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MOTOR VEHICLE ACCIDENT
SURVIVORS AND PTSD
Edward B. Blanchard1 and
Edward J. Hickling2
Center for Stress and Anxiety Disorders
State University of New York at Albany
Over 3 million Americans are injured in motor vehicle accidents (MVAs) each
year. The National Comorbidity Study (Kessler et al., 1995) found acci-dents
(most of which were probably MVAs) to be the most frequent traumatic event experienced
by males (25%) and second most frequent event for females (13.3%). Given what
we have learned about MVAs as a cause of PTSD, MVAs may be the leading cause
of short-term (duration of a year or less) PTSD in the USA.
Blanchard and Hickling (1997) in their book, After the Crash, have summarized
much of the English-language literature on the psychosocial sequelae of MVAs
as well as detailing their own research on the psychological assessment and
treatment of MVA survivors. Taylor and Koch (1995) provided a com-prehensive
review of the psychiatric consequences of MVAs through 1994 with particular
attention to anxiety disorders. Mayou (1992) provided an ear-lier review of
this literature.
What Fraction of Injured MVA Survivors Develop PTSD? This rhetorical question
draws a variety of answers from studies of non-referred populations assessed
and followed up prospectively: ranging from 8% at 3 months and 11.1% within
12 months, diagnosed by Present State Examination (Mayou et al., 1993), to 39.2%
(43.7% including delayed onset) diagnosed with the CAPS (Blanchard et al., 1995).
Other values include 23.8% at 3 weeks (SCID diag-nosis; Delahanty et al., 1997),
25.4% at 6 months (Composite International Diagnostic Interview; Harvey & Bryant,
1998), and 23.1% of 888 cases (Posttraumatic Stress Symptoms Scale question-naire
diagnosis; Ehlers et al., in press). Using the Ehlers figure (because of the
large sample size), this would translate into roughly 800,000 new cases of PTSD
per year in the USA.
What Are the Other Psychosocial Consequences of MVAs? The primary psychosocial
consequences of MVAs beyond PTSD fall into the category of psychi-atric co-morbidity,
with four findings emerging. First, mood disorders, especially new cases of
major depression, are the most common co-morbid prob-lem: Blanchard et al. (1995)
found that 43.5% of their MVA survivors with PTSD also developed a new major
depressive episode and that 56.5% of the survivors with PTSD had a current mood
disorder. Feinstein and Dolan (1991) found that 12.5% of their total sample
had notable depressive symptoms; Mayou et al. (1993) found that 6.9% of a total
188 cases had a diagnosable mood disorder or anxiety at 3 months post-MVA. Second,
Blanchard et al. (1995) found that 27.4% of survivors with PTSD had an-other
current co-morbid anxiety disorder. Third, several studies use a measure of
³caseness,² or sufficient symptoms on some measure to constitute a psychiatric
case: Mayou et al. (1993) found that 13.3% had psychiatric disorders; Green
et al. (1993) found significant symptoms in 33%; and Malt et al. (1993) identified
37% of 183 hospitalized MVA sur-vivors as psychiatric cases with the GHQ.
Finally, there is travel anxiety and driving reluc-tance: Mayou et al. (1993)
found that 18.4% had travel anxiety at a 1-year post-MVA assessment; Kuch et
al. (1994) reported 38.2% with accident phobia. Blanchard et al. (1995) found
15.1% of PTSDs to have a driving phobia, whereas 93% mani-fested ³driving reluctance²
(some form of avoid-ance behavior).
Who Develops PTSD from MVAs? The answer to this question yields noticeably
contradictory an-swers. Blanchard et al. (1996c) found four indepen-dent predictors
of who develops PTSD: (a) a history of a pre-MVA major depressive episode (although
Mayou et al., 1993, found immediate post-MVA depression did not predict PTSD
at 3 months); (b) extent of physical injury, which was replicated in part by
Ehlers et al. (in press) (however, Feinstein & Dolan, 1991, Green et al., 1993,
and Bryant & Harvey, 1996, found that extent of injury did not predict PTSD);
(c) the degree of fear of dying in the MVA (replicated by Green et al., 1993,
and Ehlers et al., in press); and (d) whether litigation was initiated (Ehlers
et al., in press, confirmed this variable).
Other predictors hypothesized are strong ³hor-rific and intrusive memories²
(Mayou et al., 1993), a finding which was replicated by Green et al. (1993),
as well as not being responsible for the MVA, which was found to predict significantly
greater likelihood of developing PTSD in a 1997 study by Delahanty et al. (We
replicated this finding and also the slower remission reported by Delahanty
et al., in 1997). Also significant was the presence of initial Acute Stress
Disorder (ASD) or sub-clinical ASD predicted at 6 months (Harvey & Bryant, 1998);
Ehlers et al. (in
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press) also found that initial dissociative symptoms, the
hallmark of ASD, predicted PTSD at 3 months. Finally,
female gender was found by Ehlers et al. (in press) to
predict development of PTSD independently (a finding
reported earlier by Blanchard et al., 1995).
Delayed-onset PTSD. That the onset of PTSD can signifi-
cantly lag the trauma is well recognized; four MVA studies
have documented this phenomenon among MVA survi-
vors. Green et al. (1993), in a prospective study of 24 MVA
survivors, found 5 cases (20.8%) of delayed-onset PTSD at
18 months. All had a sub-syndromal form of PTSD at 1
month post-MVA. Mayou et al. (1993) found 6 (of 174,
3.4%) cases of PTSD at 1 year who had not been positive at
3 months. From our laboratory, Buckley et al. (1996) iden-
tified 7 cases (4.4% of the original sample) of delayed-onset
PTSD. All had an initial diagnosis of sub-syndromal PTSD;
interestingly, they were significantly lower in social sup-
port and had more overall distress than those with sub-
syndromal PTSD who did not develop delayed onset. A
proximal stressor could be identified in only 3 of the 7
cases. Finally, Ehlers et al. (in press) found 6.2% of their
sample (n = 34) who were not positive for PTSD at 3 months
were positive at the 12-month follow-up.
