Oxford University Department of Psychiatry, Warneford Hospital, Oxford
Correspondence: Richard Mayou, Warneford Hospital, Oxford OX3 7JX, UK. Tel: 01865 226477
See editorial, pp.
392393, this issue.
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To describe outcomes and predictors as compared with other types of road accident injury.
Method Consecutive emergency department attenders (n=1148; whiplash 278) assessed by self-report at baseline, 3 months, 1 year and 3 years.
Results Moderate to severe pain was reported by 27% of whiplash sufferers at 1 year and by 30% at 3 years. Psychiatric consequences were common and persistent. Whiplash victims and those with bony injury were more likely to seek compensation. Accident and early post-accident psychosocial variables predicted the pain at 1 year. Claiming compensation at 3 months predicted the pain at 1 year for those with whiplash or bony injury.
Conclusions There is no special psychiatry of whiplash neck injury. Psychological variables and consequences are important following whiplash in a similar manner to other types of injury.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Those with head injury who had been unconscious for more than 15 min were excluded. Information from the ambulance and emergency department notes was coded by the research nurse, who categorised them into three injury types: no injury, soft-tissue injury only and bony injury. The soft-tissue injury group was divided into those with whiplash injury, defined as a diagnosis of whiplash or any mention of neck pain or discomfort, and those with all other soft-tissue injury. At a later stage this classification was checked by another member of the research team in collaboration with an emergency medicine specialist, and the injury severity score (ISS) of the Abbreviated Injury Scale (American Association for Automotive Medicine, 1990) was calculated. The ISS is a score comprising the sum of the squares of the three worst injury scores in up to three different body areas.
One set of medical records was missing. Of the remaining 1440, 337 (23%)
were identified as having a whiplash injury, 570 (40%) as other soft-tissue
injury, 247 (17%) as bony injury and 286 (20%) as no injury. In the
whiplash group the great majority (81%) had no other injury and
an ISS score of unity, but one-fifth had other minor soft-tissue injuries. In
the other soft-tissue group nearly all (97%) had only minor
lacerations or abrasions and ISS scores of 3. The bony
injury group had a median ISS score of 4 (range 1-25).
Data were collected in the emergency department or by immediate mailing using self-completion questionnaires. The base-line questionnaire covered details of family background, previous travel and road accident injury, trait worry and emotional problems in the previous month (Ehlers et al, 1998). A six-question version of the SF-36 Health Survey (Ware et al, 1992) was used to measure health problems and limitation of activities in the month before the accident. Respondents also rated the accident in terms of how well they remembered it, how frightening they had found it (from very frightening to not frightening) and whether they felt to blame. They also rated their emotional reactions to the accident on five-point rating scales from not at all to extremely on ten specified emotions; these included feeling angry, anxious, shaky, weepy, calm and dissociative symptoms (dazed and numb).
Follow-up questionnaires, which were sent at 3 months, 1 year and 3 years after the accident, covered physical recovery, further treatment, financial, work and legal problems, return to travelling and cognitions and cognitive strategies to deal with unpleasant memories of the accident. The health and activities questionnaire was repeated and participants completed the Post-Traumatic Stress Symptoms (PSS) scale (Foa et al, 1993) and the Hospital Anxiety and Depression (HAD) scale (Zigmond & Snaith, 1983). The 3-year questionnaire was sent only to participants who had also completed either the 3-month or the 1-year questionnaire (n=917).
Cognitive maintaining factors
The frequency of cognitions about memories of the accident was rated by
respondents from 0 (never) to 4 (always): 1,
rumination was the mean score of Why did it happen to
me? and I dwell on memories of the accident; 2,
thought suppression was the mean score of I try to push them
out of my mind and I try to distract myself; 3,
negative interpretations of intrusive recollections was the mean of
I must be going out of my mind and I will never get over
it; 4, anger cognition was the score on Others have
harmed me.
Outcome variables
Physical
Recovery. A three-point rating of back to normal,
minor problems only or major problems in reply to
the question How well have you recovered from your accident
injuries?.
Subjective pain. A six-point rating from none to very severe to the question How much bodily pain have you had generally during the last 4 weeks?.
Psychological
Phobic travel anxiety. A measure based on previous research
(Mayou & Bryant, 1994)
combining increased nervousness about travelling and avoidance with cut-off
points consistent with the DSM-IV (American
Psychiatric Association, 1994) criteria for phobia.
