Original articleRelationship between posttraumatic stress disorder symptoms and the course of whiplash complaints
Introduction
Whiplash is one of the most prevalent posttraumatic diagnoses following traffic accidents. The term whiplash refers to the presumed movement of the neck during an accident. The distortion of the neck that can follow from such movement usually declines over subsequent days or weeks. Even in the absence of identifiable structural injuries, victims may suffer from long-lasting complaints that are characterized by persistent neck pain, often accompanied by cognitive complaints. This persistent syndrome is usually known as whiplash-associated disorder or post-whiplash syndrome. Studies on the etiology of this chronic syndrome have led to conflicting opinions regarding the nature of the complaints and the relevance of psychological factors [1], [2], [3].
Although the majority of victims show spontaneous recovery within the first months after the traffic accident, as many as 40% of the victims suffer from long-lasting symptoms, sometimes with severely disabling effects [4]. Insight into factors that are responsible for this chronic course is therefore of great importance. The determination of such predictive factors may provide clues for effective interventions, in addition to its utility in the context of prevention. Several prognostic factors have already been identified by earlier research [5].
First, it has been found that high initial pain intensity, female gender, and increasing age are predictive of delayed recovery [3], [4], [6]. In addition, studies have shown that individual coping style may be involved in the course of whiplash complaints. More specifically, a palliative coping style has been proven to be predictive of a chronic course [3], [6].
The presence of posttraumatic stress symptoms is another factor that may play an important role in the persistence of whiplash symptoms following a motor vehicle accident [7].
Post-whiplash syndrome and posttraumatic stress disorder (PTSD) are both relatively common conditions following traffic accidents [8], [9], [10], [11]. As many as 23% of traffic accident victims are reported to have developed PTSD, which is known to have high psychiatric and medical comorbidity [12], [13], [14], [15].
The symptoms of PTSD may be involved in the development of post-whiplash syndrome in several ways.
First, anxiety is an important feature of most PTSD symptoms. Because anxiety is known to influence the perception and experience of pain, PTSD symptoms may alter the perception and experience of acute neck pain [16]. Inflated pain levels may subsequently fuel (avoidance) behaviors that facilitate a chronic course [17], [18], [19].
Second, PTSD symptoms may result in heightened vigilance, which may inflate the perception of pain [20].
Third, PTSD symptoms may give rise to a dysfunctional (catastrophic) interpretation of acute neck pain, which may subsequently inflate pain intensity, disability, and psychological distress, independent of the level of the actual physical impairment [21].
Finally, PTSD shares several symptoms with acute whiplash syndrome, including insomnia, irritability, and cognitive problems. These symptoms may further intensify the perception of symptoms or lead to misattribution.
In support of the idea that the presence of PTSD symptoms affects the symptomatology of whiplash, earlier research has provided preliminary evidence to indicate that the acute posttraumatic stress response (i.e., reexperiencing and avoidance symptoms) is related to the intensity of whiplash symptoms 4 weeks after the accident [22].
In addition, the results of a recent study have provided further evidence that PTSD symptoms may also influence the course of whiplash symptoms. More specifically, the study revealed the reexperiencing and avoidance subscales of the Impact of Events Scale to be associated with relatively persistent whiplash complaints at 6 months follow-up [23], [24]. Unfortunately, both previous studies tested only two of the three PTSD symptom scales and neither included the hyperarousal symptom cluster scale. Nonetheless, these symptoms may be highly relevant to the proper understanding of the relationship between PTSD and whiplash complaints [7]. A study by Mayou and Bryant did consider all three PTSD symptoms scales. The participants that they recruited, however, included only victims who had visited an emergency room following their accidents, thereby possibly biasing the results toward patients who were more frightened or whose injuries were more serious [25].
The present study was therefore designed to provide further testing of the robustness and validity of these earlier findings, which suggest that PTSD symptoms are related to the intensity of whiplash complaints and that they have predictive validity regarding recovery from whiplash complaints following motor vehicle accidents. This study includes the hyperarousal symptom cluster in addition to reexperiencing and avoidance symptoms. To test for generalizability, we did not restrict the range of victims to emergency-room visitors. Finally, we examined whether the relationship between PTSD symptoms and whiplash complaints had increased or decreased at prolonged (12-month) follow-up.
More specifically, the present study addresses the following questions:
- 1.
Are PTSD symptoms more frequent among individuals who have post-whiplash syndrome?
- 2.
Are PTSD symptoms related to the severity of whiplash complaints?
- 3.
Is the presence of PTSD symptoms predictive of delayed recovery from post-whiplash syndrome?
Section snippets
Study design
We used a prospective longitudinal design. Participants were assessed at 1 month (Q1), 6 months (Q2), and 12 months (Q3) after their accidents.
Participants and procedure
Traffic accident victims who had initiated compensation claim procedures for personal injury with a Dutch insurance company were asked to participate in this study. In the Netherlands, settlement of personal injury claims is based on liability insurance; accident victims seek compensation from the insurance company of the driver who was at fault. The
General results
Table 2 provides an overview of the basic characteristics of participants (n=240). Of the 240 participants in the final sample, 32 (20 with post-whiplash syndrome on Q1) did not return the second questionnaire, and 18 (11 with post-whiplash syndrome on Q1) did not return the third questionnaire. Analysis indicated no significant differences between those who did and those who did not return the questionnaire with respect to their scores during the first assessment.
Table 2 provides an overview
Discussion
The major results of the present study can be summarized as follows:
- 1.
PTSD and the number of its symptoms are more prevalent among car accident victims who have post-whiplash syndrome than they are among victims who do not have post-whiplash syndrome.
- 2.
The presence of PTSD symptoms was associated with relatively more severe concurrent post-whiplash syndrome complaints.
- 3.
Specifically, the initial number of hyperarousal symptoms was found to have predictive validity for the persistence and severity of
Acknowledgments
The authors wish to thank R.E. Stewart, MSc, for statistical advice.
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