M.S. BHATIA*， Priyanka GAUTAM

Case report of a child's anxiety disorder precipitated by tremors from a distant earthquake that was extensively covered in local news stories

M.S. BHATIA*， Priyanka GAUTAM

earthquake； news reports； natural disaster； other specified anxiety disorder； selective serotonin reuptake inhibitor； children； India

1. Introduction

Earthquakes are among the most common and most devastating natural disasters known to mankind， but much still needs to be understood about the mental health consequences of earthquakes and about the risk factors that increase the likelihood of a mental disorder following a major earthquake.［1］Numerous mental health conditions are known to occur after earthquakes，events that often result in significant losses for many members of the affected communities.［1］Major earthquakes have been associated with an increased prevalence of major depression （MDD）， anxiety disorders， post-traumatic stress disorders （PTSD），［2］sleep disorders，［3］and other neurological complaints such as dizziness.［4］The estimated prevalence of MDD among earthquake survivors is approximately 12% and that of PTSD is 8%.［5］Female survivors have higher rates of most psychiatric disorders following earthquakes than male survivors. Other factors that increase the risk of mental disorders following an earthquake include being divorced or widowed， having a low education，and experiencing significant damage to one's home.［5］A survey that investigated the psychological reactions and recovery process of children and adolescents who had experienced a major earthquake found that fear- and anxiety-related mental disorders occurred earlier and resolved more quickly than depressive disorders and psychophysical symptoms.［6］

Most research studies on the mental health effects of earthquakes focus on survivors living in communities that were severely affected by the earthquake.［5，7］Few studies assess the mental health effects on communities that are further from the earthquakes' epicenters where residents experience minor trembling and aftershocks but no structural damage or injury. Non-destructive earthquake tremors and aftershocks are known to cause episodes of dizziness， presumably due to a disturbance in the brain's equilibrium mechanisms，［8］but there have been no reports of the prevalence of major mental disorders among individuals who experience such nondestructive earthquake phenomena.

We report a case of a 10-year-old girl who came to our outpatient psychiatry department with symptoms of anxiety after experiencing a non-destructive earthquake tremor caused by a distant earthquake.

2. Case report

A 10-year-old girl was brought to our outpatient psychiatry department with symptoms of anxiety that began after experiencing an earthquake tremor while sitting in her Delhi home two weeks earlier.The epicenter of the earthquake was in Afghanistan where there was severe destruction and loss of life，but Delhi had only experienced minor tremors with no loss of life or property. The girl had seen coverage of the earthquake in news reports and became fearful that a major earthquake would occur in Delhi. She refused to leave her home and became afraid of anything that moved. When taken out of her home by family members， she became anxious when seeing moving motor vehicles and even when seeing leaves move on trees. Family members tried to reassure her that no earthquake was occurring and that the movements around her were normal， but she was not convinced and believed that she was experiencing another earthquake tremor. In the two weeks before coming to the outpatient department， she had stopped attending school and playing outdoors with her friends.Continually apprehensive about earthquakes， she was unable to study. She repeatedly scanned the walls，furniture， and appliances in her home， asking family members for reassurance that they were not moving due to an earthquake. She refused to sit in front of a fan or air conditioner and asked that others switch them off. Her sleep became disturbed； she woke multiple times during the night and cried out with fear that an earthquake was occurring. Her parents reported that she had no significant past history of psychological problems and was previously well-adjusted. There was no family history of any psychiatric disorder.

The mental status examination at the time of her first clinic visit found that she was conscious and oriented to time， place， and person. She was wellgroomed and had no abnormal perceptions， but her affect was anxious and she was preoccupied with the possibility of the occurrence of an earthquake. Her general physical examination was normal. Her routine laboratory tests （including blood profile； liver， kidney，and thyroid function tests； electrocardiogram； and urine test） were all within normal limits.

We taught her relaxation exercises and prescribed alprazolam 0.25 mg once daily. However， at the twoweek follow-up visit she showed little improvement， so the alprazolam was augmented with escitalopram 10 mg daily. At the 4-week follow-up visit， 2 weeks after starting the escitalopram， she reported significant improvement： she no longer felt afraid of moving objects， was able to play outdoors with her friends， and was able to return to school.

3. Discussion

This case report is unique in that the young girl's anxiety was precipitated by experiencing only the tremors of an earthquake without suffering any actual physical damage or loss. Apparently her emotional response to this relatively mild exposure to the earthquake was intensified by news reports of major destruction at the earthquake's epicenter. Her symptoms were quite severe and disabling， but they had only lasted for 2 weeks at the time of first evaluation， so she did not fit neatly into any of the currently available specific diagnostic categories.

The International Classification of Diseases-Tenth Revision （ICD 10）［9］criteria for Acute Stress Reaction stipulate that symptoms from transient stressors must diminish in less than 8 hours and symptoms from persistent stressors must diminish within 48 hours；but in our case the symptoms persisted and became progressively worse for 2 weeks following the initial stressor. The corresponding diagnosis in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders （DSM-5）［10］is ‘Acute Stress Disorder'； the required duration is 3 days to a month， which fits our case， but there must be a precipitating event that is life threatening and repeated exposure by television and other media is explicitly excluded so， again， our case does not fit these criteria. PTSD symptoms need to persist for at least a month and the symptoms of Generalized Anxiety Disorder （GAD） need to persist for 6 months， so neither diagnosis was appropriate for this patient.

