Post-traumatic Stress Reactions Following Motor Vehicle Accidents



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Am Fam Physician. 1999 Aug 1;60(2):524-530.

  See related patient information handout on post-traumatic stress after traffic accidents, written by the authors of this article.

Despite improvements in road conditions, vehicle safety and driver education, over 3 million persons are injured in motor vehicle accidents each year. Many of these persons develop post-traumatic stress symptoms that can become chronic. Patients with post-traumatic stress disorder experience disabling memories and anxiety related to the traumatic event. Early identification of these patients is critical to allow for intervention and prevent greater impairment and restriction. The family physician is in an ideal position to identify, treat or refer patients with traumatic responses to traffic accidents. The physician's awareness of patient characteristics and pre-accident functioning allows him or her to critically evaluate symptoms that may begin to interfere with the resumption of daily activities.

Most Americans will be involved in a motor vehicle accident in their lifetime, and one quarter of the population will be involved in accidents that result in serious injuries.1 Annually, more than 3.5 million persons in the United States are injured in a motor vehicle accident, and nearly 42,000 die as a result of their injuries.2

Vehicular accidents sometimes lead to post-traumatic stress symptoms.39 Traffic accidents have become the leading cause of post-traumatic stress disorder (PTSD) since the Vietnam war.10 It is estimated that 9 percent of survivors of serious accidents develop significant post-traumatic stress symptoms1 and that many other survivors have PTSD-like reactions.

Illustrative Case

A 34-year-old man presented to his new family physician with headaches, insomnia, gastrointestinal discomfort and persistent worry. He was otherwise healthy but reported that he had sustained a broken jaw and hip, as well as a compound fracture of the left leg, in a traffic accident 12 years earlier. He was evaluated, treated with anxiolytic medication and referred for counseling.

The patient said he often became preoccupied with family and work details while driving and pulled over to the roadside as often as twice per week for 20 to 30 minutes at a time, during a dissociative state. He reported that in the accident (when he was 22 years of age), he had been driving a van and struck a bridge abutment. The patient had been trapped against the steering wheel and dashboard, semiconscious and in severe pain.

Emergency personnel arrived about 45 minutes later, during which time the patient could smell gasoline. It took workers 30 minutes to extract the patient from the vehicle. He reported that he had felt disconnected from these events and that he had lost bowel control.

After extensive rehabilitation, the patient returned to work but immediately experienced difficulties. He feared “contamination,” developed showering rituals and would only walk around garbage cans by facing them. He became nauseated by the smell of gasoline, refused to drive, was anxious in public and drank to calm his nerves. The patient left his job and began receiving psychiatric care; after two years of treatment with medication and psychotherapy, he again found employment. Six years after the accident, the patient received a $17,000 settlement. Eight years after the accident he married but soon separated, primarily because of sexual difficulties.

The patient recognized the similarity between his dissociative driving events and the features of his accident. He also revealed that he maintained one accident-related ritual: following each bowel movement, he would spend 20 to 30 minutes cleaning himself.

The patient shared details of his accident with his physician and seemed to be making progress—but his symptoms would reappear during stressful times. With symptom-directed medication and continued psychotherapy, the patient recovered from these episodes and is currently symptom-free 18 years after his accident.

Diagnostic Criteria

The diagnostic criteria for PTSD are listed in Table 1.11 Symptoms in children present in a less-defined manner.3,12 Acute stress disorder is a time-limited variation of PTSD in which symptoms last a minimum of two days and a maximum of four weeks and occur within four weeks of the traumatic event. In this disorder, at least three of the PTSD dissociative symptoms must be present. This diagnostic challenge is further complicated because onset of PTSD can be delayed for months after the triggering event.

TABLE 1

Diagnostic Criteria for Post-traumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present:

1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

2. The person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

B. The traumatic event is persistently re-experienced in one (or more) of the following ways:

1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

2. Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.

3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific re-enactment may occur.

