Motor Vehicle Accidents and Traumatic Stress

By Eric G. Mart, Ph.D., ABPP
From Massachusetts Bar Association Lawyers Journal, Vol. 5, No. 4, December 1997.

In recent years, psychologists and other mental health professionals have made some progress in understanding the effects of trauma in the development of various psychological disorders. It comes as no surprise that victims of rape, torture, domestic abuse, and natural and man-made disasters may suffer trauma-related symptoms as a result of their experiences, given the rare occurrence of such terrible events. However, it may come as a surprise that in modern industrial civilizations the major cause of psychological disorders related to environmental stressors is motor vehicle accidents.

This seems counter-intuitive, given how common motor vehicle accidents (MVAs) are and how much less spectacular they are than volcanic eruptions and plane crashes. But on closer examination of the criteria for trauma-related diagnoses, it is clear that all of the trauma-producing elements are present in MVAs.

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) lists a number of diagnoses that include as part of their criteria the presence of external stress caused by traumatization, including Posttraumatic Stress Disorder (PTSD), Acute Stress Disorder, and various forms of Adjustment Disorder. These disorders are related to environmental threats or stressors, as opposed to intra-psychic conflicts. In the case of PTSD and Acute Stress Disorder, the DSM-IV criteria state:

The person has been exposed to a traumatic event in which both of the following were present:

(1) the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

(2) the person's response involved intense fear, helplessness or horror. In addition, the trauma must be re-experienced through intrusive thoughts, flashbacks or nightmares, abidance must be exhibited for stimuli associated with the trauma and symptoms of increased autonomic arousal must be present. Acute Stress disorder differs from PTSD primarily in the length of time after the experience of the trauma that symptoms occur. (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.)

Threatened death, physical injury, loss of control and feelings of extreme terror are often present in MVAs, and the fact that such accidents are commonplace does nothing to lessen their impact. Despite this, there is little scientific literature which addresses trauma-related conditions in the aftermath of MVAs. For example, John Briere's excellent book, Psychological Assessment of Adult Posttraumatic States, lists disasters, large scale transport accidents, war, sexual assault, domestic violence, and torture as stressors likely to produce PTSD, but no mention is made of MVAs.

Despite this lack of a specific focus on MVAs and PTSD, it is clear from contemporary research that the problems is widespread. In their book After the Crash; Assessment and Treatment of Motor Vehicle Accident Survivors, Blanchard and Hickling review the literature on this subject and also discuss the results of their own massive research program on the psychological sequelae of MVAs. Their review of the literature indicates that estimates for the prevalence of PTSD in survivors of serious (variously defined) MVAs ranged from less than 5 percent to 40 percent. Unfortunately, there are a great many serious MVAs every year. The U.S. Department of Safety estimated that 3,386,000 people were injured in MVAs in 1995. Even if only a small percentage of survivors develop stress related symptoms, this constitutes a large group.

As with any other source of trauma, the development of PTSD and other stress-related disorders always involves a complex interaction between factors relating to the nature of the MVA and the pre-morbid personality of the victim. There are predisposing personality traits as well as the presence of certain situational factors that can increase the chances that a given individual will develop stress-related symptoms. Blanchard and Hickling suggest that previous episodes of serious depression or PTSD increase the chances that they will develop MVA-related PTSD. There is also a greater likelihood that the accident victim will develop such symptoms if the victim is female, experiences nightmares or flashbacks, tends to avoid thinking of the accident, is intensely afraid of death, or was involved in an accident which resulted in a fatality or serious injury.

MVA-related PTSD is identical to other forms of PTSD, and does not involve substantially different symptoms. MVA survivors who suffer from PTSD experience the same types of symptoms as other PTSD sufferers, such as re-experiencing the event, hyper-arousal, and negative impact on daily activities. In addition, a subgroup of MVA survivors develop delayed-onset PTSD months after the accident. One symptom which is more common with MVA survivors than with other PTSD patients is subsequent fears of traveling and riding in automobiles. This is a logical consequence of the avoidant symptoms of PTSD, which cause the patient to avoid stimuli which trigger memories and feelings associated with the precipitating trauma.

Anyone who has sustained a serious injury in an MVA, or who has been in an MVA that resulted in a fatality, should be screened by a mental health professional for signs of PTSD and other anxiety related disorders, particularly if any other of the previously mentioned risk factors are present. If the client is the plaintiff in a personal injury suit, he or she should be referred for evaluation by an experienced forensic psychologist or psychiatrist. As with other forensic evaluations of psychological distress, the evaluation should be comprehensive. A thorough history and record review should be undertaken to establish the patient's pre-morbid level of functioning. A mental status evaluation and clinical interview should be performed and psychological testing administered. Testing should include a standardized personality test such as the Millon Multiphasic Personality Inventory-2, the Personality Assessment Inventory, or the Millon Clinical Multi-axial Inventory-III, and trauma specific instruments such as the Trauma Symptom Inventory or Davidson Trauma Scale. In some cases, testing should include an instrument specifically designed to detect malingering, such as the Structured Interview of Reported Symptoms. If post-traumatic symptoms are found, the patient should be referred to a mental health professional experienced in treating trauma related disorders.

The relative lack of scholarly literature on a phenomenon as widespread as MVA-related PTSD indicates that this area has been neglected by both mental health professionals and attorneys. The recent research on this subject makes it clear that both groups of professionals can better assist their clients by becoming more aware of this issue.