Posttraumatic Stress Disorder Following Motor Vehicle Accidents: Review of the Literature

Jeffrey W. Braunstein, Ph.D.

Epidemiology

Approximately 3.5 million people in the United States are injured every year from serious Motor Vehicle Accidents (MVAs).¹  MVAs are defined as serious if the driver, passenger, or pedestrian require medical treatment.  Persons injured in MVAs frequently develop symptoms of traumatic stress (e.g. frequent reexperiencing of the traumatic event with symptoms of increased arousal and avoidance of stimuli associated with the trauma, difficulty remembering important parts of the trauma, and problems with sleep, concentration, and anger) but the duration of symptoms can be variable.  Survivors with symptoms of traumatic stress that occur immediately after the traumatic event but last no longer than one month can be diagnosed with Acute Stress Disorder (ASD).²  Survivors with symptoms of traumatic stress that last longer than one month can receive a diagnosis of Posttraumatic Stress Disorder (PTSD).²

Epidemiological studies have suggested that 10-45% of survivors of serious MVAs develop PTSD from the accident.^{3, 4, 5, 6, 7, 8, 9, 10}  The variability in prevalence may be the result of methodological problems in assessment such as biased sampling and differences in assessment methods and diagnostic criterion.¹¹  Studies have indicated that although PTSD symptoms tend to decrease over time,¹² long-term outcome studies of motor vehicle accident survivors suggest that a significant number of victims continue to experience symptoms of PTSD after 5 years.¹³  Studies have suggested that 78-80% of MVA survivors diagnosed with ASD eventually develop PTSD after two years.^{14, 15, 16, 17} 

Psychosocial Risk Factors, Predictors, and Comorbidity

Many studies have examined the psychosocial risk factors and predictors of PTSD in MVA and pedestrian survivors.  Victims with a prior history of PTSD, MVAs, depression and other emotional disturbances appear to be more likely to suffer from PTSD after a MVA.^{3, 4, 6, 17, 18}  The severity of physical injury, initial degree of vulnerability, fear of dying during the accident, anxiety sensitivity, initial level of posttraumatic symptoms, and status of legal proceedings may influence the development of PTSD.^{19, 20, 21, 22} Victims who dissociated during the accident are more likely to develop PTSD symptoms.^{4, 23, 24}  Female victims may be more likely than male victims to suffer from PTSD after a serious MVA.^{3, 4}  MVA victims with PTSD demonstrate greater impairment in role functioning ¹⁸  and are more likely to experience comorbid symptoms of depression and other anxiety disorders.^{6, 25, 26, 27, 10, 18, 28} 

Previous research has suggested that a victim’s thoughts and perceptions regarding the threat to life may be more important than demographic or accident variables when examining risk factors and predictors of PTSD in MVA survivors.²⁹  Research examining cognitive strategies and thinking suggest that an increase in catastrophic ideation and reliance on thought suppression, rumination, and distraction for coping with traumatic events may result in increased PTSD severity.^{30, 31}  In addition, the use of an avoidant coping style appears to predict an increase in intrusive symptomatology.³²  MVA survivors with PTSD who blame themselves for the accident tend to exhibit fewer initial symptoms and experience an accelerated remission of symptoms than PTSD survivors who blame others for the accident.^33,34     

Cognitive-Behavioral Therapy

Cognitive-Behavioral Therapy (CBT) is a type of psychotherapy based on the assumption that the way people think directly impacts their emotions and behavior.  CBT is typically provided as a brief model of treatment (up to 15-20 sessions).  Treatment focuses on providing patients with education about their disorder, coping skills (self-monitoring and relaxation training), techniques for examining and changing maladaptive ways of thinking, methods for confronting feared images, memories, and situations.  In addition, cognitive-behavioral therapists also utilize biofeedback and other psychophysiological monitoring approaches.  The efficacy of short-term, cognitive-behavioral treatment for PTSD has been well documented during the past 20 years, focusing primarily on the treatment of violent/sexual assault victims and war veterans. 

Despite the predominance of CBT for PTSD victims, reviews of the MVA PTSD literature reveal a paucity of controlled treatment studies, with the majority of research in this area involving small sample size studies and case studies.  In addition, these studies have been primarily conducted with middle income and Euro-American patient populations.  Case studies have provided evidence for the efficacy of CBT and coping skills models of treatment.^{5, 35, 36, 37}  Small sample size treatment studies have also demonstrated treatment efficacy.^{38, 39, 40, 41, 42, 43}

References

1.  Traffic Safety Facts 1994:  A Compilation of Motor Vehicle Crash Data from the Fatal Accident Reporting System and General Estimates Systems.  (1995, August).  National Highway Traffic Safety Administration, U.S. Department of Transportation, August 1995.

2.  American Psychiatric Association.  (1994).  Diagnostic and statistical manual of mental disorders (4^th ed.).  Washington, DC:  Author.