Given the severity of the symptoms and the degree of disability， the patient merited a psychiatric diagnosis despite not meeting criteria of PTSD or any of the specific anxiety disorders. After excluding the other possible diagnoses， the remaining diagnosis was‘Other Specified Anxiety Disorder，' a non-specific DSM 5 category that covers situations in which significant anxiety is present with associated social dysfunction，but the individual does not meet criteria of any other specific condition.

Treatment was tailored according to the needs of the case as no standardized guidelines exist for the management of Other Specified Anxiety Disorder. Her severe， disabling anxiety was not controlled after two weeks of relaxation exercises and monotherapy with a benzodiazepine （alprazolam）， so a selective serotonin reuptake inhibitor （SSRI） was added （escitalopram）.After two weeks on this combined treatment with a benzodiazepine and a SSRI， her symptoms improved dramatically and her social functioning returned to normal. In an earlier report［11］we described a similar case of a 19-year-old male who suffered from debilitating anxiety that was only controlled after treatment with a SSRI.

Research is needed to explore how earthquakes and other major disasters affect the mental health of those who only indirectly witness the events via news reports or who experience only minimal physical effects， such as non-destructive earthquake tremors and aftershocks.

Funding

No funding was received to prepare this case report.

Conflict of interest statement

The authors report no conflict of interest related to this case report.

Informed consent

The patient's father provided written informed consent for the publication of this case report.

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（received， 2015-07-07； accepted， 2015-10-10）

Professor M.S Bhatia obtained a bachelor degree of medicine in 1982 from Maulana Azad Medical College in Delhi University and an MD in psychiatry in 1987 from Lady Hardinge Medical University in Delhi University， New Delhi. He currently is a professor and the head of the Department of Psychiatry， University College of Medical Sciences and Guru Teg Bahadur Hospital， Dilshad Garden， Delhi， India. He also is an editor of the Delhi Psychiatry Journal， fi eld editor of the Indian Journal of Psychiatry， an executive member of the Indian Psychiatric Society （North Zone） and the Indian Association for Social Psychiatry， a member of the World Psychiatric Association， the World Association of Social Psychiatry， and the World Federation for Biological Psychiatry. His research interests are psychopharmacology， cultural psychiatry， consultation liaison psychiatry， and somatoform disorders.

當(dāng)?shù)匦侣剬h(yuǎn)距離地震所致非破壞性震感的過度報道促發(fā)兒童焦慮障礙的病例報告

Bhatia MS， Gautam P

地震；新聞報道；自然災(zāi)害；其他焦慮障礙；選擇性5-羥色胺再攝取抑制劑；兒童； 印度

Earthquakes are relatively common natural disasters in many parts of the world， but research about the mental health effects of earthquakes remains limited. Individuals experiencing an earthquake often suffer significant loss and are at increased risk for developing mental disorders. However， the prevalence of mental disorders following less dramatic or non-destructive earthquake phenomena is unknown. We report the case of a 10-year-old girl who came to a psychiatric outpatient department with a 2-week history of severe， disabling anxiety symptoms precipitated by non-destructive tremors from a distant earthquake that received extensive coverage in the local press. Her condition did not meet criteria for any of the specific anxiety-related disorders， so the non-specific DSM-5 category ‘Other Specified Anxiety Disorder' was considered most appropriate. Her symptoms resolved over 4 weeks when treated with both a benzodiazepine and a selective serotonin reuptake inhibitor.

［Shanghai Arch Psychiatry. 2016； 28（1）： 52-55.

http：//dx.doi.org/10.11919/j.issn.1002-0829.215077］

Department of Psychiatry， University College of Medical Sciences and Guru Teg Bahadur Hospital， Dilshad Garden， Delhi， India

*correspondence： Professor M. S. Bhatia， D-1 Naraina Vihar， New Delhi-110028， India. E-mail： manbhatia1@rediffmail.com

A full-text Chinese translation of this article will be available at http：//dx.doi.org/10.11919/j.issn.1002-0829.215077 on May 25， 2016..

概述：地震是世界上許多地區(qū)比較常見的自然災(zāi)害，但地震對心理健康影響的研究還很有限。經(jīng)歷地震的人往往遭受重大損失，患精神障礙的風(fēng)險增加。然而，規(guī)模不大、非破壞性地震現(xiàn)象所致精神障礙的患病率還是未知的。本文報告了一名就診于精神科門診的10歲女孩，她出現(xiàn)嚴(yán)重影響功能的焦慮癥狀已2周，其誘因是經(jīng)歷了一場較遠(yuǎn)地區(qū)的地震，而在當(dāng)?shù)貎H有非破壞性震感，媒體卻過度報道。她的情況不符合任何特定的焦慮相關(guān)障礙，因此最合適的診斷是精神障礙診斷與統(tǒng)計手冊第五版 （Diagnostic and StatisticalManual of Mental Disorders， Fifth Edition， DSM-5）非 特異性分類中的“其它特定焦慮障礙”。經(jīng)過一種苯二氮?類藥物和一種選擇性5-羥色胺再攝取抑制劑的治療，患者的癥狀4周后消失。

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