INTRODUCTION
Natural disasters are considered among the most significant traumatic events due to their destructive and large-scale impact, the distressing scenes they generate, their uncontrollable and undesired consequences, and the socioeconomic difficulties they impose [1]. Earthquakes, in particular, are among the eISSN 1976-3026 OPEN ACCESS natural disasters with the most significant potential to adversely affect public health, as they occur suddenly, cause extensive destruction, and expose thousands of people to the risk of sudden death, physical injury, property loss, or homelessness [2]. Turkey, situated in a seismic zone, experienced two major earthquakes on February 6, 2023, with magnitudes of 7.6 and 7.7, centered in Pazarcık and Elbistan, occurring nine hours apart. The effects of these earthquakes were felt across 11 provinces in Turkey and neighboring regions of Syria, impacting approximately 13 million people [3]. Following these two significant earthquakes, thousands of aftershocks were recorded in the affected areas. Survivors who lost relatives, homes, property, or jobs either relocated to other cities or were forced to endure the difficult living conditions in the region. Referred to as the “disaster of the century” by the Republic of Turkey, the earthquakes irreversibly altered the lives of millions of people [4].
After an earthquake, survivors may experience various psychiatric symptoms. Early reactions to trauma are usually normal and tend to subside over time. Research has shown that a subset of survivors may develop psychiatric disorders such as posttraumatic stress disorder (PTSD), depression, anxiety disorders, and sleep disturbances [4-6]. The development of psychiatric disorders among earthquake survivors can be influenced by multiple interrelated factors, including coping styles, biological predispositions, social support, and psychological resilience [7,8].
Psychological resilience, in particular, is defined as the individual’s capacity to solve problems and cope with adversity. American Psychological Association defines resilience as the process of effectively adapting in the face of adversity, trauma, tragedy, threats, or other significant sources of stress. Resilience helps survivors adapt to the difficult conditions that follow an earthquake. Enhancing resilience skills not only reduces stress but also promotes healthier and longer lives [8,9].
Another major psychological challenge faced by survivors is the feeling of hopelessness, which arises when individuals believe that their circumstances will not improve physically, emotionally, or socially. Disaster-related helplessness increases anxiety levels and contributes to distress, sadness, and hopelessness. Furthermore, economic crises triggered by the earthquakes exacerbate uncertainty about the future, while diminished expectations and a lack of motivation for future planning deepen hopelessness [10,11].
Linden et al. [12], in studies conducted in Germany, reported that individuals who experienced adverse life events often sought treatment for complaints resembling PTSD and adjustment disorder, though not fully meeting the diagnostic criteria for either. These symptoms were categorized under posttraumatic Embitterment Disorder (PTED), and the PTED Scale was developed accordingly. Individuals with PTED symptoms attribute their psychiatric complaints to the traumatic event and display extreme emotional and behavioral responses beyond what is considered typical. They often report feelings of embitterment toward life, emotional pain, brooding, and uncontrollable anger, typically associated with the belief that they have been treated unjustly [13].
Following the February 6 earthquakes, survivors were subjected to thousands of aftershocks and faced uncertainty regarding safety, the construction of permanent housing, the sustainability of aid, and the restoration of their daily routines. This uncertainty may have exacerbated psychological distress, including frustration, perceptions of injustice, feelings of helplessness, and anger [14]. Moreover, although earthquakes are natural disasters, numerous human errors contributed to the worsening of conditions [15]. Research shows that human-induced traumas can deeply undermine individuals’ sense of justice and trust, leading to various adverse psychological responses [6].
Although the literature includes many studies examining PTSD in earthquake survivors [7,8], no study to date has specifically investigated PTED symptoms in this population. The presence of human-related factors in the aftermath of the disaster may have undermined survivors’ belief in justice, triggering feelings of embitterment and anger and thereby eliciting PTED symptoms. Furthermore, ongoing hardships, feelings of helplessness, and uncertainty may intensify feelings of hopelessness, further worsening the overall clinical picture.
This study aimed to investigate the mediating role of hopelessness in the relationship between psychological resilience and posttraumatic embitterment symptoms among survivors of the February 6 earthquakes. The following hypotheses were tested:
H1: Psychological resilience has a statistically significant direct effect on embitterment.
H2: Psychological resilience has a statistically significant direct effect on hopelessness.