What Is the Natural History of MVA-Related PTSD and
What Predicts Remission? Given that the MVA-survivor has
developed PTSD, the next important questions are framed
above: how much spontaneous remission is there, and
what variables predict remission versus persistence of the
diagnoses? Early answers to these questions from prospec-
tive follow-up studies were: (a) remission by 6 months of 5
out of 12 (41.7%, Feinstein & Dolan, 1991); (b) no remission
at an 18-month follow-up; indeed, 5 out of 7 with sub-
clinical PTSD were worse (Green et al., 1993); and (c)
remission at 12 months of 5 out of 13 (38.5%) who were
positive for PTSD at 3 months (Mayou et al., 1993). No
predictors of remission were identified in these studies.
From our laboratory, we (Blanchard & Hickling, 1997)
found that 48% of those initially diagnosed with PTSD had
remitted 6 months later; in a longer follow-up (12 months)
we (Blanchard et al., 1996a) found that only 33% of those
initially diagnosed with PTSD still met the diagnostic
criteria. There was little additional remission at 18 months.
Variables that predicted remission at 6 months were: initial
CAPS score; initial severity of injury; degree of physical
recovery by month 4; and whether there had been a new
trauma for a family member. The one-year prediction
included an initial degree of irritability, a sense of fore-
shortened future, and a heightened degree of vulnerability
when traveling.
Delahanty et al. (1997) found a 53% remission rate at the
12-month follow-up, with the attribution of a responsibil-
ity variable (those who blamed themselves remitted more
quickly than those who blamed someone else) being the
major predictor. Ehlers et al. (in press) found a 50% remis-
sion rate in their large-scale study at a 12-month follow-up
point.
Finally, Mayou et al. (1997) reported on the 5-year fol-
low-up assessment of their initial (Mayou et al., 1993)
prospective follow-up sample. Although most initial cases
of PTSD had remitted, there were a number of delayed-
onset cases resulting in approximately 10% of the sample's
being positive for PTSD throughout the follow-up. PTSD at
5 years was predicted by continued physical problems and
continued intrusive memories and emotional distress.
The Role of Litigation and its Settlement. As Blanchard and
Hickling (1997) note on this topic, "It is widely believed
that litigation and its settlement play a large role in the
natural history of psychological symptoms and disability
among accident victims" (p.171). The empirical data to
support this point are weak, however. Both Ehlers et al. (in
press) and Blanchard et al. (1996c) found that having
initiated litigation early after the MVA predicted a higher
likelihood that a MVA survivor would meet the criteria for
PTSD. In a 3-year follow-up of his 200 MVA survivors seen
in the ER, Mayou (1995) pointed out a lack of effect of
initiating (or not initiating) litigation on long-term out-
come. Moreover, for those litigants who had settled by the
3-year point, there was some evidence of more improved
status than those whose suits were still pending.
Blanchard et al. (1998) found those who initiated litiga-
tion had a greater degree of physical injury and higher
CAPS scores than those who did not file suit. Comparing
litigants who settled within the first 12 months to those
who did not, there are non-significant trends toward more
symptomatic improvement for those who settle than for
those who have not settled (both groups improve over time
significantly on CAPS, BDI, and IES). There was also a
trend for those who had been employed full-time pre-
MVA and who had not settled to be less likely to have
returned to work (84%) than among comparable litigants
who had settled by 12 months (100%).
Psychophysiological Assessment and MVA-Related PTSD.
Measurement of psychophysiological responses to cues
reminiscent of the MVA trauma has found a role in the
comprehensive assessment of MVA survivors, especially
in the measurement of heart rate (HR) response to idiosyn-
cratic audiotaped descriptions of the accident. Blanchard
et al. (1994) reported this finding on their first 50 MVA
survivors and then reported a replication with another 105
MVA survivors (Blanchard et al., 1996b). The average HR
response of those MVA survivors with PTSD was +4.2
beats per minute (bpm) as compared to a response of +0.3
bpm among those with sub-syndromal PTSD. Diagnostic
efficiency was 67.9% with a cutoff of +2 bpm.
Interestingly, Blanchard et al. (1996b) found among ini-
tial PTSDs that HR response predicted clinical status at a
12-month follow-up: those who continued to be positive
for PTSD 12 months later had greater responsivity than
those who remitted partially or fully (77.1% diagnostic
efficiency).
Shalev et al. (1998) has found that elevated basal HR
(greater than 90 bpm) in the ER predicts a higher likelihood
of the MVA survivor's being diagnosed with PTSD at a
3-month follow-up than for those with lower resting HRs.
It appears that a high level of initial sympathetic activation
at the time of the trauma is a risk for developing PTSD.
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Treatment of MVA-Related PTSD. There are summarized
in Chapter 14 of Blanchard and Hickling's (1997) book a
number of case reports and uncontrolled trials of various
forms of psychological treatment for MVA-related PTSD.
Three randomized controlled trials have been conducted
with MVA survivors; all were characterized by relatively
brief interventions delivered within days to weeks of the
MVA.