4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma

2. Efforts to avoid activities, places, or people that arouse recollections of the trauma

3. Inability to recall an important aspect of the trauma

4. Markedly diminished interest or participation in significant activities

5. Feeling of detachment or estrangement from others

6. Restricted range of affect (e.g., unable to have loving feelings)

7. Sense of foreshortened future (e.g., does not expect to have a career, marriage, children or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

1. Difficulty falling or staying asleep

2. Irritability or outbursts of anger

3. Difficulty concentrating

4. Hypervigilance

5. Exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.


Reprinted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:427–9. Copyright 1994.

TABLE 1   Diagnostic Criteria for Post-traumatic Stress Disorder

View Table

TABLE 1

Diagnostic Criteria for Post-traumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present:

1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

2. The person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

B. The traumatic event is persistently re-experienced in one (or more) of the following ways:

1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

2. Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.

3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific re-enactment may occur.

4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma

2. Efforts to avoid activities, places, or people that arouse recollections of the trauma

3. Inability to recall an important aspect of the trauma

4. Markedly diminished interest or participation in significant activities

5. Feeling of detachment or estrangement from others

6. Restricted range of affect (e.g., unable to have loving feelings)

7. Sense of foreshortened future (e.g., does not expect to have a career, marriage, children or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

1. Difficulty falling or staying asleep

2. Irritability or outbursts of anger

3. Difficulty concentrating

4. Hypervigilance

5. Exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.


Reprinted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:427–9. Copyright 1994.

Some clinicians and researchers have identified a variation of PTSD among victims of motor vehicle accidents, referred to as subsyndromal or partial PTSD. These persons tend to have high levels of hyperarousal and re-experiencing symptoms but few or no symptoms of avoidance or emotional numbing.4,7,8,13,14 In general, these persons have a better prognosis for symptom remission at six months than persons with PTSD.14

Some post-traumatic stress symptoms are frequently associated with vehicular accidents. The re-experiencing of symptoms (flashbacks, distressing memories) is often precipitated by environmental cues. Newscasts frequently report severe traffic accidents and, given high volumes of traffic and heavy dependence on automobiles for transportation, accident victims face constant reminders.

Avoidance symptoms are manifested in alteration of travel behaviors in three ways: driving phobias, limitations on driving and anxious behavior as passengers. Patients may also develop phobic-like responses secondary to the accident, including fear of or resistance to medical examinations, procedures or treatments.

Because accidents tend to be “man-made,” the physician should anticipate a complex interplay of emotional reactions. On one hand, many traumatic reactions result from experiences of terror and loss of control. The opposite can also occur: victims blame themselves and assume responsibility for the injuries. Fatalities can lead to grief reactions in survivors which, although expected, may disguise their underlying PTSD.

Risk Factors for Stress Disorders Related to Motor Vehicle Accidents

The development of post-traumatic stress symptoms is influenced by preexisting personality characteristics, the nature of the trauma, the person's reaction during the event and subsequent experiences (Table 2). Among factors that predispose persons to PTSD are prior traumatic experiences3,13 and a history of psychiatric disorders.4,6,15

TABLE 2

Risk Factors for Post-traumatic Stress Disorder Following a Motor Vehicle Accident

Severe accident

Fatalities or severe injury among those involved

Perceived life-threatening event

Intrusive memory immediately following the event (flashback)

Subsequent difficulty driving or traveling in vehicles

History of prior traumatic experiences

History of underlying psychiatric disorder

Ongoing litigation

TABLE 2   Risk Factors for Post-traumatic Stress Disorder Following a Motor Vehicle Accident

View Table

TABLE 2

Risk Factors for Post-traumatic Stress Disorder Following a Motor Vehicle Accident

Severe accident

Fatalities or severe injury among those involved

Perceived life-threatening event

Intrusive memory immediately following the event (flashback)

