Gender Differences in the Relationship between Maladaptive Behaviors and Post-Traumatic Stress Disorder. A Study on 900 L' Aquila 2009 Earthquake Survivors.

0.51 MB·English

by  Dell'Osso, Liliana

ORIGINALRESEARCHARTICLE
published:04January2013
PSYCHIATRY
doi:10.3389/fpsyt.2012.00111
Gender differences in the relationship between

maladaptive behaviors and post-traumatic stress disorder.

A study on 900 L’ Aquila 2009 earthquake survivors

LilianaDell’Osso1,ClaudiaCarmassi1*,PaoloStratta2,GabrieleMassimetti1,KareenK.Akiskal3,
HagopS.Akiskal3,IcroMaremmani1 andAlessandroRossi2

1SectionofPsychiatry,DepartmentofClinicalandExperimentalMedicine,UniversityofPisa,Pisa,Italy

2SectionofPsychiatry,DepartmentofExperimentalMedicine,UniversityofL’Aquila,L’Aquila,Italy

3InternationalMoodCenter,UniversityofCaliforniaatSanDiego,LaJolla,CA,USA

Editedby: Background:Post-traumaticstressdisorder(PTSD)representsoneofthemostfrequently
GiovanniAddolorato,Catholic psychiatric sequelae to earthquake exposure. Increasing evidence suggests the onset of
UniversityofRome,Italy
maladaptivebehaviorsamongveteransandadolescentswithPTSD,withspecificgender
Reviewedby:
differencesemerginginthelatter.Aimsofthepresentstudyweretoinvestigatetherela-
LudovicoAbenavoli,University
MagnaGraecia,Italy tionshipsbetweenmaladaptivebehaviorsandPTSDinearthquakesurvivors,besidesthe
LuigiJaniri,UniversitàCattolicadelS. gender differences in the type and prevalence of maladaptive behaviors and their asso-
Cuore,Italy ciation with PTSD. Methods: 900 residents of the town of L’Aquila who experienced
*Correspondence: the earthquake of April 6th 2009 (Richter Magnitude 6.3) were assessed by means of
ClaudiaCarmassi,Sectionof theTrauma and Loss Spectrum-Self Report (TALS-SR). Results: Significantly higher mal-
Psychiatry,DepartmentofClinicaland
ExperimentalMedicine,Universityof adaptivebehaviorprevalencerateswerefoundamongsubjectswithPTSD.Astatistically
Pisa,ViaRoma67,56100Pisa,Italy. significantassociationwasfoundbetweenmalegenderandthepresenceofatleastone
e-mail:[email protected] maladaptivebehavioramongPTSDsurvivors.Further,amongsurvivorswithPTSDsignifi-

cantcorrelationsemergedbetweenmaladaptivecopingandsymptomsofre-experiencing,

avoidance and numbing, and arousal in women, while only between maladaptive coping

and avoidance and numbing in men. Conclusions: Our results show high rates of mal-

adaptivebehaviorsamongearthquakesurvivorswithPTSDsuggestingagreaterseverity

among men. Interestingly, post-traumatic stress symptomatology appears to be a better

correlate of these behaviors among women than among men, suggesting the need for

furtherstudiesbasedonagenderapproach.

Keywords:PTSD,post-traumaticstresssymptoms,earthquake,maladaptivebehaviors,gender

INTRODUCTION 2000;Vlahov et al.,2002; Chang et al.,2005;Vehid et al.,2006;

Earthquakesareoneofthemostfrequentnaturaldisastersoccur- Cerdá et al., 2011; Dell’Osso et al., 2011a; Pollice et al., 2011;

ring across the world and, among exposed individuals, Post- Stratta et al., 2012) and little is known on other possible mal-

TraumaticStressDisorder(PTSD)representsthemostfrequently adaptive behaviors that may be developed and on any eventual

occurringpsychiatricsequelae(Majetal.,1989;Armenianetal., gender differences (McMillen et al.,2000; Bal and Jensen,2007;

2002;Laietal.,2004;Jahangirietal.,2010;Dell’Ossoetal.,2011a; Goenjian et al.,2009; Cairo et al.,2010; Dell’Osso et al.,2011a,

Hussainetal.,2011;Zhangetal.,2011;Alietal.,2012). 2012).