H3: Hopelessness has a statistically significant direct effect on embitterment.
H4: Hopelessness mediates the relationship between psychological resilience and embitterment.
Since no previous study has used this approach, the present research makes a unique contribution. Our findings will contribute to the literature regarding potential psychopathologies and therapeutic interventions among earthquake survivors and guide future studies in this field.
METHODS
Participants and procedure
The study employed a relational survey model [16]. The study was conducted between July 20, 2023, and January 20, 2024, in Malatya, one of the 11 provinces affected by the earthquakes. Data were collected from participants via Google Forms. Ethical approval for the study was obtained from the Bursa City Hospital Clinical Research Ethics Committee (Date: 19 July 2023, Approval Number: 2023-12/13). Each participant was restricted to a single response during data collection, and cookie and IP address checks were performed to ensure data reliability. The research was carried out in accordance with the Declaration of Helsinki, and informed consent was obtained from all participants.
Although there is no universally agreed-upon sample size requirement for path analysis with observed variables (PAWOV), Schumacker and Lomax [17] suggest that sample sizes between 250 and 500 are commonly used, while Kline16 recommends that PAWOV analyses should include at least 200 participants. Based on these recommendations, the present study included 801 participants.
Participants were recruited through researchers’ social networks (e.g., WhatsApp, Telegram) using non-probability sampling methods, including voluntary response sampling and snowball sampling. Various social media platforms, online student communities, and online communities involving public officials were selected as starting points. Data was collected from various target groups to develop a sample by reaching different communities using online methods. The inclusion criteria were: being between 18 and 65 years of age, literate, having directly experienced the February 6 earthquakes, and having the ability to use online technology. Exclusion criteria were: individuals with a current psychiatric diagnosis under treatment, alcohol or substance dependence, or physical/mental health conditions that could affect the cognitive capacity required to complete the forms (e.g., Parkinson’s disease, dementia, intellectual disability, schizophrenia), and incomplete completion of questionnaires.
Data collection tools
PTED Scale
Developed by Linden et al. [12] to assess the dimension and characteristics of embitterment in response to adverse events, based on clinical presentations of patients. It is a 19-item, 5-point Likert-type self-report scale. Scores range from 0 to 76, with a mean score of 2.5 or higher indicating clinically significant embitterment. The scale is one-dimensional and higher scores reflect greater severity. A cutoff of 1.6 indicates high embitterment, whereas 2.5 indicates clinically significant embitterment. The Turkish adaptation demonstrated good reliability and validity, with a Cronbach’s alpha of 0.89 [13].
Psychological Resilience Scale
Originally developed by Friborg et al. [18], this 33-item selfreport scale includes both positively and negatively worded items arranged in a 5-point Likert format to minimize biased responses. Scoring allows for both high and low resilience evaluations. The Turkish adaptation demonstrated adequate validity and reliability, with a Cronbach’s alpha of 0.81 [19].
Statistical analysis
Data analyses were performed using SPSS 25 (Statistical Package for the Social Sciences; IBM Corp.). The normality of data distribution was examined with the Kolmogorov-Smirnov test [22]. The significance level for comparisons was set at p=0.05. Since the data met standard distribution assumptions (p>0.05), parametric tests were applied. Descriptive statistics were reported as frequencies, percentages, means, and standard deviations. Correlations between scale scores and age were investigated using Pearson’s rank correlation analysis.
The internal reliability of the scales was assessed using Cronbach’s α coefficients. Scales can be used in a format suitable for statistical calculations without re-applying analyses in scales whose validity and reliability studies have been performed before. Therefore, the validity analyzes of the scales were not repeated [23]. The formula for Average Variance Extracted (AVE) and Composite Reliability (CR) values is given below and was calculated and interpreted separately for each sub-dimension and the total scale using factor loadings; PTED Scale: AVE=0.519, CR=0.951; Beck Hopelessness Scale: AVE=0.510, CR=0.953; Psychological Resilience Scale: AVE=0.500, CR=0.970.
PAWOV analyses were performed using AMOS 24 (IBM Corp.). To verify multivariate normality, Mahalanobis distance values were examined using the “Observations Farthest from the Centroid” function in AMOS. The skewness value of the model was calculated as 3.917, which was below the threshold of 8, thus satisfying the assumption of multivariate normality [24].
