Evidence-Based Reviews

Treating posttraumatic stress in motor vehicle accident survivors

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Stopped at a red light, Mr. O glances in the rearview mirror and sees headlights coming up fast. The sport utility vehicle behind him is not slowing down. He braces himself as the SUV plows into the back of his car, snapping his head back and forth violently.

As white smoke fills his eyes and lungs. Mr. O realizes he has been pushed into the intersection, and for a moment thinks about never seeing his wife and children again. As he hears tires screeching, his car is struck by a truck.

Mr. O does not die, as he feared, but 6 months later he is “just not ready” to return to work. The doctor who is treating his whiplash injury refers him for evaluation of lingering anxiety.

Posttraumatic stress disorder (PTSD) resulting from a motor vehicle accident (MVA) can have a persistent disabling effect. To help you effectively treat patients such as Mr. O, this article examines:

  • common PTSD symptoms in accident survivors
  • recommended diagnostic interviews and assessment tools
  • techniques for using psychotherapy to overcome residual PTSD symptoms.

CASE CONTINUED: Lingering impairment

In the 6 months since the accident, Mr. O’s sleep is disrupted by pain and worry; when he can sleep, he frequently has nightmares about the accident. Mr. O feels anxious and irritable, and thoughts of that evening play over and over in his mind.

Mr. O doesn’t like to talk about the accident and has not resumed driving. He avoids all but required trips, such as to doctors’ appointments, which he endures with extreme anxiety. Whenever his wife drives without him, he insists that she immediately call him when she reaches her destination. At the same time, he feels emotionally distant from her and the children. He shows little interest in hobbies he’d previously enjoyed.

3 symptom clusters of PTSD

To meet DSM-IV-TR criteria for PTSD, a person must have experienced, witnessed, or been confronted by an event that involved actual or threatened death or serious injury, to which he responded with intense fear, helplessness, or horror.1 PTSD’s 3 symptom clusters—reexperiencing, avoidance/numbing, and hyperarousal—encompass 17 core symptoms, and a patient must exhibit at least the minimum number of symptoms from each cluster (Table 1).

MVA survivors with PTSD often have intrusive memories and nightmares. They might avoid talking about the accident and resist or abstain from driving or traveling by car. They often fear and avoid people, places, activities, and reminders of the MVA that can trigger upsetting reactions, such as anxiety, tachycardia, and panic. They may be irritable, detached, or estranged from loved ones, or have difficulty sleeping or concentrating. These symptoms must persist for ≥30 days and cause clinically significant distress and impaired functioning for a person to meet the criteria for chronic PTSD.

Table 1

Patients experience 3 ‘clusters’ of PTSD symptoms

Symptom clusterSymptoms
Reexperiencing
(≥1 required)
  • Distressing recollections of the trauma
  • Distressing dreams of the trauma
  • Acting/feeling as if the trauma were recurring
  • Psychological distress upon confronting trauma cues
  • Physiologic reactivity upon confronting trauma cues
Avoidance/numbing
(≥3 required)
  • Avoiding trauma-related thoughts, feelings, or conversations
  • Avoiding activities, places, or people reminiscent of the trauma
  • Inability to recall an important aspect of the trauma
  • Diminished interest or participation in significant activities
  • Feeling of detachment or estrangement from others
  • Restricted range of affect
  • Sense of foreshortened future
Hyperarousal
(≥2 required)
  • Sleep difficulties
  • Irritability or outbursts of anger
  • Difficulty concentrating
  • Hypervigilance
  • Exaggerated startle response
Note: In addition to having the minimum number of symptoms from each cluster as indicated above, for a patient to meet PTSD criteria, symptoms must cause clinically significant distress and impairment in functioning.
PTSD: posttraumatic stress disorder
Source: DSM-IV-TR

CASE CONTINUED: Reaching a diagnosis

Using a combination of interviews and self-report measures, the psychiatrist diagnoses Mr. O with chronic PTSD. Since the MVA, Mr. O has developed the required number of reexperiencing, avoidance/numbing, and hyperarousal symptoms. These symptoms have persisted for >30 days and significantly impair his functioning.

Use multiple assessment tools

To assess an MVA survivor for PTSD and related problems, we advocate using a combination of:

  • unstructured clinical interviews
  • structured clinical interviews
  • self-report measures.

Also collect information from collateral sources, such as patients’ spouses or significant others, when appropriate and available.

In an unstructured interview, obtain:

  • a thorough, detailed description of the MVA, including what occurred and the patient’s thoughts and feelings during and since the accident
  • a description of physical injuries, medical treatments, and medication use.

This information can rule out physical causes of PTSD-like symptoms, such as a traumatic brain injury that results in concentration difficulties and irritability. Also assess the MVA’s effect on travel behavior because this information will help inform treatment.

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