There is increasing evidence in the literature on the specific Maladaptive behaviors are defined as volitional behaviors

clinicalandneurobiologicalcorrelatesof PTSDandparticularly, whose outcome is uncertain and which entail negative con-

onthespecificgenderdifferencesinPTSDprevalencerates,with sequences that impact everyday activities (Irwin, 1990; Pat-

women being more affected than men across different cultures Horenczyketal.,2007;Hartleyetal.,2008;Dell’Ossoetal.,2012).

andatdifferentages(Armenianetal.,2000;Kessler,2000;Green, Anecdotaldatahavebeenreportedonmaladaptivebehaviors,such

2003;Cohen,2008;LiberzonandSripada,2008;Alhasnawietal., as risk-taking behaviors,dangerous driving,or promiscuous sex

2009;Dell’Ossoetal.,2010,2011a,b;Pratchettetal.,2010;Fried- emerginginpatientswithPTSD.Aggressiveandunsafedrivinghas

manetal.,2011;Rabinaketal.,2011;SherinandNemeroff,2011; beenreportedamongstmaleveteransoftheIraqandAfghanistan

Xu and Song,2011). Increasing data agree on the tendency to a wars, with PTSD severity being associated to aggressive driving

chroniccourse,higherincidenceof alcoholandsubstanceabuse but not other forms of unsafe driving (Kuhn et al., 2010). Iraq

andheightenedriskforsuicideinPTSDpatients(Kessler,2000; and Afghanistan war veterans with PTSD also showed signifi-

KrysinskaandLester,2010;McFarlane,2010;Jessupetal.,2012; cantlyhigherratesofaggressivetraits,includingviolentbehaviors,

Pietrzak et al.,2012). However,data on mass trauma survivors, compared to those without PTSD (Jakupcak et al., 2007; Elbo-

particularly on earthquake victims, are scarce (Shimizu et al., gen et al., 2010). More data have been reported on risk-taking

www.frontiersin.org January2013|Volume3|Article111|1
Dell’Ossoetal. PTSD,gender,andmaladaptivebehaviors
behaviors,suchassmoking,alcohol,andsubstanceuse,carracing, INSTRUMENTSANDASSESSMENTS
weapon carrying, violence, and delinquency among adolescents The TALS-SR was developed by researchers who comprise the
and young adults with PTSD due to terrorism,fire,or violence. Italian-Americanteambelongingtotheso-calledSpectrum-Project
Interestingly, in these studies higher rates have been reported (Franketal.,1998;Cassanoetal.,1999).TheTALS-SRincludes116
in victims with PTSD compared to non-affected subjects, with itemsexploringthelifetimeexperienceof arangeof lossand/or
boysreportingsignificantlyhigherratesthangirls(Glodichand traumaticeventsandlifetimesymptoms,behaviorsandpersonal
Allen,1998;Sugar,1999;Gore-FeltunandKoopman,2002;Steven characteristicsthatmightrepresentmanifestationsand/orriskfac-
etal.,2003).Consideringtherelevanceof theseconditions,par- tors for the development of a stress response syndrome. Items
ticularlythatofsubstanceusedisorderswhenco-occurringwith responses are coded dichotomously (yes/no). The instrument is
mood or anxiety disorders (Sbrana et al., 2005; Bizzarri et al., organizedintoninedomainsanddomainscoresareobtainedby
2007;Maremmanietal.,2012),furtherstudiesarewarrantedon countingthenumberofpositiveanswers.Inaccordancewiththe
PTSD. aims of the present study subjects were asked to fulfill domains
Despite the fact that literature has been increasingly focused V, VI, VII, and VIII, referring symptoms that occurred after
onpost-traumaticstressreactionsemergingingeneralpopulation earthquake exposure. Domain V (“Re-experiencing”), domain
samplesofearthquakeadultsurvivors,tothebestofourknowl- VI (“Avoidance and numbing”), and domain VIII (“Arousal”)
edgenostudyhasyetexploredgenderdifferencesinmaladaptive include re-experiencing, avoidance and numbing, and arousal
behaviorsoccurringinthesepatients.OnApril6th2009,at3:32 symptomsrespectively.DomainVII(“Maladaptivecopying”)tar-
a.m.,anearthquakeofmagnitude6.3ontheRichterscalestruck gets maladaptive coping and behaviors including: no self-care,
L’Aquila, Italy, a town with a population of 72,000 inhabitants, scarceadherencetoon-goingmedications,alcoholordrugabuse,
withamassivedestroyingeffectonbuildings,inducingthedeath risk-takingbehaviors(dangerousdriving,promiscuoussex,etc.),
of 309 people and the injury of more than 1,600. Furthermore, thoughts of death, suicidal ideations, and attempts. Each items
afterthiseventcontinuoustremorshavebeengoingoninthetown exploreswhethertheseoccurredafterexposuretolossortrauma.
ofL’Aquilaandstillpresenttoday.Inapreviousstudyon512stu- ThepresenceofPTSDwasassessedbymeansoftheTALS-SR
dentswhosurvivedtheearthquake10monthsearlier(Dell’Osso items corresponding to DSM-IV-TR criteria for PTSD diagno-
etal.,2011a),wereportedPTSDprevalenceratesashighas37.5%, sis (Dell’Osso et al., 2011a,b). A diagnosis of partial PTSD was
with significantly higher rates of maladaptive behaviors among assessedwhencriteriaBandorCorDforDSM-IVweresatisfied.
boyscomparedtogirls. According to the aim of the present study we also analyzed the
Aims of the present study were to investigate the relation- prevalenceratesofendorsementoftheitemsoftheTALS-SRon
ships between maladaptive behaviors and PTSD in earthquake domainVII.
survivors, besides the gender differences in the type and preva- Inordertoexploretheassociationbetweenmaladaptivebehav-
lenceofmaladaptivebehaviorsandtheirassociationwithPTSD. iors, gender, and PTSD, we adopted also a dichotomic variable
With these aims in view, we investigated 900 L’Aquila residents indicatingthepresenceofatleastoneofthemaladaptivebehaviors
whoexperiencedtheearthquakeofApril6th2009. ineachsubject.