Subsequent difficulty driving or traveling in vehicles

History of prior traumatic experiences

History of underlying psychiatric disorder

Ongoing litigation

Accident severity, fatalities and severe injuries contribute to the potential for development of PTSD. Patients who perceived a significant threat to their life, regardless of actual injury, should be carefully assessed.7 Horrific and intrusive memories immediately following a motor vehicle accident are a strong predictor of PTSD symptoms, regardless of severity.3

Another variable associated with symptom persistence is litigation. This predictor is problematic because those pursuing legal action may be more severely injured or may be inclined to portray themselves as symptomatic.4 Other factors that complicate the diagnosis of PTSD are chronic physical impairment6 and financial strain.9

Evaluation

Psychologic assessment of the patient after a traffic accident is seldom considered unless the accident was unusual or life-threatening, or if the patient's symptoms are obviously debilitating. Screening for PTSD is important, however, because early treatment can prevent the occurrence of symptoms. Many symptoms do not manifest until patients attempt to resume daily activities. The family physician can improve recognition of post-traumatic disorders by using the following approach:

At the initial visit, the physician should obtain a thorough history of the motor vehicle accident, including the patient's reaction to it. The police accident report can be helpful. This information enables the clinician to consider the range of physical injuries and fosters discussion of any psychologic impact; it also allows the clinician to observe the patient's reaction to the retelling of the event. Any indication of head trauma must be thoroughly evaluated, since the symptoms of head injuries can be quite similar to post-traumatic reactions or, at times, can even mask PTSD symptoms.

The following three questions are useful in screening patients with psychologic symptoms. Any affirmative answer warrants further discussion. Affirmative answers to all three questions increase the likelihood that acute stress disorder or post-traumatic stress disorder is present:

“Do you have flashbacks or nightmares of the accident?” These may include daydreams, nightmares, slow-motion replays and “freeze-frame” images experienced during the event.11 These thoughts are intrusive and unwanted, and may result in the re-experiencing of feelings of anxiety, helplessness or horror. Some patients, especially those with head trauma, experience amnesia.

“Have you had any difficulty with driving or traveling in vehicles since the accident?” Although complete driving avoidance is rare,6 most motor vehicle accident victims subsequently experience distress when driving or riding as passengers. Patients may report self-imposed limitations on their driving (e.g., only in daylight, only on city streets) or general uneasiness when in a vehicle. The physician can broaden this inquiry to determine if the patient has developed any ritualistic behaviors.

A fourth question could also be asked: “Do you anticipate contacting an attorney or do you intend to pursue litigation?” The physician needs to determine as soon as possible if the patient is pursuing legal recourse. Litigation de-emphasizes confidentiality and requires extensive documentation.

These questions should typically be asked at a visit soon after the accident. However, because of initial preoccupation with physical symptoms and the potential for delayed onset of PTSD, it is advisable to return to these issues at subsequent visits by including open-ended questions such as,“What has happened with you since the accident?”

Intervention and Treatment

The goal of intervention is to enable the patient to re-establish psychologic equilibrium and return to pre-accident functioning, if possible.6,16 This can often be accomplished by discussing the motor vehicle accident, offering reassurance, educating the patient about PTSD, emphasizing coping strategies and prescribing medication when indicated.

Patients can achieve some control over their symptoms by sharing details of the accident in the safety of the examination room. The family physician may be the first professional to hear a comprehensive account of the events. Patients should be reassured that PTSD is a reaction to the stress of trauma, that it follows a predictable course and that it often resolves with timely intervention.

Educating patients about the traumatic effects of a motor vehicle accident begins with discussing PTSD symptoms and their prevalence among accident survivors.17,18 This normalizes the patient's experience and may reduce any reluctance to disclose symptoms. Because some symptoms are delayed, highlighting symptoms during the examination may prevent the patient from overreacting later if the symptoms do occur. Reviewing symptoms also helps patients overcome the belief that PTSD is only associated with veterans of combat or the Vietnam war. Physicians are cautioned, however, to avoid symptom reviews with patients who are highly suggestible, have a history of somatization or are known to have initiated personal injury litigation.

