Victims of motor vehicle crashes (MVCs) suffer from a myriad of psychiatric complications, including posttraumatic stress disorder (PTSD), generalized anxiety disorder, depression, and specific phobic anxieties.1-3 The development of and prognosis for these posttraumatic psychiatric illnesses is influenced by a number of factors, including cognitive factors, such as repeated rumination about the accident, and emotional factors, such as negative interpretations of intrusive recollections. These factors can, in turn, be independently influenced by the sociocultural context.
Studies exploring psychiatric morbidity following MVCs have primarily been done in the West, with the exception of a recent study from Nairobi.4 Studies of PTSD in India have chiefly examined victims of major disasters, such as earthquakes and riots. India accounts for nearly 10% of the world's road traffic crashes.5 Unlike in major disasters, the victim of an MVC is usually alone (apart from the family) in his or her suffering. In developing nations such as India, most victims of MVCs who present to the emergency department receive treatment for their surgical and orthopedic problems. However, the psychological impact of the MVC is often overlooked, which can lead to significant disability and impairment in quality of life. Rapid industrialization and increased motorization in developing nations warrant an in-depth investigation into the psychological morbidity associated with MVCs. We describe a pilot study in which we examined the prevalence of and factors that influence psychological morbidity in victims of MVCs.
Thirty patients between 18 and 65 years of age who had been involved in an MVC, either as a driver, passenger, pedestrian, or passerby, 1 to 6 months earlier (mean 1.7 months before the study) participated in this pilot study. The participants were patients who had been consecutively hospitalized in the orthopedic or surgical wards for management of post-trauma injuries. Individuals under the influence of intoxicating substances at the time of the accident and individuals with Glasgow Coma Scores6 below 13 at the time of presentation to the hospital were excluded from the study.
Consenting patients were assessed by qualified psychiatrists, and a semi-structured questionnaire concerning socio-demographic characteristics was administered. Severity of injury was scored on the Abbreviated Injury Scale (AIS).7 The AIS measures "threat to life" from the injury on a scale of 1-6, with 1 being mild and 6 the most severe. Psychopathology was measured using the Impact of Events Scale (IES)8 and the Hospital Anxiety Depression Scale (HADS).9 The IES scores psychopathology on three phenomenological subscales that reflect criteria for PTSD: hyperarousal, avoidance, and intrusiveness. A total score greater than 26 indicates presence of PTSD symptoms, while a score higher than 40 indicates PTSD. The HADS is a 21-item scale that independently measures both anxiety and depression, with scores greater than or equal to 8 indicating the presence of anxious or depressive symptoms and scores higher than 11 indicating the presence of an anxiety or depressive disorder. Peritraumatic emotions (i.e., negative emotions and dissociation experienced at the time of the injury) were assessed retrospectively using a 5-point Likert scale. This was similar to a questionnaire used in an earlier study1 that examined the influence of peritraumatic emotions on psychopathology, assessing the following 10 emotions: angry, numbed, shaky, excited, relieved, weepy, anxious, guilty, dazed, and calm, and then subsequently determining dissociation and negative emotions by summating appropriate emotions. The language in the original questionnaire was modified to suit the sociocultural background of this study population. Because a majority of the population being studied was illiterate, all the questionnaires were administered by a single rater, thereby eliminating any inter-rater bias. Significant head injury and substance intoxication at the time of the accident were excluded, since both can influence recall of peritraumatic emotions.
The data were analyzed using the Statistical Package for Social Sciences (SPSS version 11.5).