Hobbs et al. (1996) approached consecutively admitted
MVA survivors at a British hospital, eliminating those with
no psychological symptoms and those who could not
remember the MVA (because of head trauma). Only 8 of
114 eligible MVA survivors declined: 54 in the intervention
group received one hour's treatment emphasizing review
of the traumatic experience, emotional expression, and
cognitive processing of the experience and education on
what to expect as well as an information booklet. The 52
controls were assessed only initially. All were re-assessed
at 4 months post-MVA. Twenty-two percent were lost to
post-assessment. Overall, there was no effect from the
intervention and no decrease in IES score in either group at
the 4-month follow-up.
Brom et al. (1993) were able to recruit 20.4% of 738 Dutch
MVA survivors approached by the Dutch police, with
more responses from those randomized to treatment (36%)
than to assessment only (13%). Treatment was 3 to 6
sessions 2-3 months post-MVA, focusing on education,
support, and reality testing. There was noticeable im-
provement in both groups on a Dutch version of the IES at
a point 6 months post-MVA. Thus the study showed no
advantages for brief, early treatment.
Bryant et al. (in press) randomized 24 MVA survivors
with ASD to 5 sessions of cognitive behavior therapy (CBT)
or supportive counseling (SC) within two weeks of the
MVA. Fewer participants in CBT (8%) than in SC (83%) met
criteria for PTSD at post-treatment. There were also fewer
cases of PTSD at a 6-month follow-up in the CBT condition
(17%) than in the SC condition (67%).
Hickling and Blanchard (1997) reported on the system-
atic cognitive behavioral treatment of 10 MVA survivors
with PTSD or severe sub-syndromal PTSD, 6 to 24 months
post-MVA. Treatment involved relaxation, exposure, cog-
nitive restructuring, and pleasant events scheduling over
8 to 12 sessions. Average CAPS score dropped from 67 to
22, with a further drop to 18 at a 3-month follow-up. Eight
out of 10 were noticeably improved.
Given the relatively high spontaneous remission rate
over the first year after the trauma (50% or better), and the
poor results from brief early interventions, it appears that
a good strategy may be to withhold treatment over the first
6 months post-MVA and then treat those who are notice-
ably symptomatic at that point with a brief cognitive
behavioral package. Alternatively one may want to iden-
tify those with ASD and use the intervention of Bryant et al.
(in press) early on. Research interest in this widespread
problem appears to be growing, which bodes well for the
thousands of MVA survivors who develop posttraumatic
stress symptoms.
SELECTED ABSTRACTS
BLANCHARD, E.B., & HICKLING, E.J. (1997). After the crash:
Assessment and treatment of motor vehicle accident survivors. Wash-
ington, DC: American Psychological Association. This book de-
scribes the details of a 5-year study of MVA survivors in the
Albany, New York area. We have tried to summarize and inte-
grate the results from this worldwide array of research groups
with our own findings to present a comprehensive view of what
is known about the survivors of serious MVAs. This book covers
four cross-cutting conceptual themes. First, we identify the scope
of the problem to try to arrive at an answer to the question, "What
proportion of motor vehicle accident survivors develop PTSD?"
The second broad theme is a description of the short-term psy-
chosocial consequences of having been in a serious MVA. The
third theme is the short-term history of MVA-related PTSD and
factors that can influence this, such as physical injury, litigation
and delayed-onset PTSD. Our fourth conceptual theme is the
psychological treatment of the MVA survivor with PTSD. We
foresee three broad audiences for this book: psychologists, psy-
chiatrists and other mental health professionals who assess and
treat the survivors of serious MVA; attorneys who handle MVA
survivor cases; and physicians who treat MVA survivors.
BLANCHARD, E.B., HICKLING, E.J., BARTON, K.A., TAY-
LOR, A.E., LOOS, W.R., JONES-ALEXANDER, J. (1996). One-
year prospective follow-up of motor vehicle accident victims.
Behaviour Research and Therapy, 34, 775-786. 132 victims of motor
vehicle accidents (MVAs), who sought medical attention as a
result of the MVA, were assessed at 3 points in time: 1-4 months
post-MVA, 6 months later, and 12 months later. Of the 48 who met
the full criteria for PTSD initially, half had remitted at least in part
by the 6-month follow-up point and two-thirds had remitted by
the 1-yr follow-up. Using logistic regression, 3 variables com-
bined to correctly identify 79 percent of remitters and non-
remitters at the 12-month follow-up point: initial scores on the
irritability and foreshortened future symptoms of PTSD and the
initial degree of vulnerability the subject felt in a motor vehicle
after the MVA. 4 variables combined to predict 64 percent of the
variance in the degree of post-traumatic stress symptoms at 12
months: presence of alcohol abuse and/or an Axis-II disorder at
the time of the initial assessment as well as the total scores on the
hyperarousal and on avoidance symptoms of PTSD present at the
initial post-MVA assessment.
BLANCHARD, E.B., HICKLING, E.J., BUCKLEY, T.C., TAY-
LOR, A.E., VOLLMER, A., & LOOS, W. R. (1996). Psychophysi-
ology of posttraumatic stress disorder related to motor vehicle
accidents: Replication and extension. Journal of Consulting and
Clinical Psychology, 64, 742-751. Psychophysiological assessment
data, including heart rate (HR), blood pressure, and frontal
electromyogram (EMG) responses to mental arithmetic, idiosyn-
cratic audiotape descriptions of motor vehicle accidents (MVAs),
and a standard videotape of MVAs, were collected on 105 injured
victims of recent MVAs and 54 non-MVA controls. Their data
replicated data from an earlier report and support the utility of
HR response to the audio taped description of the MVA as useful
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in distinguishing MVA victims with PTSD from those with
subsyndromal PTSD and non-PTSD. At a 1-year follow-up, the
psychophysiological assessment was repeated on 125 MVA vic-
tims; results showed a general diminution of psychophysiologi-
cal responding. Initial psychophysiological assessment results
predicted 1-year follow-up clinical status (continued PTSD or full
or partial remission) for 37 of 48 individuals who initially met
criteria for PTSD.