3.  Ursano, R. J., Fullerton, C. S., Epstein, R. S., Crowley, B., Kao, T. C., Vance, K., Craig, K. J., Dougall, A. L., & Baum, A. (1999). Acute and chronic posttraumatic stress disorder in motor vehicle accident victims. American Journal of Psychiatry, 156 (4), 589-95.

4.  Ehlers, A., Mayou, R.A., & Bryant, B. (1998). Psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents. Journal of Abnormal Psychology, 107 (3), 508-19.

5.  Jaspers, J.P. (1998). Whiplash and post-traumatic stress disorder. Disability and Rehabilitation, 20 (11), 397-404.

6.  Blanchard, E.B., Hickling, E.J., Taylor, A.E., Loose, W.R., & Gerardi, R.J. (1994). Psychological morbidity associated with motor vehicle accidents. Behaviour Research and Therapy, 32 (3), 283-90.

7.  Green, M.M., McFarlane, A.C., Hunter, C.E., & Griggs, W.M. (1993). Undiagnosed post-traumatic stress disorder following motor vehicle accidents. Medical Journal of Australia, 159 (8), 529-34.

8.  Kuch, K., Cox, B. J., & Evans, R. J. (1996). Posttraumatic stress disorder and motor vehicle accidents: A multidisciplinary overview. Canadian Journal of Psychiatry, 41 (7), 429-434.

9.  Taylor, S., & Koch, W. J. (1995). Anxiety disorders due to motor vehicle accidents: Nature and treatment. Clinical Psychology Review, 15 (8), 721-738.

10.  Kuch, K., Cox, B.J., & Evans, R.J. (1996). Posttraumatic stress disorder and motor vehicle accidents: a multidisciplinary overview. Canadian Journal of Psychiatry, 41 (7), 429-34.

11.  Blaszczynski, A., Gordon, K., Silove, D., Sloane, D., Hillman, K., & Panasetis, P. (1998). Psychiatric morbidity following motor vehicle accidents: a review of methodological issues. Comprehensive Psychiatry, 39 (3), 111-21.

12.  Blanchard, E.B., Hickling, E.J., Vollmer, A.J., Loose, W.R., Buckley, T.C., & Jaccard, J. (1995). Behaviour Research and Therapy, 33 (4), 369-77.

13.  Mayou, R., Tyndel, S., & Bryant, B. (1997). Long-term outcome of motor vehicle accident      injury. Psychosomatic Medicine, 59 (6), 578-84.

14.  Harvey, A. G., & Bryant, R. A. (1999). The relationship between acute stress disorder and posttraumatic stress disorder: A 2-year prospective evaluation. Journal of Consulting and Clinical Psychology, 67 (6), 985-988.

15.  Harvey, A. G., & Bryant, R. A. (1998). The relationship between acute stress disorder and posttraumatic stress disorder: A prospective evaluation of motor vehicle accident survivors. Journal of Consulting and Clinical Psychology, 66 (3), 507-512.

16.  Harvey, A.G., & Bryant, R.A. (2000). Two-year prospective evaluation of the relationship between acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury. Am Journal of Psychiatry, 157 (4), 626-8.

17.  Harvey, A.G., & Bryant, R.A. (1999). Predictors of acute stress following motor vehicle accidents. Journal of Traumatic Stress, 12 (3), 519-25.

18.  Blanchard, E.B., Hickling, E.J., Taylor, A.E., & Loos, W. (1995). Psychiatric morbidity associated with motor vehicle accidents. Journal of Nervous and Mental Disease, 183 (8), 495-504.

19.  Blanchard, E.B., Hickling, E.J., Taylor, A.E., Loos, W.R., Forneris, C.A., & Jaccard, J. (1996). Who develops PTSD from motor vehicle accidents? Behaviour Research and Therapy, 34 (1), 1-10.

20.  Buckley, T.C., Blanchard, E.B., & Hickling, E.J. (1996). A prospective examination of delayed onset PTSD secondary to motor vehicle accidents. Journal of Abnormal Psychology, 105 (4), 617-25.

21.  Blanchard, E.B., Hickling, E.J., Barton, K.A., Loos, W.R., & Jones-Alexander, J. (1996). One-year prospective follow-up of motor vehicle accident victims. Behavior Research and Therapy, 34 (10), 775-86.

22.  Blanchard, E.B., Hickling, E.J., Mitnick, N., Taylor, A.E., Loos, W.R., & Buckley, T.C. (1995). The impact of severity of physical injury and perception of life threat in the development of post-traumatic stress disorder in motor vehicle accident victims. Behaviour Research and Therapy, 33 (5), 529-34.

23.  Fullerton, C.S., Ursano, R.J., Epstein, R.S., Crowley, B., Vance, K.L., Kao, T.C., & Baum, A. (2000). Peritraumatic dissociation following motor vehicle accidents: relationship to prior trauma and prior major depression. Journal of Nervous and Mental Disease, 188 (5), 267-72.