Of the 30 patients, 17 (57%) had HADS scores suggestive of anxiety and depressive symptoms (≥ 8 on either subscale), with 9 of these patients (30%) having scores suggesting "caseness" while 6 patients (20%) had IES scores higher than 40, suggesting PTSD. The mean scores on the HADS and IES in the sample of 30 patients were 14.73 (SD 9.4) and 24.33 (SD 14.3), respectively. While the age of the victim did not influence either HADS or IES scores, female gender was associated with higher scores; however, this difference was not statistically significant (Table 1). Lower educational status (p < 0.05) and unemployment (p < 0.002) were associated with higher HADS but not IES scores. Although the degree of severity of injury among the four groups did not differ, the role of the victim in the accident seemed to influence severity of symptoms, with drivers having significantly lower IES scores compared with passengers, pedestrians, or passers-by (p < 0.01) (Table 1 and 2). Severity of injury was significantly correlated with high HADS and IES scores, with patients with more severe injuries (AIS ≥ 4) more likely to have significant HADS (> 10) and IES (> 26) scores (p values of 0.006 and 0.029, respectively) (Table 1).
Negative emotions experienced at the time of the accident correlated in a highly significant manner with the anxiety subscale of the HADS (p < 0.001) and the hyperarousal scale of the IES (p < 0.001). There was also significant correlation between negative emotions and other symptoms except for avoidance (Table 3). On the other hand, dissociation at the time of the accident correlated with high scores on all three IES subscales and with higher depression and total scores on the HADS but not with higher HADS anxiety scores. Thus, negative emotions (p = 0.001) seemed to predict anxiety in a more significant manner than dissociation (p = 0.071), while dissociation (p = 0.014), on the other hand, had a stronger correlation with depression than negative emotions (p = 0.048) (Table 3).
Rates of PTSD in victims of MVCs reported in studies from the West range from 8%10 to 46%.11 PTSD was noted in 20% of the patients in our sample, while 30% had an anxiety or depressive disorder; and symptoms of anxiety or depression were noted in more than half the population studied (57%). The mean IES score of 24 in our sample is comparable with the mean IES score of 22.5 reported in an earlier study from the West.12 Women have a greater risk for motor vehicle related PTSD; the risk for chronic PTSD at 6 months, however, is similar to men.13 In our study, women reported more symptoms than men, although this difference was not statistically significant. It has been suggested that a higher frequency of peritraumatic dissociation in females14 probably results in higher rates of PTSD in women.15 Perception of an external locus of control and attribution of responsibility for the MVC have been found to contribute to suffering resulting from the trauma and also to influence the chronicity of PTSD.16,17 We found that, despite similar degrees of severity of injury, passengers and pedestrians were more likely to have psychiatric complications compared with drivers, suggesting a possible influence of contributory role in the accident. Perception of an external locus of control and an external attribution of responsibility for the MVC, as would be expected in passengers and pedestrians, could have contributed to the increased suffering.16,17 A number of studies have reported that severity of injury is the strongest predictor of psychological distress following an MVC,18 and our study also found a positive association between severity of injury and psychological symptoms. This in all probability is also influenced by the lower wage-earning capacity of the socioeconomic group attending the hospital; more physical disability associated with increased severity of injury could also probably explain this finding.
Although the predictive value of early PTSD symptoms has often been questioned,19 early symptoms of heightened arousal and coping with disengagement have been found to be independent predictors of PTSD severity.20 Similarly, peritraumatic dissociation, intrusive symptoms, and negative interpretations of these intrusive recollections affect the development of PTSD.21 Although the association was not strong in our study, negative emotions experienced at the time of the accident seemed to predict anxiety, whereas dissociation appeared to predict depression; thus, it appears that the type of initial emotions experienced may possibly influence the type of psychopathology that develops.
This study is limited in its small sample size and retrospective assessment of peritraumatic experiences. Although recall bias cannot be completely discounted, the exclusion of serious head injury and intoxication at the time of the trauma reduces the risk of this type of bias. Indian society is often credited with having a strong social buffer that protects against psychological distress. While social support was not assessed in detail here, this study suggested that MVC survivors in India are exposed to a similar degree of psychological stress as MVC survivors in the West. It was also noted that the type of emotion experienced at the time of the accident seemed to determine the psychological symptoms that developed. Immediate assessment of the patient can thus help determine the most appropriate type of therapeutic intervention.