Anxiety case. The recommended anxiety cut-off of 10 or more on the HAD scale (Zigmond & Snaith, 1983).
Depression case. The recommended HAD depression cut-off of 10 or more.
Post-traumatic stress disorder. The minimum number of symptoms on the PSS scale (Foa et al, 1993) required by DSM-IV criteria.
Social
Financial and work problem. Three-point ratings of
no, yes, minor or yes, major to the
questions Has the accident resulted in financial problems for you
now? and Has the accident caused problems for your work
situation now (e.g. your ability to work/the sort of work you can do/lost job,
etc.)?.
Limitation in daily activities and limitation in social activities. Five-point ratings from not at all to extremely in reply to two questions on the health and daily activities questionnaire.
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
In the sample as a whole, men and younger people aged under 30 years were
less likely to participate at baseline. Those with bony or whiplash injury
were more likely to participate initially than others (89% bony, 83% whiplash,
76% other soft tissue, 77% no injury; 2=21.46, d.f. 3,
P<0.001).
Non-participants and drop-outs
There were no relationships between participation and vehicle type, driver
status or previous road accident injury. Participants who remained in the
study were compared with those who dropped out at later stages. Dropping out
was not related to any of the health and psychological measures assessed at
baseline. Those in manual occupations were less likely to remain in the study,
and this was significant for the whiplash and other soft-tissue injury
groups.
Characteristics of the participants
Characteristics of the participants are shown in
Table 1. Whiplash sufferers
were no more likely than other groups to report previous psychological
problems or to describe themselves as worriers.
|
Immediate reactions to the accident
Immediate reactions to the accident are shown in
Table 2. Whiplash subjects were
more likely than other accident victims to have found the accident frightening
and to feel they were not to blame. The whiplash and uninjured subjects were
more likely to have a clear memory of the accident. Whiplash subjects also
rated themselves as feeling more weepy, anxious and angry and, together with
the other soft-tissue injury group, as more shaky. Anger was more conspicuous
in the whiplash group than in other groups, even when controlling for blame
for the accident.
|
Outcome
Outcomes at 3 months, 1 year and 3 years are shown in
Table 3.
|
Psychological outcomes
The patterns of psychological consequences at the 3 month and 1-year
follow-ups were very similar in all the groups. About one-third had
psychological complications at 1 year.
Physical outcomes
Recovery was worst for the bony injury group and best for the other
soft-tissue and no injury groups, with the whiplash group intermediate. The
picture was similar for those reporting continuous moderate to very severe
pain, but at 3 years slightly more of the whiplash subjects than the bony
injury subjects were reporting pain. Use of general practice consultation and
physiotherapy also was similar in the whiplash and bony injury subjects; 48%
in the whiplash group and 56% in the bony injury group reported treatment by a
physiotherapist, osteopath or chiropractor in the first 3 months, compared
with less than 15% with soft tissue or no injury.
Social outcomes
There were some differences in social consequences. The whiplash and bony
injury groups were more likely throughout to report financial and work
problems and limitation of daily activities than those with soft tissue or no
injury. At three months those with bone injury also reported more limitation
in their social life.
Compensation
The whiplash and bony injury groups were significantly more likely to claim
compensation than the other two groups. These differences remained significant
after controlling for blame. Among those feeling not to blame, 71% of those
with whiplash and bony injury made claims compared with 53% of those with
other soft-tissue injury and 42% of those not injured (2=28.6,
d.f. 3, P <0.001). Thirty per cent of claims made by whiplash
sufferers had been settled within the year; this was similar to the other
soft-tissue and no injury groups and compared with very few settlements among
those with bony injury.
Predictors of outcome
Logistic regression was used to determine predictors of psychological
consequences and reported pain at 1 year. Twelve variables, chosen on the
basis of theoretical considerations and our previous findings
(Ehlers et al, 1998),
were entered into the models. These were gender, prior emotional problems,
negative emotion, injury severity (bony injury group only), perceived threat,
blame, initial emotional distress, four cognitive maintaining factors and
claiming compensation at 3 months.
Predictors of any psychological consequences
In the sample as a whole, significant predictors after adjustment for the
effect of other variables were female gender, psychological vulnerability and
3-month cognitive factors of rumination, anger and negative interpretations of
intrusive memories of the accident; these accounted for 21% of the
deviance.