A mediation analysis was conducted within PAWOV using the bootstrap method with AMOS 24. Previous research suggests that bootstrap estimates are more reliable than traditional methods (Baron & Kenny approach) and Sobel tests. The bootstrap procedure was based on 5,000 resamples. If the 95% confidence interval (CI) of the lower and upper bounds does not include zero, the mediation effect is considered statistically significant [25].
RESULTS
Clinical and sociodemographic characteristics
A total of 817 participants were initially recruited for the study. Sixteen individuals who were undergoing psychiatric treatment at the time were excluded, resulting in a final sample of 801 participants. Of these, 453 (56.6%) were female and 348 (43.4%) were male. The mean age was 37.82±11.03 years, and 537 (67.0%) were married. A total of 143 participants (17.9%) reported having a physical illness. Moreover, 339 participants (42.3%) reported having previously experienced an earthquake of similar intensity, while 188 (23.5%) reported losing a relative during the earthquake. Sociodemographic variables are presented in Table 1.
Mean scale scores were as follows: PTED Scale: 43.99±17.17; Beck Hopelessness Scale: 8.79±6.22; and Resilience Scale: 102.06±11.74. The cut-off score on the PTED Scale was assessed as 2.5 points, and PTED symptoms were present in 389 participants (48.6%). Descriptive statistics for the scales are provided in Table 2.
Pearson correlation analysis was performed between scale scores and age. The correlation analysis revealed a statistically significant moderate positive correlation between embitterment and hopelessness, and a statistically significant low negative correlation between embitterment and age (p<0.05). A statistically significant low negative correlation was found between hopelessness and psychological resilience (p<0.05). The analysis results were presented in Table 3.
Mediation model results
To examine the mediating role of hopelessness in the relationship between psychological resilience and embitterment, PAWOV was constructed. First, a structural model was developed to test the relationship between psychological resilience and embitterment. The structural model is presented in Figure 1. In the model, psychological resilience was specified as the independent variable, embitterment as the dependent variable, and e1 as the error term. Path coefficients for the model are reported in Table 4.
Psychological resilience had a statistically significant direct negative effect on embitterment (B=-0.271, p=0.001). Specifically, a one-point increase in psychological resilience was associated with a 0.185-point decrease in embitterment scores (β=-0.185). Psychological resilience accounted for 3.4% of the variance in embitterment (R²=0.034).
A mediation model was then developed in which hopelessness was included as a mediator. The model diagram is shown in Figure 2, and the regression coefficients with their corresponding significance levels are reported in Table 5.
In this model, hopelessness served as the dependent variable for psychological resilience and as the independent variable for embitterment. A statistically significant negative re-lationship was found between psychological resilience and hopelessness (B=-0.125, p=0.001). A one-point increase in psychological resilience was associated with a 0.066-point decrease in hopelessness (β=-0.066). Psychological resilience explained 2% of the variance in hopelessness scores (R²=0.020).
There was a significant negative association between psychological resilience and embitterment (B=-0.105, p=0.001) and a significant positive association between hopelessness and embitterment (B=0.640, p=0.001). Specifically, embitterment decreased by 0.154 points (β=-0.154) for each one-point increase in psychological resilience, while it increased by 1.767 points (β=1.767) for each one-point increase in hopelessness. Together, psychological resilience and hopelessness accounted for 43.7% of the variance in embitterment (R²=0.437).
Bootstrap analyses were conducted to test the mediation effect. Results indicated that hopelessness had a statistically significant indirect (mediating) effect on the relationship between psychological resilience and embitterment (β=-0.080, CI [-0.121, -0.036]). Since the 95% CI did not include zero (CI lower=-0.121, CI upper=-0.036), the mediation effect was confirmed as statistically significant.
In the structural model, the unstandardized regression coefficient between psychological resilience and embitterment was β=-0.185, whereas in the mediation model, this coefficient decreased to β=-0.154. This reduction suggests a partial mediation effect [26,27].
To summarize, both psychological resilience and hopelessness were found to have significant direct predictive effects on embitterment, and hopelessness also demonstrated a significant mediating role in this relationship.