Posttraumatic psychiatric symptoms and peritraumatic experiences can independently result in significant psychosocial impairments.22 Rapid industrialization in developing nations is resulting in an exponential increase in the number of motor vehicles on the road, which in turn translates into more MVCs. The high psychological morbidity rate of 57% found in this sample indicates the importance of including psychiatric services as an integral part of emergency and trauma services.
1. Mayou R, Bryant B, Ehlers A. Prediction of psychological outcomes one year after a motor vehicle accident. Am J Psychiatry 2001;158:1231-8.
2. Blanchard EB, Hickling EJ, Taylor AE, et al. Who develops PTSD from motor vehicle accidents? Behav Res Ther 1996;34:1-10.
3. Blanchard EB, Hickling EJ, Freidenberg BM, et al. Two studies of psychiatric morbidity among motor vehicle accident survivors 1 year after the crash. Behav Res Ther 2004;42:569-83.
4. Ongecha-Owuor FA, Kathuku DM, Othieno DM, et al. Post traumatic stress disorder among motor vehicle accident survivors attending the orthopaedic and trauma clinic at Kenyatta National Hospital, Nairobi. East Afr Med J 2004;81:362-6.
5. Thomas VJ. Other disasters. In: Parsuraman S, Unnikrishnan PV, eds. India disasters report: Towards a policy initiative, 2000. Oxford: Oxford University Press 2000:341-3.
6. Teasdale G, Jennet B. Assessment of coma and impaired consciousness: A practical scale. Lancet 1974;2:81-4.
7. Yates DW. Scoring systems for trauma. Br Med J 1990;301:1090-3.
8. Horowitz M, Wilner M, Alvarez W. Impact of Event Scale: A measure of subjective stress. Psychosom Med 1979;41:209-18.
9. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983;67:361-70.
10. Malt UF, Blikra G. Psychosocial consequences of road accidents. Eur Psychiatry 1983;8:227-28.
11. Mayou R, Bryant B, Duthie R. Psychiatric consequences of road traffic accidents. Br Med J 1993;307:647-51.
12. Richmond TS, Kauder D. Predictors of psychological distress following serious injury. J Trauma Stress 2000;13:681-92.
13. Ursano RJ, Fullerton CS, Epstein RS, et al. Acute and chronic posttraumatic stress disorder in motor vehicle accident victims. Am J Psychiatry 1999;156:589-95.
14. Bryant RA, Harvey AG. Gender differences in the relationship between acute stress disorder and posttraumatic stress disorder following motor vehicle accidents. Aust N Z J Psychiatry 2003;37:226-9.
15. Fullerton CS, Ursano RJ, Epstein RS, et al. Gender differences in posttraumatic stress disorder after motor vehicle accidents. Am J Psychiatry 2001;158:1486-91.
16. Delahanty DL, Herberman HB, Craig KJ, et al. Acute and chronic distress and posttraumatic stress disorder as a function of responsibility for serious motor vehicle accidents. J Consult Clin Psychol 1997;65:560-7.
17. Hickling EJ, Blanchard EB, Buckley TC, et al. Effects of attribution of responsibility for motor vehicle accidents on severity of PTSD symptoms, ways of coping, and recovery over six months. J Trauma Stress 1999;12:345-53.
18. Jeavons S. Predicting who suffers psychological trauma in the first year after a road accident. Behav Res Ther 2000;38:499-508.
19. Shalev AY. Posttraumatic stress disorder among injured survivors of a terrorist attack: Predictive value of early intrusion and avoidance symptoms J Nerv Ment Dis 1992;180:505-9.
20. Mellman TA, David D, Bustamante V, et al. Predictors of posttraumatic stress disorder following severe injury. Depress Anxiety 2001;14:226-31.
21. Freedman SA, Brandes D, Peri T, et al. Predictors of chronic post-traumatic stress disorder. A prospective study. Br J Psychiatry 1999;174:353-9.
22. Kuhn E, Blanchard EB, Hickling EJ. Posttraumatic stress disorder and psychosocial functioning within two samples of MVA survivors. Behav Res Ther 2003;41:1105-12.