When predictor variables were entered singly, there were many similarities between the injury groups. For all four groups, emotional distress immediately after the accident and rumination, anger and negative interpretations at 3 months were significant. For the whiplash, other soft-tissue and no injury groups, psychological vulnerability and perceived threat were significant. After adjustment, psychological vulnerability and negative interpretations remained significant predictors for the other soft-tissue and no injury groups. In the whiplash group the only predictor variable to remain significant was rumination. In the bony injury group there were no variables significant at the 0.005 level (Bonferroni correction). Claiming compensation was not significant after adjustment for any of the groups.
Predictors of pain at 1 year
Subjective pain at 1 year was used as the main physical outcome variable.
The results are shown in Table
4. When variables were entered on their own, feeling not to blame
for the accident and claiming compensation at 3 months predicted pain at 1
year for those with whiplash and bony injury, and being a claimant predicted
pain at 1 year for those with other soft-tissue injury. Initial anger or anger
cognitions at 3 months were significant predictors for all the groups except
the bony injury group. In the other soft-tissue group initial high emotional
distress and all the cognitive maintaining factors predicted outcome.
Pre-accident emotional state was not a significant predictor except for those
in the no injury group.
|
After adjustment for the effects of the other variables, only claiming compensation at 3 months remained significant for those with whiplash and bony injury, with claimants being four times more likely to report pain at 1 year than non-claimants. In the no injury group only gender remained significant; women in this group were ten times more likely to report pain at 1 year than men were. Severity of injury did not predict pain at 1 year, even in the bony injury group. The total amounts of deviance explained were modest.
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
What are the physical, psychological and social consequences of
whiplash neck injury and other types of injury in road accidents?
Whiplash sufferers differ from those with no injury and those with other
soft-tissue injury in that they report more pain and use of health care and
more effects on finances, work and leisure activities, and in these respects
their outcome resembles the outcome for those with bony injury. However, the
psychiatric complications were similar for whiplash and other injuries. Apart
from the higher frequency of post-traumatic stress disorder in this study
(which can be attributed to the choice of a standard instrument that enabled
DSMIV diagnosis), they were also similar to those that we have
described for whiplash victims in an earlier prospective study
(Mayou & Bryant,
1996).
Do psychological and social factors that can be assessed at the time
of the injury or at 3-month follow-up predict pain and psychiatric outcomes at
1 year for whiplash victims and are the predictors different from those for
other types of injury?
There were a number of factors that predicted psychological outcome in the
sample as a whole, with few major differences between the injury categories.
As in our previous study (Mayou et
al, 1993), evidence of previous psychological vulnerability
predicted the outcome of whiplash neck injury. Claiming compensation was not a
predictor of psychological outcome in any of the injury groups.
Physical outcome was not predicted by measures of pre-accident psychological status and the principal predictors were variables relating to the accident itself, initial psychological response, subsequent cognitions and claiming compensation. It was notable that, even in those who had suffered fracture, injury severity did not contribute to the regression.
Is there a psychiatry of whiplash?
The findings show that there is no special psychiatry of whiplash.
Psychiatric outcomes are entirely comparable to those following other types of
road traffic accident. Predictors of pain generally are very similar to those
identified after other types of injury.
Most writers on whiplash have considered physical and psychological explanations of physical symptoms as separate alternatives. This is incorrect; they are interacting, with both physical and psychiatric factors contributing to the overall impairment of the quality of everyday life. It is to be expected that the psychological consequences may influence perception of physical symptoms and that physical symptoms may maintain psychological problems. Behavioural reactions may have effects on posture and movement, with substantial effects on the course of recovery; anxiety and depression will affect the perception of physical symptoms; inconsistent or over-cautious medical advice is likely to exacerbate problems; slow, bewildering and apparently unsympathetic legal processes may perpetuate difficulties. Our findings demonstrate that these issues are important for the outcome of all types of road accident injury, not whiplash alone. Indeed, these conclusions are fully consistent with wider literature on back and other chronic pain (Linton, 1998, 2000) and medically unexplained symptoms (Mayou et al, 1995).