The overall model fit was examined using multiple fit indices. PAWOV considers the evaluation of all indices collectively, rather than focusing on a single index. In the present model, the goodness-of-fit indices were as follows: χ²/df=3.081; Root Mean Square Error of Approximation (RMSEA)=0.019 (indicating adequate sample size, RMSEA<0.08); Goodness of Fit Index=0.993; Comparative Fit Index=0.998; Incremental Fit Index=0.998; and Normed Fit Index=0.997. These values indicate an excellent model fit [28].
DISCUSSION
In this study, the effects of psychological resilience and hopelessness on symptoms of PTED were examined among earthquake survivors of the February 6 earthquakes. Both variables were found to have a statistically significant impact on symptoms of embitterment. Moreover, hopelessness was identified as a mediating factor in the relationship between psychological resilience and embitterment.
Linden et al. [12], through his research on German immigrants, defined PTED and introduced its scale into the literature. According to his description, a single exceptional life event may accelerate the onset of the disorder. Feelings of embitterment and injustice dominate the clinical picture. Other features may include helplessness, self-blame, rejection of help, moral symptoms, dysphoria, melancholic depression, nonspecific somatic complaints, irritability, pain, appetite, and sleep disturbances. While PTED can be confused with PTSD, the prevailing emotional response is not anxiety—as in PTSD—but embitterment [12].
Yun et al. [29], in a study of 56 relatives of passengers who died in the 2014 ferry disaster in Korea, evaluated PTED symptoms at 18- and 30-month post-disaster. They reported that 64.3% of relatives showed PTED symptoms at the first assessment, and 76.8% at the second. Participants whose embitterment increased over time also reported higher rates of anxiety, PTSD, and complicated grief. Families expressed that fundamental issues regarding the causes of the accident had not been resolved. Contributing factors included an inexperienced crew, overloading, and inadequate rescue efforts. Misleading television reports initially claiming that all student passengers had been rescued further intensified families’ anger and distrust.
Perceived injustice strongly shapes survivors’ psychological reactions in such disasters. Feelings of revenge may emerge, but when unattainable, aggression can turn inward, resulting in pathological self-blame. Survivors may reject offers of help, and since emotional regulation remains impaired, the disorder may easily go undetected without careful assessment.
The high prevalence of PTED symptoms in our study, observed in 48.6% of earthquake survivors, necessitates a critical discussion on the disorder’s etiology, particularly in the context of natural disasters. PTED is fundamentally defined as a reaction to a negative life event perceived as involving injustice, emotional pain, and anger [12]. Studies on human-made traumas, such as the Sewol ferry disaster, have confirmed that embitterment is closely linked to the perception that the traumatic event resulted from preventable error or negligence rather than a purely natural occurrence [29]. Our findings extend this understanding to the context of the February 6 earthquakes. Although the event was a natural disaster, the significant exacerbation of its outcomes by human-related factors—including poorly constructed buildings, inadequate inspections, insufficient preparedness, organizational failures in disaster response and aid delivery, problems with sheltering, a shortage of experienced professionals—triggered a powerful sense of injustice and anger among survivors. These factors may have intensified perceptions of injustice and fueled emotional pain, embitterment, and anger, thereby triggering PTED symptoms.
Our findings further demonstrated a negative and statistically significant effect of psychological resilience on embitterment. The concept of resilience is rooted in Garmezy’s [30] studies on children at risk due to parental psychopathology. Psychological resilience has since become a significant focus in psychiatry, with multiple studies investigating its relationship to psychopathology following disasters. Heetkamp and de Terte [31] reported a negative relationship between psychological resilience and PTSD among adolescents after the New Zealand earthquakes. Similarly, in Turkey, Sakarya and Güneş [32] found a significant negative association between psychological resilience and PTSD among survivors of the Van earthquake.
Psychological resilience is defined as the ability to recover following a traumatic or life-altering event. It reflects a person’s capacity to adapt quickly and effectively to stress and to return to a state of well-being. Assessing psychological resilience in each patient is essential, as it may help predict the course of psychiatric disorders and the risk of recurrence. Early identification of vulnerable individuals in disaster-affected populations is crucial to implementing resilience-based interventions [33]. Our findings are consistent with prior research reporting a negative association between psychological resilience and psychopathology. Similar findings were reported in recent studies examining post-earthquake mental health in Turkey, which showed that factors such as gender, loss, and coping strategies significantly predicted persistent post-traumatic stress symptoms among survivors of the February 6 Turkey earthquakes [34].
