Post-traumatic stress reactions after injury

Background: Many individuals experience psychological distress after injury. It is unclear whether poor psychological outcome reflects pretrauma variables. Methods: In a prospective, cross-sectional study, 152 accident and emergency department patients with physical injuries and an acute stress reaction completed trauma and psychometric questionnaires, including the Impact of Event Scale and the Hospital Anxiety and Depression Scale. Results: Although levels of pretrauma social, occupational, and familial functioning were high, and the modal Abbreviated Injury Scale score was 1, there were high levels of psychological distress at 3 weeks. Mean Hospital Anxiety and Depression Scale anxiety and depression scores were 11.8 (SD, 4.4) and 8.7 (SD, 4.4), respectively. The mean total Impact of Event Scale score was 46.0 (SD, 16.1). Stepwise linear regression analysis found unemployment and previous history of trauma to be associated with increased symptoms of traumatic stress. Conclusion: Trauma patients with high levels of pretrauma functioning may develop acute psychological distress. Unemployment and previous trauma increase risk. Psychological well-being should be considered in routine injury assessments. Epidemiologic studies have shown that a significant minority of those physically injured in a traumatic event will develop psychiatric disorders, including anxiety, depression, and posttraumatic stress disorder (PTSD). For adults, rates of PTSD after serious accident including motor vehicle crashes (MVCs) have ranged from 11.6 to 23.6% and for physical assault from 13 to 30.8%. 1-3 Several prospective studies have suggested that high initial distress after physical injury is predictive of later psychological sequelae. 4-6 Furthermore, in a study of assault and accident victims with facial injuries, 6 oral surgery house officers (residents) were able to predict who would score more highly on anxiety measures 7 weeks after trauma. Despite this finding, little is known about the pretrauma background of acutely distressed, recently injured individuals. Furthermore, little is known about their perceptions of the trauma (for example, threat to life and attributions of responsibility). The relationship between severity of injury and psychological distress is unclear. At least two studies 6,7 have found no relationship between these variables. One 8 reported a positive relationship between PTSD and the percentage of burn, whereas another study found the extent of injury after MVC to be moderately predictive of later PTSD. 9 Conversely, one study found that burn patients with smaller percentage burns were more likely to suffer from PTSD. 10 Thus, severity of injury does not necessarily predict severity of psychological sequelae. Little information exists on the differential effect of type of trauma on posttraumatic symptomatology. Shepherd et al. 11 found no differences on measures of anxiety and depression between assault and accident victims 1 week after injury. However, at 3 months, assault victims scored significantly higher on these measures. One study 12 found that survivors of combat, sexual assault, physical assault, and war-related experiences reported more avoidance and arousal symptomatology than natural disaster and accident victims. Most reexperiencing symptoms were found among combat, physical assault, war-related experiences and sexual assault groups. Other variables shown to be associated with increased likelihood of posttraumatic psychological sequelae included female sex, 1,13 prior exposure to traumatic events, 14 unstable job behavior, 15 impaired social support, 15 and low perceived social support. 10 The present study describes the background characteristics of a sample of individuals who experienced significant psychological distress shortly after physical injury. It was hypothesized that even where injury was mild, significant psychological sequelae would be present and that type of trauma (assaults, MVCs, and other accidents) would not predict levels of psychological symptomatology