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, 1-10. Within 1 to 4 months of their motor vehicle
accident (MVA), we assessed 158 MVA victims who sought
medical attention as a result of the MVA. Using the Clinician-
Administered PTSD Scale, we found that 62 (39 percent) met
DSM-III-R criteria for PTSD. Using variables from the victim's
account of the accident and its sequelae, pre-MVA psychosocial
functioning, demographic variables, pre-MVA psychopathology
and degree of physical injury, we found that 70 percent of the
subjects could be classified as PTSD or not with 4 variables: prior
major depression, fear of dying in the MVA, extent of physical
injury and whether litigation had been initiated. Using multiple
regression to predict the continuous variable of total CAPS score,
as a measure of post-traumatic stress symptoms, we found that 8
variables combined to predict 38.1 percent of variance (Multiple
R = 0.617).
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, 495-504. The
primary purpose of this report was to determine the extent of
psychiatric morbidity and comorbidity among a sample of recent
victims of motor vehicle accidents (MVAs) in comparison to a
nonaccident control population. Victims of recent MVAs (N =
158), who sought medical attention as a result of the MVA, were
assessed in a University-based research clinic, 1 to 4 months after
the accident for acute psychiatric and psychosocial consequences
as well as for pre-MVA psychopathology using structured clini-
cal interviews (Clinician-Administered PTSD Scale, SCID, SCID-
II, LIFE Base). Age- and gender-matched controls (N = 93) who
had no MVAs in the past year served as controls. 62 MVA victims
(39.2 percent) met DSM-III-R criteria for PTSD, and 55 met DSM-
IV criteria. The MVA victims who met the criteria for PTSD were
more subjectively distressed and had more impairment in role
function (performance at work/school/homemaking, relation-
ships with family or friends) than the MVA victims who did not
meet the PTSD criteria or the controls. A high percentage (53
percent) of the MVA-PTSD group also met the criteria for current
major depression, with most of that developing after the MVA. A
prior history of major depression appears to be a risk factor for
developing PTSD after an MVA (p = .0004): 50 percent of MVA
victims who developed PTSD had a history of previous major
depression, as compared with 23 percent of those with a less
severe reaction to the MVA. A prior history of PTSD from earlier
trauma also is associated with developing PTSD or a subsyndromal
form of it (25.2 percent) (p = .0012). Personal injury MVAs exact
substantial psychosocial costs on the victims. Early intervention,
especially in vulnerable populations, might prevent some of this.
BRYANT, R. A., HARVEY, A.G., DANG, S.T., SACKVILLE,
T., & BASTEN, C. (in press). Treatment of acute stress disorder:
A comparison of cognitive behavior therapy and supportive
counseling. Journal of Consulting and Clinical Psychology. Acute
stress disorder (ASD) is a precursor of chronic PTSD. Twenty -
four participants with ASD following civilian trauma were given
5 sessions of either cognitive behavior therapy (CBT) or support-
ive counseling (SC) within 2 weeks of their trauma. Fewer partici-
pants in CBT (8%) than SC (83%) met criteria for PTSD at post-
treatment. There were also fewer cases of PTSD in the CBT (17%)
than SC (67%) conditions 6 months posttrauma. There were
greater statistically and clinically significant reductions in intru-
sive, avoidance, and depressive symptomatology in the CBT than
SC participants. This study represents the first demonstration of
successful treatment of ASD with CBT, and its efficacy in prevent-
ing chronic PTSD.
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, 617-
625. 7 participants who did not meet the DSM-III-R criteria for
PTSD 1-4 months post- motor vehicle accident (MVA) and devel-
oped delayed onset PTSD during a 1-year follow-up interval
were compared with 38 MVA controls who did not develop
PTSD, as well as to 62 MVA participants who met criteria for
acute onset PTSD on variables related to demographics, pre-
MVA functioning, post-MVA functioning, and follow-up. The
delayed onset participants were more symptomatic at the time of
the initial interview than the controls. The delayed onset partici-
pants had poorer social support than the controls prior to and
after the MVA. For the month prior to the MVA, the delayed onset
participants had lower Global Assessment of Functioning scores
than the controls.
DELAHANTY, D.L., HERBERMAN, H.B., CRAIG, K.J., HAY-
WARD, 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 ve-
hicle accidents. Journal of Consulting and Clinical Psychology, 65,
560-567. In this study on the effects of attributions of responsibil-
ity for traumatic events, stress, coping, and symptoms of PTSD
were measured, including intrusive thoughts, among 130 victims
of serious motor vehicle accidents (MVAs) 14-21 days and 3, 6,
and 12 months after their accident. MVA victims and 43 control
participants were categorized by accident and attribution of
responsibility for their accidents (self-responsible, other-respon-
sible, and control). Although initially all MVA victims reported
higher levels of intrusive thoughts and were more likely to meet
criteria for PTSD diagnoses, only other-responsible participants
continued to demonstrate increased distress 6 and 12 months
postaccident. Self-responsible participants used more self-blame
coping than other-responsible participants, although within the
self-responsible group, use of self-blame was associated with
more distress.