MATERIALSANDMETHODS STATISTICALANALYSES
STUDYPARTICIPANTS We utilized the Chi-Square test to examine PTSD and gender
ThetargetpopulationincludedresidentsofthetownofL’Aquila, differences in the rates of endorsement of maladaptive behav-
wholivedintheurbanareaofthetownandexperiencedtheearth- iors.Multiplelogisticregressionanalyseswereperformedto:(1)
quake of April 6th 2009. Ten months earlier,all residents of the studytheassociationbetweengenderandPTSDandtheirpossible
townofL’Aquilaweredirectlyexposedtothedisaster,hadreceived interactioninpredictingthepresenceofatleastonemaladaptive
assistanceintheemergencyconditionsthatprevailedandweredis- behavior; (2) identify the maladaptive behaviors items that best
placedinlocationswithina150kmareafromthetownorintents predictedgender.
located in the urban area. Even 10months after the earthquake, Pearson correlation coefficients were adopted to explore the
only25%oftheinhabitantswereabletoreturntotheirhomes. association between PTSD symptoms, determined by means of
The instruments were administered to an original sample of theTALS-SRdomainsIV,V,andVItotalscores,andmaladaptive
939 subjects but complete data were available for 900 subjects, behaviors,determinedbymeansoftheTALS-SRdomainVIItotal
446womenand454men.Withinthewholesample,372survivors score.
reportedPTSD,122menand250women.PatientswithPTSDhad AllstatisticalanalyseswerecarriedoutusingStatisticalPackage
ameanageof24.90±12.15,26.17±13.6,24.28±11.35yearsin forSocialScience,version16.0(SPSSInc.,Chicago2010).
thetotalsampleandamongmenandwomenrespectively.
Symptoms of post-traumatic stress related to the earthquake RESULTS
were explored on the Trauma and Loss Spectrum-Self Report Earthquake survivors with PTSD reported significantly higher
(TALS-SR,Dell’Ossoetal.,2008,2009). prevalence rates of maladaptive behaviors than those without
TheEthicsCommitteeoftheUniversityofL’Aquilaapprovedall PTSD(seeTable1).
recruitmentandassessmentprocedures.Eligiblesubjectsprovided Amultiplelogisticregressionshowedastatisticallysignificant
written informed consent after receiving a complete description interactiongender∗PTSDinpredictingthepresenceof atleast
ofthestudyandhavinganopportunitytoaskquestions. onemaladaptivebehavior(seeTable2).Indeed,theprevalenceof
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Dell’Ossoetal. PTSD,gender,andmaladaptivebehaviors
Table1|Maladaptivebehaviors(TALS-SRDomainVII)prevalenceratesin900L’Aquilaearthquakesurvivors:PTSDvs.NoPTSD.