The significance of compensation
There are several reasons why whiplash neck injury is so prominent a cause
of compensation claims. It is the most common type of road traffic accident
injury (24% of this series) and, compared with other injury categories, it is
much more likely that the sufferer is an innocent victim and that the
liability of the other driver will not be disputed. The proportion of victims
who claim compensation is higher than for innocent victims with either no
injury or other soft-tissue injuries (mainly abrasions, bruises and
lacerations). It is similar to the proportion of claimants among those with
bony injuries and this perhaps reflects the unpleasantness of the acute
symptoms and the significant limitations of valued everyday activities
associated with continuing whiplash symptoms.
The influence of compensation on course and outcome is complex, partly because proceedings are more likely, and also more likely to be prolonged, in those with the most distressing physical symptoms. Our findings are consistent with our 6-year follow-up of claimants (Bryant et al, 1997). We believe that the practical difficulties, the anger associated with being an innocent victim and the slowly progressing litigation mean that it is one of several social variables influencing overall quality of life following the accident. It is probable that post-traumatic stress disorder and other psychiatric complications are maintained by psychological variables such as reminders of the accident, continuing physical problems, further accidents and disability (Ehlers et al, 1998; Ehlers & Clarke, 2000), and that seeking compensation acts in a similar manner in relation to pain.
Implications
An understanding of the multi-causal aetiology of the consequences of
trauma, especially post-accident variables, leads to conclusions about more
effective management:
Better clinical understanding of psychological and behavioural issues would have benefits for patients and also could be expected to reduce the demands on medical resources. It would further enable changes in legal and compensation proceedings that would minimise their role in exacerbating the subjective severity of pain and other physical symptoms.
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
American Association for Automotive Medicine (1990) The Abbreviated Injury Scale. Des Plaines, IL: American Association for Automotive Medicine.
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSMIV). Washington, DC: APA.
Bryant, B., Mayou, R. & Lloyd-Bostock, S. (1997) Compensation claims following road accidents: a six-year follow-up study. Medicine, Science and the Law, 37, 326-336.
Ehlers, A., Mayou, R. A. & Bryant, B. (1998) Psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents. Journal of Abnormal Psychology, 107, 508-519.[CrossRef][Medline]
Ehlers, A. & Clarke, D. M. (2000) A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319-345.[CrossRef][Medline]
Foa, E. B., Riggs, D. S., Dancu, C. V., et al (1993) Reliability and validity of a brief instrument for assessing posttraumatic stress disorder. Journal of Traumatic Stress, 6, 459-473.
Linton, S. J. (1998) The socioeconomic impact of chronic back pain: is anyone benefiting? Pain, 75, 163-168.[CrossRef][Medline]
Linton, S. J. (2000) A review of psychological risk factors in back and neck pain. Spine, 25, 1148-1154.[CrossRef][Medline]
Mayou, R., Bryant, B. & Duthie, R. (1993) Psychiatric consequences of road traffic accidents. BMJ, 307, 647-651.[Medline]
Mayou, R. & Bryant, B. (1994) Effects of road accidents on travel. Injury, 25, 457-460.[Medline]
Mayou, R., Bass, C. & Sharpe, M. (1995) Treatment of Functional Somatic Symptoms. Oxford: Oxford University Press.
Mayou, R. & Bryant, B. (1996) Outcome of whiplash neck injury. Injury, 27, 617-623.[CrossRef][Medline]
Mayou, R. & Radanov, B. P. (1996) Whiplash neck injury. Journal of Psychosomatic Research, 40, 461-474.[CrossRef][Medline]
Mayou, R. & Bryant, B. (2001) Outcome in
consecutive emergency department attenders following a road traffic accident.
British Journal of Psychiatry,
179,
528-534.
Spitzer, W. O., Skovron, M. L., Salmi, L. R., et al (1995) Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining whiplash and its management. Spine, 20 (suppl. 8), 1S73S.[Medline]
Ware, J. E., Nelson, E. C., Sherbourne, C. D., et al (1992) Preliminary tests of a 6-item general health survey: a patient application. In Measuring Functioning and Well Being (eds A. L. Stewart & J. E. Ware), pp. 291-303. Durham, NC: Duke University Press.
Zigmond, A. S. & Snaith, R. P. (1983) The Hospital Anxiety and Depression scale. Acta Psychiatrica Scandinavica, 67, 361-370.[Medline]
Received for publication November 28, 2000. Revision received June 1, 2001. Accepted for publication June 8, 2001.
Related articles in BJP: