Evidence-Based Reviews

Treating posttraumatic stress in motor vehicle accident survivors

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References

Structured diagnostic interviews are straightforward and easy to administer with minimal training. We prefer the 30-question Clinician Administered PTSD Scale (CAPS) because evidence supports its reliability and validity.2,3 Use the CAPS to rate intensity and frequency of the 17 core PTSD symptoms over the past week, month, or lifetime. The CAPS can be scored for a PTSD diagnosis and for symptom severity. This tool’s drawback is that it takes 30 to 60 minutes to administer and a few more minutes to score.

Self-report measures are quick to administer and score and provide valuable information about symptom presence and severity.4 We recommend the PTSD Checklist (PCL), a widely used measure that has been shown to reliably and validly assess MVA-related PTSD.5,6 Consisting of 17 items corresponding to the DSM-IV-TR PTSD symptoms, the PCL takes about 5 minutes to complete and 1 or 2 minutes to score. A score ≥44 is a highly accurate indication of PTSD.6

Patients with MVA-related PTSD often have psychiatric comorbidities.7 The most frequently diagnosed are:

  • major depressive disorder (in about one-half of persons with MVA-related PTSD)
  • anxiety disorders, such as generalized anxiety disorder (in about one-third)
  • chronic pain
  • alcohol or other substance abuse.

We use the Structured Clinical Interview for DSM-IV (SCID) to diagnose comorbid conditions.8 If you do not have time to administer a structured clinical interview, we recommend using psychometrically sound self-report measures, such as the Beck Depression Inventory9 and the State Trait Anxiety Inventory.10

Length of time since the MVA gives a good indication of how likely PTSD is to remit without intervention. Longitudinal studies have found that within 1 year, PTSD will remit without intervention in nearly two-thirds of those diagnosed within 1 to 4 months of the MVA. PTSD that persists after 1 year is much less likely to resolve without treatment.11 Other predictors of PTSD persistence include:

  • lack of physical recovery
  • major depression within the first 2 months of the MVA
  • current major depression
  • alcohol abuse before the MVA
  • perceived vulnerability during the MVA
  • poor family relationships after the MVA.11

PTSD symptoms that initially do not meet diagnostic criteria (subsyndromal PTSD) can worsen in the first year postMVA and lead to a diagnosis of delayed-onset PTSD.12 Having less social support and experiencing additional life stressors—such as another accident, worsening physical health, or change in job—can contribute to delayed-onset PTSD.

CASE CONTINUED: Overcoming fears with psychotherapy

As part of cognitive-behavioral therapy (CBT), the therapist teaches Mr. O a simple breathing exercise to reduce anxiety. He also leads Mr. O through a progression of imaginal and in vivo exposure exercises. The former involves having the patient think about provocative situations in a graded fashion, from easiest to most difficult, while in the psychiatrist’s office. The latter involves having Mr. O seek out red lights—first as a passenger in a vehicle, then as a driver with a passenger, and then while driving alone—until they no longer cause distress.

The American Psychiatric Association,13 Veterans Affairs/Department of Defense,14 International Society of Traumatic Stress Studies,15 and other organizations recommend CBT to treat PTSD.16 Randomized, controlled trials and other evidence support CBT’s efficacy for MVA-related PTSD.11,17

Before implementing CBT, cultivate a strong therapeutic relationship with MVA survivors. The exercises may be acutely distressing, and you will be asking them to complete between-session practice tasks.

CBT for MVA-related PTSD can be delivered to individuals or groups,18 typically in 8 to 16 weekly or semi-weekly, 60- to 90-minute sessions. (Table 2) explains which elements of CBT address specific PTSD symptoms.11

Therapy usually begins with psychoeducation about PTSD symptoms and expected reactions to trauma (the “flight, fight, or freeze” response) to normalize these reactions and place them within the cognitive-behavioral conceptualization. Teach your patients that avoiding memories and reminders of the trauma maintains PTSD and that they must overcome avoidance for treatment to be successful. Note that avoidance can be subtle, such as a patient going to a feared place but distracting himself while there.

CBT for PTSD often includes teaching an anxiety management skill (Box). Imaginal and in vivo exercises also are usually part of treatment.

In imaginal exposure, patients repeatedly and fully confront their frightening memories within session by recounting as much detail about the MVA as possible, including what they were sensing, feeling, and thinking. This description of the MVA can be recorded during the session or written outside of therapy and read aloud by the patient during sessions.

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