TALS-SRdomainVII(maladaptivecopying) PTSD(N=372)N(%) NoPTSD(N=528)N(%) χ2 p

97....Stoptakingcareofyourself,forexample,notgetting 164(44.1) 59(11.2) 125.07 <0.001

enoughrestornoteatingright?
98....Stoptakingprescribedmedicationsorfailtofollow-up 39(10.5) 14(2.7) 22.77 <0.001

withmedicalrecommendations,suchasappointments,

diagnostictests,oradiet?
99....Usealcoholordrugsorover-the-countermedications 87(23.4) 59(11.2) 22.94 <0.001

tocalmyourselfortorelieveemotionalorphysicalpain?
100....Engageinrisk-takingbehaviors,suchasdrivingfast, 55(14.8) 44(8.3) 8.63 =0.003

promiscuoussex,hangingoutindangerousneighborhoods?
101....Wishyouhadn’tsurvived? 64(17.2) 34(6.4) 24.97 <0.001
102....Thinkaboutendingyourlife? 32(8.6) 15(2.8) 13.57 <0.001
103....Intentionallyscratch,cut,burn,orhurtyourself? 34(9.1) 15(2.8) 15.62 <0.001
104....Attemptsuicide? 19(5.1) 10(1.9) 6.27 =0.012

Table2|Binarylogisticregressionanalysis(PTSDandgenderas p<0.001) while in men,a significant correlation emerged with
predictorsofatleastonemaladaptivebehavior)appliedto372 domainVIonly(r=0.31p=0.001).
L’AquilaearthquakesurvivorswithPTSD.
DISCUSSION

B(SE) Oddsratio C.I.95% p To the best of our knowledge, the present study is the first
population-based study exploring gender impact on the mal-
Constant −0.98(0.13) <0.001
adaptivebehavioralsequelaeofamajorearthquake.Unlikeother
PTSD 1.80(0.23) 6.06 3.84–9.58 <0.001
studiesthathaveexploredmaladaptivebehaviorsinspecialpopu-
Gender 0.13(0.20) 1.14 0.77–1.68 =0.509
lations,suchasveteransoradolescents(GlodichandAllen,1998;
PTSDbyGender −0.68(0.31) 0.51 0.28–0.92 =0.026
Sugar,1999;Gore-FeltunandKoopman,2002;Stevenetal.,2003;
(χ2=101.60,p<0.001,CoxR2=0.11,NegelkerkeR2=0.14). Jakupcak et al.,2007;Pat-Horenczyk et al.,2007;Elbogen et al.,
2010;Kuhn et al.,2010;Dell’Osso et al.,2011a),we examined a
O.R.,oddsratio;C.I.,coefficientinterval.
sampleofItalianciviliansurvivorstotheearthquakethatmassively
affectedthetownofL’AquilainApril2009.
atleastoneofthemaladaptivebehaviorsissignificantlyhigherin Ourresultsindicateanalarmingrateofself-reportedmaladap-
menthaninwomenamongsurvivorswithPTSDonly(69.4%vs. tive behaviors by L’Aquila earthquake survivors 10months after
56.6%,p=0.024). theeventoccurred,withsignificantlyhigherratesamongvictims
In particular, men reported statistically significant higher reportingPTSDcomparedtothosewithout.Inanexplorationof
endorsementratesinitemsN=98(“Stoptakingprescribedmed- substanceabuseamongyoungpeopleexposedtothissameevent,
ications or fail to follow-up with medical recommendations...?,” Pollice et al. (2011) brought to light a marked increase in levels
χ2=7.73;p=0.005),N=99 (“Use alcohol or drugs or over-the- ofabusecomparedtopriortothetrauma.Ourdatashowsignifi-
counter medications to calm yourself ...?,”χ2=8.19; p=0.004), cantlyhigherratesofalcoholordrugabuseinearthquakesurvivors
N=100 (“Engage in risk-taking behaviors...?,” χ2=29.52; withPTSD,reportedintheaftermathof theevent,withratesas
p<0.001), N=103 (“Intentionally scratch, cut, burn or hurt highasmorethan20%,comparedtosurvivorswhodidnotreport
yourself...?,”χ2=12.84;p<0.001),andN=104(“Attemptsui- PTSDpresentingratesaround10%.AlmosthalfofPTSDsurvivors
cide...?,”χ2=26.80;p<0.001)oftheTALS-SR(seeTable3). alsoreportedadecreaseinself-care(e.g.,notgettingenoughrest,
The Scattergram reported in Figure 1 shows the differen- noteatingproperly),withmorethan10%reportingsuspension
tial association between maladaptive behaviors, evaluated by ofon-goingtreatmentsormedicalrecommendations.Inlinewith
adopting TALS-SR domain VII total scores, gender, and PTSD previous studies on war veterans and adolescents (Glodich and
symptoms, evaluated by the sum of TALS-SR domains V (Re- Allen,1998;Sugar,1999;Gore-FeltunandKoopman,2002;Steven
experiencing), VI (Avoidance and numbing), and VIII scores etal.,2003;Jakupcaketal.,2007;Cepedaetal.,2010;Elbogenetal.,
(Arousal). In particular, a moderate Pearson correlation coef- 2010)wefoundsignificantlyhigherratesofrisk-takingbehaviors
ficient with PTSD symptoms, between moderate and good, (suchasunsafedriving,promiscuoussex)amongsurvivorswith
emergedinwomen(r=0.43,p<0.001)butnotinmen(r=0.15, PTSD.Further,morethanonethirdofthesesubjectsalsoreported
p=0.097). To note, in women significant correlations also atleastoneendorsementamongitemsexploringsuicidalideation
emerged between maladaptive coping and each of the total orattempts.
scores of the three symptomatological domains (domain V Re- Significant gender differences emerged among survivors
experiencing, r=0.23, p<0.001; domain VI Avoidance and with PTSD, with men reporting significantly higher rates of
numbing, r=0.44, p<0.001; domain VIII Arousal, r=0.25, maladaptivebehaviorsthanwomen.Inparticular,wefoundthat
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Dell’Ossoetal. PTSD,gender,andmaladaptivebehaviors
Table3|Maladaptivebehaviors(TALS-SRDomainVII)prevalenceratesin372L’AquilaearthquakesurvivorswithPTSD:genderdifferences.