EHLERS, A., MAYOU, R.A., & BRYANT, B. (in press). Psycho-
logical predictors of chronic posttraumatic stress disorder after
motor vehicle accidents. Journal of Abnormal Psychology. A pro-
spective longitudinal study assessed 967 consecutive patients
who attended an emergency clinic shortly after a motor vehicle
accident, again at 3 months and at 1 year. The prevalence of PTSD
was 23.1% at 3 months and 16.5% at 1 year. Chronic PTSD was
related to some objective measures of trauma severity, perceived
threat, and dissociation during the accident, to female gender, to
previous emotional problems, and to litigation. Maintaining
psychological factors, that is, negative interpretation of intru-
sions, rumination, thought suppression, and anger cognitions,
enhanced the accuracy of the prediction. Negative interpretation
of intrusions, persistent medical problems, and rumination at 3
months were the most important predictors of PTSD symptoms
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at 1 year. Rumination, anger cognitions, injury severity, and prior
emotional problems identified cases of delayed onset.
HARVEY, A.G., & BRYANT, R.A. (1998). The relationship
between acute stress disorder and posttraumatic stress disor-
der: A prospective evaluation of motor vehicle accident survi-
vors. Journal of Consulting and Clinical Psychology, 66, 507-512.
Motor vehicle accident survivors (n = 92) were assessed for acute
stress disorder (ASD) within 1 month of the trauma and reas-
sessed (n = 71) for PTSD 6 months posttrauma. ASD was diag-
nosed in 13 percent of participants, and a further 21 percent had
subclinical levels of ASD. At follow-up, 78 % of ASD participants
and 60% of subclinical ASD participants met criteria for PTSD.
The strong predictive power of acute numbing, depersonaliza-
tion, a sense of reliving the trauma, and motor restlessness, in
contrast to the low to moderate predictive power of other symp-
toms, indicates that only a subset of ASD symptoms is strongly
related to the development of chronic PTSD. Although these
findings support the use of the ASD diagnosis, they suggest that
the dissociative and arousal clusters may require revision.
HICKLING, E.J., & BLANCHARD, E.B. (1997). The private
practice psychologist and manual-based treatments: Post-trau-
matic stress disorder secondary to motor vehicle accidents.
Behaviour Research and Therapy, 35, 191-203. This paper discusses
the issues of providing an empirically validated, manual-based
treatment when viewed from the perspective of a practicing
clinical psychologist. The trend for empirically proven treatment
is reviewed briefly, and initial data are provided illustrating a
manual-based-treatment for PTSD following a motor vehicle
accident. The relatively brief (9-12 session) psychological treat-
ment was effective in reducing PTSD symptoms as measured on
the Clinician Administered PTSD Scale, for all 10 subjects. The
results are discussed from the practicing clinician's perspective:
generalization to a clinical population, ethical concerns of limited
treatment goals, individually tailored vs standardized treatments
in clinical practice, concerns for co-morbid conditions, and how
this type of study might impact on practice in an era of managed
health care. Issues of incorporating manual-based treatments
into clinical practice are discussed, with consideration of gains,
the limits and the constraints this would bring to the practice of
psychology.
HOBBS, M., MAYOU, R., HARRISON, B., & WORLOCK, P.
(1996). A randomised controlled trial of psychological debrief-
ing for victims of road traffic accidents. British Medical Journal,
313, 1438-1439. This randomised controlled study aimed to test
whether a single debriefing could reduce post-traumatic psycho-
pathology in road accident victims. [Text, p. 1438]
MAYOU, R., BRYANT, B., & DUTHIE, R. (1993). Psychiatric
consequences of road traffic accidents. British Medical Journal,
307, 647-651. OBJECTIVE: To determine the psychiatric conse-
quences of being a road traffic accident victim. DESIGN: Follow
up study of road accident victims for up to one year. SETTING:
Emergency department of the John Radcliffe Hospital, Oxford.
SUBJECTS: 188 consecutive road accident victims aged 18-70
with multiple injuries (motorcycle or car) or whiplash neck
injury, who had not been unconscious for more than 15 minutes,
and who lived in the catchment area. Main outcome measures:
Present state examination `'caseness''; PTSD and travel anxiety;
effects on driving and on being a passenger. RESULTS: Acute,
moderately severe emotional distress was common. Almost one
fifth of subjects, however, suffered from an acute stress syndrome
characterised by mood disturbance and horrific memories of the
accident. Anxiety and depression usually improved over the 12
months, though one tenth of patients had mood disorders at one
year. In addition, specific post-traumatic symptoms were com-
mon. PTSD occurred during follow up in one tenth of patients,
and phobic travel anxiety as a driver or passenger was more
common and frequently disabling. Emotional disorder was asso-
ciated with having pre-accident psychological or social problems
and, in patients with multiple injuries, continuing medical com-
plications. Post-traumatic syndromes were not associated with a
neurotic predisposition but were strongly associated with hor-
rific memories of the accident. They did not occur in subjects who
had been briefly unconscious and were amnesic for the accident.
Mental state at three months was highly predictive of mental state
at one year. CONCLUSIONS: Psychiatric symptoms and disor-
der are frequent after major and less severe road accident injury.
Post-traumatic symptoms are common and disabling. Early in-
formation and advice might reduce psychological distress and
travel anxiety and contribute to road safety and assessing `'ner-
vous shock.''
ADDITIONAL CITATIONS
Annotated by the Editors
BLANCHARD, E.B., HICKLING, E.J., FORNERIS, C.A., TAY-
LOR, A.E., BUCKLEY, T.C., LOOS, W.R., & JACCARD, J.
(1997). Prediction of remission of acute posttraumatic stress
disorder in motor vehicle accident victims. Journal
of Traumatic Stress, 10, 215-234.
Assessed PTSD in 145 MVA survivors at 1-4 months post-MVA
and then 6 months later. Remission at the second assessment
occurred in 55% of the 55 survivors with initial PTSD and 67% of
the 43 survivors with sub-syndromal PTSD. Increased likelihood
of remission was associated with lower initial PTSD severity, no
new family trauma, lower initial injuries, and lower injury at 4
months.