24.  Ursano, R.J., Fullerton, C.S., Epstein, R.S., Crowley, B., Vance, K., Kao, T.C., & Baum, A. (1999). Peritraumatic dissociation and posttraumatic stress disorder following motor vehicle accidents. American Journal of Psychiatry, 156 (11), 1808-10.

25.  Blanchard, E. B., Buckley, Todd C., Hickling, E. J., & Taylor, A. E. (1998). Posttraumatic stress disorder and comorbid major depression: Is the correlation an illusion? Journal of Anxiety Disorders, 12 (1), 21-37.

26.  Blanchard, Edward B., Hickling, E. J., Taylor, A. E., & Loos, W. (1995).   Psychiatric morbidity associated with motor vehicle accidents. Journal of Nervous and Mental Disease, 183 (8), 495-504.

27.  Maes, M., Mylle, J., Delmire, L., & Altamura, C. (2000). Pediatric morbidity and comorbidity following accidental man-made traumatic events: incidence and risk factors. European Archives of Psychiatry and Clinical Neuroscience, 250 (3), 156-62.

28.  Bloom, S. L. (1999). The complex web of causation: Motor vehicle accidents, co-morbidity and PTSD. The international handbook of road traffic accidents & psychological trauma: Current understanding, treatment and law. (pp. 155-184). New York: Elsevier Science.

29.  Jeavons, S., Greenwood, K. M., & De L Horne, D. J. (2000). Accident cognitions and subsequent psychological trauma. Journal of Traumatic Stress, 13 (12), 359-365.

30.  Steil, R., & Ehlers, A. (2000). Dysfunctional meaning of posttraumatic intrusions in chronic PTSD. Behaviour Research and Therapy, 38 (6), 537-558.

31.  Guthrie, R., & Bryant, R. (2000). Attempting suppression of traumatic memories over extended periods in acute stress disorder. Behaviour Research and Therapy, 38 (9), 899-907.

32.  Bryant, R. A., & Harvey, A. G. (1995). Avoidant coping style and post-traumatic stress following motor vehicle accidents. Behaviour Reasearch and Therapy, 33 (6), 631-635.

33.  Hickling, E.J., Blanchard, E.B., Buckley, T.C., & Taylor, A.E. (1999). Effects of attribution of responsibility for motor vehicle accidents on severity of PTSD symptoms, ways of coping and recovery over six months. Journal of Traumatic Stress, 12 (2), 345-53.

34.  Delahanty, D.L., Herberman, H.B., Craig, K.J., Hayward, M.C., Fullerton, C.S., Ursano, R.J., & Baum, A. (1997). Acute and chronic distress and posttraumatic stress disorder as a  

function of responsibility for serious motor vehicle accidents. Journal of Consulting and Clinical Psychology, 65 (4), 560-7.

35.  Kline, J. P., & Franklin, M. E. (1999). Cognitive behavioral treatment of posttraumatic stress disorder subsequent to a motor vehicle accident: A case example. Cognitive and Behavioral practice, 6 (2), 120-125.

36.  Lyons, J. A., & Scotti, J. R. (1995). Behavioral treatment of a motor vehicle accident survivor: An illustrative case of direct therapeutic exposure. Cognitive and Behavioral Practice, 2 (2), 343-364.

37.  Koch, W. J., & Taylor, S. (1995). Assessment and treatment of motor vehicle accident victims. Cognitive and Behavioral Pracice 2 (2), 327-342.

38.  Hickling, E.J., & Blanchard, E.B. (1997). The private practice psychologist and manual-based treatments: posttraumatic stress disorder secondary to motor vehicle accidents. Behaviour Research and Therapy, 35 (3) 191-203.

39.  Rusch, M. D., Grunert, B. K., Mendelsohn, R. A., & Smucker, M. R. (2000). Imagery rescripting for recurrent, distressing images. Cognitive and Behavioral Practice, 7 (2), 173-182.

40.  Fecteau, G. W. (2000). Treatment of posttraumatic stress reactions to traffic accidents. Dissertation Abstracts International: Section B: The Sciences and Engineering, 61 (1-B), 527.

41.  Fecteau, G., & Nicki, R. (1999). Cognitive behavioural treatment of post traumatic stress disoder after motor vehicle accident. Behavioural and Cognitive Psychotherapy, 27 (3), 201-214.

42.  Blanchard, E. B., & Hickling, E. J. (1997). After the crash: Assessment and treatment of motor vehicle accident survivors. ?

43.  Hickling, E. J., Blanchard, E. B., Schwarz, S. P., Silverman, D. J. (1992). Headaches and motor vehicle accidents: Results of the psychological treatment of post-traumatic headache. Headache Quarterly, 3 (3), 285-289.

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