TALS-SRDomainVII(Maladaptivecopying) Men(N=122)N(%) Women(N=250)N(%) χ2 p

97....Stoptakingcareofyourself,forexample,notgetting 51(41.8) 113(45.2) 0.26 0.611

enoughrestornoteatingright?
98....Stoptakingprescribedmedicationsorfailtofollow-up 21(17.2) 18(7.2) 7.73 0.005

withmedicalrecommendations,suchasappointments,

diagnostictests,oradiet?
99....Usealcoholordrugsorover-the-countermedications 40(32.8) 47(18.8) 8.19 0.004

tocalmyourselfortorelieveemotionalorphysicalpain?
100....Engageinrisk-takingbehaviors,suchasdrivingfast, 36(29.5) 19(7.6) 29.52 <0.001

promiscuoussex,hangingoutindangerousneighborhoods?
101....Wishyouhadn’tsurvived? 23(18.9) 41(16.4) 0.20 0.658
102....Thinkaboutendingyourlife? 15(12.3) 17(6.8) 2.451 0.117
103....Intentionallyscratch,cut,burn,orhurtyourself? 21(17.2) 13(5.2) 12.84 <0.001
104....Attemptsuicide? 17(14.0) 2(0.8) 26.80 <0.001

FIGURE1|Genderdifferencesinthecorrelationsbetweenpost-traumaticstresssymptomsandTALS-SRdomainVIItotalscore.

men reported significantly more than women interruption of age and female gender associated with the increased number of
on-goingtreatments,alcohol,ordrugabuse,orover-the-counter prescriptions.
medicationusetocalmthemselves,risk-takingbehaviors,includ- Ourresultsalsosuggestasignificantassociationbetweensome
ingself-injuringandsuicideattempts.Inapreviousstudy,some specificmaladaptivebehaviors,suchasengagementinrisk-taking
of our group (Rossi et al., 2011) compared the rates of new behaviors and suicide attempts, and male gender in PTSD sur-
psychopharmacological prescriptions in the 6months after the vivors.Inthisregard,inasampleof409Israeliadolescentsexposed
L’Aquila2009earthquaketothesameperiod1yearbefore,show- torecurrentterrorism,Pat-Horenczyketal.(2007)reportedsig-
ing a 37% increase of new prescriptions for antidepressants nificantly higher maladaptive behaviors, as a manifestation of
and a 129% increase for antipsychotic prescriptions,with older functionalimpairment,invictimswithPTSD,particularlyamong

FrontiersinPsychiatry|AddictiveDisordersandBehavioralDyscontrol January2013|Volume3|Article111|4
Dell’Ossoetal. PTSD,gender,andmaladaptivebehaviors
boys.Virtually all studies of the psychological effects of trauma rating of the clinician, in order to detect PTSD symptoms and
indicate that women are more inclined to report anxiety and evendiagnosis.Aself-reportofPTSDsymptomsmaybe,infact,
mood symptoms (Green,2003; Shaw,2003; Lai et al.,2004; Bal consideredlessaccurate.Thethirdlimitationisthelackofinfor-
and Jensen, 2007; Cohen, 2008; Goenjian et al., 2009; Pratchett mation on the presence of Axis I psychiatric comorbidities and
etal.,2010;XuandLiao,2011;XuandSong,2011;Zhangetal., thismayaccountfortheanswersondomainVIIquestionregard-
2011;Alietal.,2012)andareathigherriskfordevelopingpost- ingalcoholordrugabuse. Fourthly,inthepresentinvestigation
traumatic distress than men (Davis and Siegel, 2000). However wedidnotassesssocialsupport,thoughsuchsupportisgenerally
our data suggest that men tend to manifest more disruption in believedtobehighinItalyduetothecloselyknitfamilystructure,
theirbehavioraladaption.Someauthorsinfactinterpretedsim- andgenderdifferencesmayalsooccurinthisregard.
ilar results in adolescents, suggesting that men tend to express Despite these limitations, our results confirm the pervasive
psychologicaldisturbancesthroughactingoutandexternalbehav- effects of a disaster, such as an earthquake, not only for men-
ior,whereaswomentendtoexpresstheirdistressbyturningtheir tal health in the general population exposed, but also for the
feelingsinwards,leadingtodepressionandanxiety(Ostrovetal., possible development of risk-taking behaviors that may affect
1989;Hirschbergeretal.,2002;Pat-Horenczyketal.,2007;Xuand men and women differently. In this regard, our results high-
He,2012). light the need to investigate such behaviors among earthquake
When looking at the possible associations between post- exposedpopulationsmoreindetail,withparticularattentionto
traumaticstresssymptomatologyandmaladaptivebehaviorssig- gender differences,in order to get a more accurate understand-
nificantcorrelationsemergedinwomen,witheachoftheTALS-SR ing of post-traumatic stress psychopathology. Previous research
symptomatologicaldomains,whilethesamewasconfirmedonly (Armenian et al., 2000, 2002) has shown depression to be one
for avoidance and numbing symptoms in men. Pat-Horenczyk of the major complications of earthquakes, possibly as a result
etal.(2007)reportedpost-traumaticstresssymptoms,including of the multiple losses sustained. Given that women are vulner-
fear, re-experiencing, avoidance, and functional impairment, to able not only to PTSD,but also to anxiety disorders and major
be significant predictors of the severity of risk-taking behaviors depression that can interfere and delay the recovery of the for-
beyondgenderandlevelofexposure.Ourresultsdonotreplicate mer,therapeuticinterventionshouldbebroadenedbeyondPTSD.
these data as a significant association with post-traumatic stress Finally,thedifferenceinmaladaptivebehaviorsinmenandwomen
symptomsemergedinwomenwhileinmenthiswasconfirmed mightbeacorrelateof thepredominanceof anxious-depressive
foravoidanceandnumbingonly. symptomatology in women. In other words anxious depression
Some important limitations of the study should be kept in might serve as a “break” on maladaptive behavior in women.
mindbeforeinterpretingtheresults:firstthelimitednumberof These hypotheses deserve investigation in future analyses and
subjects;second,theuseofself-reportinstruments,insteadofthe studies.

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Dell’Ossoetal. PTSD,gender,andmaladaptivebehaviors
earthquake. Public Health 125, Received: 25 November 2012; accepted: studyon900L’Aquila2009earthquake MaremmaniandRossi.Thisisanopen-
293–300. 12December2012;publishedonline:04 survivors. Front. Psychiatry 3:111. doi: accessarticledistributedundertheterms
January2013. 10.3389/fpsyt.2012.00111 of the Creative Commons Attribution

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authors declare that the research was Stratta P, Massimetti G, Akiskal KK, in Addictive Disorders and Behavioral andreproductioninotherforums,pro-
conducted in the absence of any Akiskal HS,MaremmaniIandRossiA Dyscontrol, a specialty of Frontiers in vided the original authors and source
commercial or financial relationships (2013) Gender differences in the rela- Psychiatry. are credited and subject to any copy-
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conflictofinterest. and post-traumatic stress disorder. A Stratta, Massimetti, Akiskal, Akiskal, graphicsetc.

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