BLANCHARD, E.B., HICKLING, E.J., TAYLOR, A.E.,
BUCKLEY, T.C., LOOS, W.R., & WALSH, J. (1998). Effects
of litigation settlements on posttraumatic stress symptoms
in motor vehicle accident victims. Journal of Traumatic
Stress, 11, 337-354.
Assessed the effects associated with litigation in 132 MVA survi-
vors who were studied 1-4 months and 12 months post-accident.
Of the 67 survivors who initiated litigation, 27% had settled by 1
year. Litigation was associated with more severe injuries and
higher initial PTSD symptoms. Litigants did not improve in
anxiety and depression ratings, whereas nonlitigants improved
in these domains.
BLANCHARD, E.B., HICKLING, E.J., TAYLOR, A.E., LOOS,
W.R., & GERARDI, R.J. (1994). The psychophysiology of
motor vehicle accident related posttraumatic stress disorder.
Behavior Therapy, 25, 453-467.
Performed psychophysiological assessment of 50 MVA survi-
vors and 40 non-MVA controls. Increased heart rate in response
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to an idiosyncratic trauma script distinguished survivors with
full PTSD from controls and survivors with partial or no PTSD.
Groups did not differ in response to other stressors.
BROM, D., KLEBER, R.J., & HOFMAN, M.C. (1993). Victims of
traffic accidents: Incidence and prevention of post-
traumatic stress disorder. Journal of Clinical Psychology, 49, 131-
140.
Randomly assigned survivors of serious MVAs in The Nether-
lands to either an intervention group (n = 68) or to a monitoring
control condition (n = 83). Participants were selected from police
logs and were not seeking treatment. Controlling for initial
symptom severity, the authors failed to find a difference between
conditions at a 6-month follow-up.
BRYANT, R.A. & HARVEY, A.G. (1996). Initial posttraumatic
stress responses following motor vehicle accidents.
Journal of Traumatic Stress, 9, 223-234.
Assessed PTSD symptoms in 114 MVA survivors within 2 weeks
of hospital admission. Intrusion and avoidance were related to
different risk factors: intrusion was best predicted by fear of the
MVA and absence of head injury, whereas avoidance was best
predicted by fear of the accident and recent stressful events.
FEINSTEIN, A. & DOLAN, R. (1991). Predictors of post-
traumatic stress disorder following physical trauma: An
examination of the stressor criterion. Psychological Medicine,
21, 85-91.
Prospectively assessed 48 adults who had experienced an acci-
dental physical injury; 21% of the accidents involved pedestrians,
6% involved autos, and 29% involved motorbikes. Two variables
predicted the presence of PTSD at 6 months: initial PTSD symp-
toms and excessive alcohol consumption.
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, 529-534.
Prospectively assessed 24 MVA survivors at 1 and 18 months
post-MVA. At 18 months, 25% had PTSD, although none had
been diagnosed or treated. One month measures that predicted
the development of PTSD at 18 months included perceived life
threat, PTSD symptoms, depression symptoms, global distress,
and immature defenses.
KESSLER, R.C., SONNEGA, A., BROMET, E.J., HUGHES, M.,
& NELSON, C.B. (1995). Posttraumatic stress disorder in
the National Comorbidity Survey. Archives of General Psychia-
try, 52, 1048-1060.
Assessed PTSD as a function of different types of trauma in a
nationally-representative sample of over 5,000 US men and women
(age 15-54). Twenty-five percent of the men and 14% of the
women had experienced a life-threatening accident (including
MVAs). The prevalence of PTSD among accident survivors was
6% among men and 9% among women.
KUCH, K., COX, B.J., EVANS, R., & SHULMAN, I. (1994).
Phobias, panic, and pain in 55 survivors of road vehicle
accidents. Journal of Anxiety Disorders, 8, 181-187.
Assessed 55 minimally-injured MVA survivors who had little
chronic pain. Almost 40% met DSM criteria for simple phobia
with onset of the MVA and 24% met criteria for PTSD. Phobics
and nonphobics did not differ in gender, pain location, or pain
severity.
MALT, U.F., HOIVIK, B., & BLIKRA, G. (1993). Psychosocial
consequences of road accidents. European Psychiatry,
8, 227-228.
Briefly reports on 3-year follow-up studies in Norway of two
cohorts of injured MVA survivors (including a child sample) and
on a cohort of family members of MVA survivors. Prevalence of
PTSD was 5%, although other psychiatric and behavioral prob-
lems were prevalent in a higher number of survivors, e.g., 14% of
children had reduced physical performance capacity.
MAYOU, R. (1992). Psychiatric aspects of road traffic acci-
dents. International Review of Psychiatry, 4, 45-54.
Discusses psychiatric issues related to MVAs. A useful aspect of
the paper is its inclusion of information about the effects of MVAs
on alcohol and substance abuse and on social outcomes, such as
occupational functioning and financial problems.
MAYOU, R. (1995). Medico-legal aspects of road traffic acci-
dents. Journal of Psychosomatic Research, 39, 789-798.
Discusses legal aspects of MVAs and primarily focuses on issues
related to compensation. Whiplash injury is specifically dis-
cussed. Three-year follow-up data from a prospective study of
compensation-seekers is presented.
MAYOU, R., TYNDEL, S., & BRYANT, B. (1997). Long-term
outcome of motor vehicle accident injury. Psychosomatic
Medicine, 59, 578-584.