Another important finding of this study is that hopelessness had a statistically significant and positive effect on embitterment. Natural disasters such as earthquakes disrupt daily life, create financial difficulties, hinder the fulfillment of basic needs, and elicit intense emotional responses that may culminate in mental health problems. Research on the psychological consequences of earthquakes has emphasized that responses vary significantly among individuals [35]. This variability may depend on personal vulnerability, susceptibility to harm, and coping skills [36].
Hope is widely regarded as an essential emotion for achieving happiness and fostering a future-oriented mindset [37]. Having meaningful life goals is a key factor supporting psychosocial well-being and resilience [38]. However, stressful life events, such as earthquakes and accidents, may hinder the attainment of such goals, requiring significant time and energy to overcome. Consequently, individuals may experience changes in motivation, cognition, and emotions related to their aspirations [39], which can negatively affect their well-being and adjustment. The finding of our study—that hopelessness positively predicts embitterment—is in line with previous research.
The most significant contribution of this research is the demonstration of the mediating role of hopelessness in the relationship between psychological resilience and embitterment. Specifically, psychological resilience and embitterment were negatively associated, while hopelessness and embitterment were positively associated. In the initial model (structural model), 3.4% of the variance in embitterment was explained by psychological resilience. In contrast, the mediation model revealed that psychological resilience and hopelessness together accounted for 43.7% of the variance in embitterment.
Hopelessness may function as a critical cognitive mechanism that triggers suffering by reinforcing the belief that a perceived injustice is irreparable. When hopelessness weakens an individual’s belief in their ability to confront the injustice or rectify the situation, this can intensify the core components of PTED: helplessness, anger, and emotional pain. According to Snyder [40], hope, being measurable, is a valuable resource for coping with adversity. Research indicates that individuals with higher levels of hope tend to cope more effectively with adverse events and improve their overall well-being [10,40]. Metaanalyses further confirm that hope serves a protective role against adversity, increases resilience, and facilitates recovery [41], This comprehensive finding expands the literature by highlighting that therapeutic interventions aimed at preventing and treating PTED in earthquake victims should not only focus on developing resilience skills but also incorporate hopebased cognitive restructuring strategies.
This study also has several strengths. While many studies have evaluated psychiatric disorders such as PTSD among earthquake survivors, this is the first to examine PTED symptoms, making it a specific original contribution. Another strength is the early timing of data collection, which occurs shortly after the earthquake, allowing us to capture acute psychiatric responses. The large sample size further strengthens the validity of the findings.
However, the study also has limitations. Data were collected online from residents of Malatya who experienced the February 6 earthquakes, and diagnostic evaluations through faceto-face interviews were not conducted. As a result, disorders such as PTSD, depression, or adjustment disorder—potentially more explanatory of embitterment—were not excluded. This method was chosen due to anticipated challenges in healthcare delivery and accessibility following the earthquake. Consequently, symptom severity was evaluated solely based on selfreport scales, which represents a limitation. Another limitation was the lack of data regarding the severity of participants’ earthquake exposure and post-earthquake stressors. Additionally, the study was limited to Malatya and did not include the other 10 provinces affected by the earthquakes, restricting the generalizability of findings. It is acknowledged that the online data collection process and the snowball sampling method entail a potential limitation, such as the over-representation of individuals with higher education levels within the sample. The fact that the vast majority of participants were university graduates can also be considered a limitation. Finally, while the Cronbach’s alpha for the resilience scale (α=0.602) was relatively low, it is generally considered an acceptable threshold for reliability in social science research, and thus its inclusion was deemed appropriate for the present analysis [42].
In conclusion, this study found that psychological resilience and hopelessness were significant predictors of embitterment among survivors of the earthquake. Hopelessness was shown to mediate the relationship between resilience and embitterment. Increased psychological resilience was associated with reduced hopelessness, while increased hopelessness was associated with greater embitterment. All the study’s hypotheses were statistically supported.
Clinicians should consider PTED when assessing earthquake survivors. Developing hope-based psychotherapeutic interventions and implementing preventive strategies in vulnerable populations may be particularly valuable. Our findings can guide health authorities in structuring post-disaster mental health services and assist in developing health policies in this regard. There is a need for more structured, prospective follow-up studies to further investigate the psychological consequences of earthquakes.
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