Both PTSD and depression were high in our sample with 75.8% of participants meeting the criteria for PCL-C criteria and 79.8% meeting the criteria for PHQ-9. Having depression was associated with 5 times the likelihood of having PTSD and 9 times the likelihood of having severe PTSD. Post-traumatic growth was almost 6 degrees higher in participants with PTSD but was not associated with depression. PTG was also approximately 5 degrees higher in females, unmarried participants, and those who were less than 1.6 km from the blast epicenter at the time of the blast. Appreciation for life was the highest-scored PTG domain.
PTSD is a debilitating disorder causing dysfunction in social contexts and interpersonal relationships. This can be exacerbated by depression [19]. A study following a church explosion demonstrated that both disorders have long-term consequences leading to overall health deterioration in the Lebanese population [20]. Recent studies estimated the prevalence of PTSD in Lebanese adults between 2 to 98% [21] and depression around 60% [22]. In a population study two months following the Beirut Blast, 37% of participants met the criteria for PTSD, a substantially lower number compared to our population who were less than 4.1 km from the blast’s epicenter. Depression prevalence was similar at 80% [23]. These high rates of PTSD and depression blast survivors imply poor quality of life, particularly for those affected by both disorders [24]. An exacerbating factor is the unstable socio-political and economic situation already prevailing in Lebanon [25].
As expected, unemployment was associated with higher rates of PTSD and depression [26]. The association could be bidirectional as psychiatric disorders pose an occupational disability that could impede job acquisition or retention [27]. Moreover, the associations between depression and loss of a job and loss of valuable possessions were consistent with existing literature [28, 29]. Finally, physical injury, especially after trauma, confers a higher likelihood of developing PTSD [24, 30]. This is consistent with this study’s results. The association between physical injury and depression was borderline statistically significant (p=0.06) which is likely due to the modest sample size.
Participants who had a psychiatric diagnosis were more likely to seek psychological care following the blast. This is consistent with the fact that experiencing more intense symptoms after a disaster makes individuals more likely to accept going to mental health services [31]. This association was also seen in the case of children and adolescents following the Beirut Blas [7].
Results regarding an association of PTSD with injury and/or death of a loved one have been contradictory [32-34]. In one review, indirect exposure through loved ones was not a predictor of PTSD whilst directly witnessing injury was [32]. In this population who was directly exposed to the traumatic event, the injury of a loved one induced a higher rate of PTSD. Therefore, the injury of a loved one may be an exacerbating factor for those directly affected by the blast. PTSD could have been also associated with the death of a loved one, however, this reached borderline significance (p=0.06).
Resilience and post-traumatic growth are two notions describing the reaction to highly challenging and stressful life events [35]. Resilience is the immediate adjustment to stress at the moment of occurrence of the incident, whereas PTG is the ability to manifest positive changes in the aftermath of this incident. Despite inconsistencies between studies, most showed a negative correlation between the two factors. It is postulated that individuals who are considered resilient are less likely to develop mental health disorders following hardships, thus experiencing less post-traumatic growth [36].
In our study, almost every participant experienced PTG irrespective of PTSD development. This is consistent with the fact that people who experience “extraordinary traumatic events” tend to report a positive change [37]. For example, in Palestinians subject to multiple traumas, the mean PTG was equivalent to a “modest to moderate degree of growth” [38], similar to our study’s case. However, in our study, those with PTSD had considerably higher PTG. This is consistent with current studies [39, 40] including a study conducted on Palestinian helpers [41]. Kira et. al found that PTG is associated with “single-event” traumas in a Palestinian sample but not other types of traumas. However, the same study found an association between depression and PTG [38] which is not the case in our sample. The implications of the PTSD-PTG association remain scarcely known. If trauma causes both a hindrance to wellbeing as well as PTG associated with increased subjective wellbeing [41], could there be common biopsychosocial mechanisms underpinning both higher PTSD and higher PTG? For instance, memory processes in PTSD could underpin a tendency for “constructive rumination”, hence a higher PTG [39, 42].
Females were twice as likely to have severe PTSD, therefore, it was expected that females show a higher PTG. This was consistent with the fact that females tend to report a higher degree of growth which may indicate a difference in trauma processing and/or an effect of gender-dictated behaviors [35, 43, 44]. Being married is a risk factor for PTSD after disasters [32] as well as a predictor of a lower quality of life [26]. Parenthood and worrying about one’s children from a disaster’s consequences can also play a role [45]. In this study, even though being married and having children were associated with a higher rate of PTSD, they were associated with a lower PTG. This implies that the association between PTSD and PTG is not strictly linear and an interplay of various factors can be involved, possibly related to different trauma types and their associations with PTSD [38].
Proximity to the blast was not associated with a higher likelihood of PTSD but with a more severe PTSD profile, the highest rate of severe PTSD (85.7%) being in the <0.8 km radius group. This proximity-severity association was similar to other explosions [45, 46]. This could mean that witnessing the blast from a closer distance (notably from <1.6 km) did not increase the risk of PTSD but rather its severity if it developed. This could be related to the initial acute stress response in survivors [47]. As proximity increases PTSD severity, it also increases the degree of PTG, especially in the “appreciation to life” domain. This could be related to surviving a lethal blast from close physical proximity. In fact, for burn victims of the Formosa Fun Coast Water Park explosion, appreciation for life was the domain with the highest mean score [48].
Limitations and Perspective
First, our sample was a sample of convenience. People with certain disabilities, those who do not have access to technology, and those who are not accustomed to technology use could not fill out our online survey. Additionally, only people interested in the survey would fill it. The sample size was modest which could lead to an underestimation of the effects of some covariates. Second, some of the tools’ items could be affected by factors unrelated to the blast like the COVID-19 pandemic and the socioeconomic situation in Lebanon. We mitigated these confounders by using targeted questions to the Beirut Blast. Finally, some limitations emanate from every self-reported online survey, which could leave room for biases like the social desirability bias. However, the use of validated questionnaires would have mitigated the effect [49]. As this study assesses PTSD, depression, and PTG at the time of survey filling, the introduction of recall bias is relatively minimal.
Albeit the aforementioned limitations, our study is the first of its kind that highlights PTG as an important construct for Beirut Blast survivors who were in the direct vicinity of the blast epicenter (<4.1 km radius). PTG may be an adaptive response to severe post-traumatic stress. It could prove a useful tool in clinical psychology and underlie a variety of cognitive processes [50]. Finally, during emergency contexts, PTG could be capitalized on to promote well-being and decrease the psychological burden on survivors [41]. Efforts post-disasters should focus on strengthening post-traumatic growth domains like adequate community support and promoting personal strength.