Conducted a 5-year follow-up of MVA survivors who had previ-
ously taken part in a 1-year prospective study. There was little
average change in outcomes across the 3 assessment points at 3
months, 1 year, and 5 years. The prevalence of PTSD was approxi-
mately 10% at all assessments, although most early cases remitted
and later cases reflected delayed onset.
SHALEV, A.Y., SAHAR, T., FREEDMAN, S., PERI, T., GLICK,
N., BRANDES, D., ORR, S.P., & PITMAN, R.K. (1998). A
prospective study of heart rate response following trauma
and the subsequent development of posttraumatic
stress disorder. Archives of General Psychiatry, 55, 553-559.
Assessed 86 MVA survivors in Israel in the hospital emergency
room and then 1 week, 1 month, and 4 months later. Heart rate in
the emergency room was elevated among survivors who had
PTSD at 4 months, relative to those who did not have PTSD; this
effect maintained even when the authors adjusted for multiple
covariates.
TAYLOR, S., & KOCH, W. J. (1995). Anxiety disorders due to
motor vehicle accidents: Nature and treatment. Clinical
Psychology Review, 15, 721-738.
Qualitatively reviews the clinical features, etiologic theories,
prevalence, and treatment of anxiety disorders related to MVAs:
accident phobia, PTSD, and partial PTSD. This is an excellent
single source for a summary of the literature prior to 1995.
Prev Page 7 Next
Research at the Pacific Islands Division
of the National Center for PTSD
Linda Revilla, PhD and Sarah Miyahira, PhD
The Pacific Islands Division became the newest member
of the National Center for PTSD in 1993. It is located at the
Honolulu VAM&ROC, under the leadership of Acting
Director Sarah Miyahira, PhD. The Division actively seeks
to contribute to the knowledge and understanding of
ethnocultural factors and PTSD; it collaborates with the
Department of Defense on PTSD issues related to active-
duty personnel and their dependents; and it seeks to
improve access to PTSD treatment in geographically re-
mote and/or distant areas. In keeping with these goals,
several Division research projects emphasize the participa-
tion of Asian American and Pacific Islanders in research
protocols and devote significant amounts of resources to
community outreach. In 1993 the Division joined with the
University of Hawaii and the World Health Organization
to co-sponsor an international conference, "Ethnocultural
Aspects of Trauma and Post-Traumatic Stress."
Edward Kubany, PhD, is one of two researchers who
have been associated with the Division since its inception.
Recently, Dr. Kubany completed his VA Merit Review
project, "Cross Validation of a Trauma Related Guilt Scale."
Dr. Kubany also completed validation studies of the Trau-
matic Life Events Questionnaire and the Distressing Event
Questionnaire. More recently Dr. Kubany, in collaboration
with LTC Elizabeth Hill, D.N.Sc., Tripler Army Medical
Center, received a DoD Triservice Nursing Program grant
to conduct a controlled clinical trial of Cognitive Trauma
Therapy with 120 battered women suffering from PTSD.
Chalsa Loo, PhD, also joined the Division when it was
established. Currently, she is working on a VA Merit
Review project, "Race Related Experiences Scale for Asian
American Veterans." This is a scale construction valida-
tion study of a screening instrument for assessing race-
related events stress experienced by Asian Americans
during the Vietnam War. Another objective of the study is
to determine whether race-related stress or trauma has an
additive effect over and above the effects of combat on
PTSD or other psychological dysfunction. Several new
questionnaires and assessment measures have been devel-
oped.
Stefan Bracha, MD, is a research psychiatrist whose
affiliation with the Division began in 1995. With funding
from the National Alliance for Mentally Ill Stanley Foun-
dation, Dr. Bracha has established a laboratory to examine
dental enamel in an effort to identify a new biological
marker in PTSD. This marker may be useful in quantifying
pre-military stressors in combat-related PTSD. In addition,
this marker may have promise in quantifying trauma in
children and adolescents and in quantifying etiological
factors predicting treatment response.
Claude Chemtob, PhD, joined the Division in 1997. His
current research interests include the impact of natural
disasters and domestic violence on children and adults and
information-processing models of PTSD. Work in this
latter area includes empirical and theoretical development
of a neuropsychological model of PTSD. Most recently, Dr.
Chemtob has initiated a collaboration with Jack Carlson,
PhD (University of Hawaii), Ray Novaco, PhD (University
of California, Irvine), and David Riggs, PhD (Behavioral
Sciences Division, National Center for PTSD) to further
develop anger treatment for patients with PTSD.
The Division also focuses on program evaluation. Anto-
nio Gino, PhD, has developed an electronic database to
collect PTSD assessment and other clinical data as well as
to extract relevant patient information from the VA Decen-
tralized Hospital Computer Program (DHCP). It is antici-
pated that the database will eventually be useful to con-
duct treatment outcome studies, to establish psychological
test validity for different ethnic groups, and to engage in
other types of research projects.
Additionally, the Division served as the PTSD represen-
tative for the Honolulu VAM&ROC and collaborated with
other VAMC researchers in developing a proposal to es-
tablish a Mental Illness Research, Education, and Clinical
Center in the Sierra-Pacific Network (VISN 21). Currently,
the Division is collaborating with the Department of De-
fense in the Pacific through a telemedicine research pro-
posal on PTSD assessment and clinical consultation.
SELECTED BIBLIOGRAPHY
BRACHA, H.S., LLOYD-JONES, J., & FLAXMAN, N. (in press).
PTSD research application of dental and archeological research
methods. In S.J. Cooper & A.E. Kelly (Eds.), Neuroscience and
Biobehavioral Reviews. NY: Elsevier Pergamon.