Since PTSD involves anxiety responses, the family physician can teach relaxation techniques that the patient can practice at home. Moderate physical exercise or activity can also relieve hyperarousal symptoms and should be recommended in a manner consistent with the patient's injuries.17

Medication has a potentially important role in the treatment of PTSD. Medication should be started as early as possible to help prevent later chronicity.19 Benzodiazepines and other medications that cause sedation may impair driving ability and should be used with caution. Despite concerns about side effects, however, medication can sometimes improve a person's driving by lessening stress symptoms and breaking the vicious cycle that occurs when driving evokes painful memories and reactions to the accident trauma.

Since research in medication for PTSD has not been as extensive as in many other disorders, a trial-and-error process may be required20,21  (Table 320). To counteract the sense of powerlessness inherent in patients with PTSD, information about medications and control over medication decisions should be given to the patient as much as possible.

TABLE 3

Medications for Treatment of Post-traumatic Stress Disorder

Target symptoms Medication class Recommended medications Comments

Dissociative flashbacks or intrusive memories

Beta blockers

Propranolol (Inderal), 10 mg, one to two tablets four times a day, as needed

Can be used as needed or on a regular basis.

Nightmares of trauma

Benzodiazepines

Various

Try to avoid chronic, daily use; cyproheptadine (Periactin), 4 mg at bedtime, is an alternative treatment.

Psychotic-like illusions or hallucinations of the trauma

Atypical neuroleptics

Olanzapine (Zyprexa), 2.5 to 5 mg once a day, as needed

Other atypical or traditional neuroleptic medications can also be used.

Avoidance, numbing and diminished interests

Antidepressants

Various (SSRIs recommended as initial therapy)

Other SSRIs, as well as tricyclic antidepressants, can be tried.

Hyperarousal or irritability

Beta blockers

Propranolol, as above

Alternatives include usual doses of antianxiety medication such as buspirone (Buspar) and benzodiazepines.

Mixed symptoms

Anticonvulsant mood stabilizers

Divalproex (Depakote), 250 to 500 mg three times a day, or all at bedtime

Carbamazepine (Tegretol), 400 to 800 mg per day, is an alternative treatment.


note: Many of these medications have limited scientific support for use in treating these symptoms.

SSRIs = selective serotonin reuptake inhibitors.

Information from Moffic HS. Inpatient treatment. In: Sperry L, ed. Psychopharmacology and psychotherapy: strategies for maximizing treatment outcomes. New York: Brunner/Mazel, 1995.

TABLE 3   Medications for Treatment of Post-traumatic Stress Disorder

View Table

TABLE 3

Medications for Treatment of Post-traumatic Stress Disorder

Target symptoms Medication class Recommended medications Comments

Dissociative flashbacks or intrusive memories

Beta blockers

Propranolol (Inderal), 10 mg, one to two tablets four times a day, as needed

Can be used as needed or on a regular basis.

Nightmares of trauma

Benzodiazepines

Various

Try to avoid chronic, daily use; cyproheptadine (Periactin), 4 mg at bedtime, is an alternative treatment.

Psychotic-like illusions or hallucinations of the trauma

Atypical neuroleptics

Olanzapine (Zyprexa), 2.5 to 5 mg once a day, as needed

Other atypical or traditional neuroleptic medications can also be used.

Avoidance, numbing and diminished interests

Antidepressants

Various (SSRIs recommended as initial therapy)

Other SSRIs, as well as tricyclic antidepressants, can be tried.

Hyperarousal or irritability

Beta blockers

Propranolol, as above

Alternatives include usual doses of antianxiety medication such as buspirone (Buspar) and benzodiazepines.

