v d . Space Environ. Med. August: 1004-1008.

Fisher, E. F. (1991). Combat exposure and the etiology of postdischarge substance abuse problems among Vietnam veterans. 1. Traum. Stress 4: 251-278.

Gibbs, M. S. (1989). Factors in the victim that mediate between disaster and psychopathology: A review. J. Traum. Stress 2: 489-514.

Goldberg. D. (1972). The Detection of Psychiatk Illness by Quesrionnaire, Oxford University Press, London.

Goldberg, D., and Hillier, V. F. (1979). A scaled version of the General Health Questionnaire. Psychological Med 9 139-146.


Green, B. L. Lindy, J. D., Grace, M. C., and Gleser, G. C. (1989). Multiple diagnosis in posttraumatic stress disorder. The role of war stressors. I. Nerv. Ment. Dir. 177: 329-335.

Horowitz, M., Wilner, N., and Alvarez, W. (1979). Impact of events scale: A measure of subjective stress. Psychosom. Med 41: 209-218.

Lima, B. R., Chavez, H., Samaniengo, N., Pompei, M. S. Pai, S., Santacmz. H., and Lozano, J. (1980). Disaster seventy and emotional disturbance: Implications for primary health care in developing countries. Acta Psychinr. Scand. 7 9 74-82.

L o p e , J. N.. Melick, M. E., and Hansen. M. (1981). Research issues and directions in the epidemiology of health effects of disasters. EpidemioL Rev. 3: 140-162.

Maj, M., Starace, F., Crepet, P., Lobrace, G., Veltro, F., De Marcos, F., and Kemali. D. (1989). Prevalence of psychiatric disorders among subjects exposed to a national disaster. Acta Psychiat. Scand. 7 9 544-549.

McFarlane, A. C. (1988a). The phenomenology of posttraumatic stress disorders following a natural disaster. I: Nerv. Ment. Dis. 176: 22-29.

McFarlane, A. C. (1988b). Relationship between psychiatric impairment and a national disaster: The role of distress. P~ychologicol Med 18: 129-139.

Olivero, A. A. and Fero, D. (1990). Affective disorders, DST, and treatment of PTSD patients: Clinical considerations. I: Truum. Stress 3: 407-414.

Resnick, P. J. (1988). Malingering of posttraumatic disorders. In Rogers, A. (ed.). Clinical Assessment of Malingering and Deception. Guildford, London, pp. 84-104.

Snaith, R. P., Bridge, G. W. K., and Hamilton, M. (1976). The Leeds Scales for the detection of anxiety and depression. Bn'r. J. Psychiat. 128: 156-165.

Titchner, J. L., and Kapp, F. T. (1976). Family and character change at Buffalo Creek. Am. I: Pvchiat. 133: 295-297.

Documents

Mental health consequences of the Lockerbie Disaster