CARLSON, J.G., CHEMTOB, C.M., RUSNAK, K., HEDLUND,
N.L., & MURAOKA, M.Y. (1998). Eye movement desensitiza-
tion and reprocessing (EMDR) treatment for combat-related
posttraumatic stress disorder. Journal of Traumatic Stress, 11, 3-24.
CHEMTOB, C.M., TOMAS, S., LAW, W. & CREMNITER, D.
(1997). Postdisaster psychosocial intervention: A field study of
the impact of debriefing on psychological distress. American
Journal of Psychiatry, 154, 415-417.
KUBANY, E.S. (1997). Application of cognitive therapy for
trauma-related guilt (CT-TRG) with a Vietnam veteran troubled
by multiple sources of guilt. Cognitive and Behavioral Practice, 3,
213-244.
KUBANY, E.S., HAYNES, S.N., ABUEG, F.R., MANKE, F.P.,
BRENNAN, J.M., & STAHURA, C. (1996). Development and
validation of the Trauma-Related Guilt Inventory (TRGI). Psy-
chological Assessment, 8, 428-444.
LOO, C.M. (1994). Race-related PTSD: The Asian American
Vietnam veteran. Journal of Traumatic Stress, 7, 637-656.
LOO, C.M. (1998). Chinese America: Mental health and quality of
life in the inner city. Thousand Oaks, CA: Sage.
MARSELLA, A.J., FRIEDMAN, M.J., GERRITY, E.T., &
SCURFIELD, R.M. (Eds.) (1996). Ethnocultural aspects of posttrau-
matic stress disorder: Issues, research and clinical applications. Wash-
ington, DC: American Psychological Association.
WU, J., AMEN, D., & BRACHA, H.S. (in press). Neuro-imag-
ing in clinical psychiatric practice. In H.I. Kaplan, B.J. Sadock &
J. Grebb (Eds.), Comprehensive Textbook of Psychiatry, 7th Edition
(CTP VII). Baltimore: Williams & Wilkins.
Prev Page 8 Next
PILOTS UPDATE
The PILOTS database is our primary bibliographical
product, but it is not our only one. Several of our publica-
tions are derived from our work on the database, and we
are always looking for new ways to increase the return on
our bibliographical investment.
One of the first spinoffs from the database was the
PILOTS Database Instruments Authority List. This was be-
gun as a way of ensuring that, in our lists of the assessment
instruments used in the research and clinical studies that
we index, consistent names are used for those instruments.
To help our indexers distinguish among similarly-named
instruments, we began to add limited bibliographical in-
formation to the list. For the same reason, we sometimes
added a brief description of the nature of the instrument.
Over the years the number of instruments, and the infor-
mation about them, has increased to the point where our
Authority List has become a substantial bibliography of
nearly 150 pages. As such, it may have uses beyond its
original purpose as a reference aid for the PILOTS database
indexing staff. Anyone wishing to obtain a copy may order
one from the National Technical Information Service (PB98-
116825; domestic price $35, paper; $14, microfiche) or
download a free copy from our Web site.
Another series of bibliographic publications derived (at
least in part) from the PILOTS database is the PTSD Re-
search Quarterly itself. We work closely with contributors,
providing searches of the database and other bibliographic
assistance. The abstracts that accompany these articles are
usually taken from the database, and we use it and the
PTSD Resource Center's collection to verify the biblio-
graphical data our contributors send us. This helps us to
make each Research Quarterly article a valuable selective
guide to the literature of its topic.
The goal of the PTSD Research Quarterly is to disseminate
timely information on traumatic stress research to aca-
demic scientists and mental health professionals. Its con-
tent is not easily accessible to non-professional readers,
from whom we receive many requests for information on
various aspects of PTSD. To satisfy their information needs,
we have produced a series of Fact Sheets. These brief
explanations of traumatic stress topics for lay readers are
limited in size to a single sheet of paper. When appropriate,
suggestions for further reading are provided.
Some of our Fact Sheets are distilled from survey articles
in the PTSD Research Quarterly; others are drafted by Na-
tional Center staff members. In either case, the collections
of our PTSD Resource Center are available to those prepar-
ing them, and the PILOTS database is heavily used in the
editorial process. This helps us to meet our goal of provid-
ing reliable, authoritative information to veterans and their
families, trauma survivors, students, and others interested
in the psychological consequences of traumatic experi-
ences.
We have recently produced our first National Center
Clinician's Update. This new series is intended to offer
brief, timely, reliable surveys to mental health practitioners
and to the primary care physicians who increasingly are
serving as the point of entry to mental health care for their
patients. They supplement our existing clinical publica-
tions by allowing us to distribute information that does not
fit into the NC-PTSD Clinical Quarterly's format or publica-
tion schedule.
All of our Fact Sheets and Clinician's Updates are avail-
able on our Web site. Like our other Web resources, they
may freely be reproduced and distributed.
Both Fact Sheets and Clinician's Updates can be pro-
duced rapidly. During the Red River floods we were asked
by mental health authorities in North Dakota for informa-
tion to be distributed to flood survivors, disaster workers,
and counselors. We had three fact sheets available within
48-hours, and in the aftermath of subsequent disasters we
were able to respond immediately to requests for informa-
tional material. Our Web site makes it possible for those in
need to have access to our publications without waiting for
our reply to an urgent telephone call, email, or fax message.
When we began our bibliographical work, our hope was
to provide a useful service to researchers and clinicians.
This we have done. The usage figures that we receive from
the Dartmouth College Libraries show a high number of
connections to the database each month, and visitors to
National Center headquarters in White River Junction give
us a qualitative idea of its value to traumatic stress workers.
By leveraging the work we put into PILOTS we are begin-
ning to make a similar impact on a broader public.
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