Mixed symptoms

Anticonvulsant mood stabilizers

Divalproex (Depakote), 250 to 500 mg three times a day, or all at bedtime

Carbamazepine (Tegretol), 400 to 800 mg per day, is an alternative treatment.


note: Many of these medications have limited scientific support for use in treating these symptoms.

SSRIs = selective serotonin reuptake inhibitors.

Information from Moffic HS. Inpatient treatment. In: Sperry L, ed. Psychopharmacology and psychotherapy: strategies for maximizing treatment outcomes. New York: Brunner/Mazel, 1995.

For treatment of symptoms associated with re-experiencing the trauma, beta blockers and, occasionally, antipsychotic medications can be used. For treatment of symptoms associated with avoidance and numbing, antidepressants may be the most effective agents. For treatment of symptoms of hyperarousal, beta blockers, buspirone (Buspar) and benzodiazepines can be helpful. However, caution should be used with benzodiazepine therapy because of the possibility of short-term memory loss, which may already be compromised as a result of the dissociation that occurs in PTSD. Patients may also experience rebound anxiety after the medications are stopped. Anticonvulsant mood stabilizers have shown some promise in improving a wide variety of PTSD symptoms. Use of a combination of medications may be appropriate at times.

If certain psychotherapies are used in conjunction with pharmacotherapy, medication can either help or hinder treatment. If medication reduces intense re-experiencing of trauma, it may allow the patient to feel comfortable enough to participate in processing the trauma. On the other hand, if certain kinds of behavioral techniques are used, such as exposure-based therapy, benzodiazepine therapy may interfere with the patient's response.

Prevention

Accident-related PTSD can have devastating effects on a patient's quality of life. The family physician has the opportunity to help prevent motor vehicle accident trauma by encouraging the use of safety belts and safe driving habits, and by counseling drivers about the risks of driving while tired or under the influence of medication, alcohol or other substances.22

The Authors

DENNIS J. BUTLER, PH.D., is associate professor in the department of family and community medicine at the Medical College of Wisconsin, Milwaukee. He is also director of Behavioral Science at the Columbia Family Practice Residency Program in Milwaukee, where he teaches and has a clinical practice. Dr. Butler received a doctorate in psychology from Marquette University, Milwaukee.

H. STEVEN MOFFIC, M.D., is a professor in the departments of psychiatry and behavioral medicine and family and community medicine at the Medical College of Wisconsin. Dr. Moffic received a medical degree from Yale University, New Haven, Conn., and completed a residency in psychiatry at the University of Chicago.

NICK W. TURKAL, M.D., is associate dean for the Milwaukee Clinical Campus of the University of Wisconsin Medical School, Madison, and is vice president for academic affairs at Aurora Health Care. He received a medical degree from Creighton University School of Medicine, Omaha, Neb., and completed a residency in family medicine at the Medical College of Wisconsin.

Address correspondence to Dennis J. Butler, Ph.D., Director of Behavioral Sciences, Columbia Family Practice Program, 210 W. Capitol Dr., Milwaukee, WI 53212. Reprints are not available from the authors.

REFERENCES

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3. Di Gallo A, Parry-Jones WL. Psychological sequelae of road traffic accidents: an inadequately addressed problem [Editorial]. Br J Psychiatry. 1996;169:405–7.

4. Blanchard EB, Hickling EJ, eds. After the crash: assessment and treatment of motor vehicle accident survivors. Washington, D.C.: American Psychological Association, 1997.

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15. Chubb HL, Bisson JI. Early psychological reactions in a group of individuals with pre-existing and enduring mental health difficulties following a major coach accident. Br J Psychiatry. 1996;169:430–3.

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19. van der Kolk BA. The psychobiology of posttraumatic stress disorder. J Clin Psychiatry. 1997;58 (suppl 9):16–24.

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22. Lyznicki JM, Doege TC, Davis RM, Williams MA. Sleepiness, driving, and motor vehicle crashes. Council on Scientific Affairs, American Medical Association. JAMA. 1998;279:1908–13.


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