Psychiatry of Whiplash Neck Injury{{ Mention of Neck Pain Or Discomfort, and Those with All Other Soft-Tissue Injury
BRITISH JOURNAL OF PSYCHIATRY 2002), 180, 180, 441^448 441^448
Psychiatry of whiplash neck injury{{ mention of neck pain or discomfort, and those with all other soft-tissue injury. At a later stage this classification was checked RICHARD MAYOU and BRIDGET BRYANT 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. Background The psychiatric outcome Whiplash neck injury is the most common One set of medical records was missing. of whiplash neck injury is controversial. type of injury following a road traffic Of the remaining 1440, 337 23%) were accident Spitzer et aletal, 1995) and claims identified as having a whiplash injury, 570 Aims Todescribe outcomes and for persistent symptoms make up 85%of 40%) as other soft-tissue injury, 247 predictors as compared with other types all motor accident personal injury claims 17%) as bony injury and 286 20%) as in the UK. There has been long-standing no injury. In the `whiplash' group the great of road accidentinjury. acrimony about whether complaints are majority 81%) had no other injury and an MethodMethod Consecutive emergency attributable to physical pathology or to ISS score of unity, but one-fifth had other psychological mechanisms such as delib- minor soft-tissue injuries. In the `other department attenders nn114 8 ; whipla sh erate exaggeration and simulation. We use soft-tissue' group nearly all 97%) had only 278) assessed by self-report at baseline, 3 data from a 1-year consecutive series of minor lacerations or abrasions and ISS months,1 year and 3 years. all attenders at a hospital emergency scores ofscoresof 443. The `bony injury' group department following a road accident had a median ISS score of 4 range 1±25). ResultsResults Moderate to severe pain was MayouMayou et aletal, 2001) in order to consider Data were collected in the emergency reported by 27% of whiplash sufferers at1 two questions: department or by immediate mailing using self-completion questionnaires. The base- year and by 30% at 3 years.Psychiatric a)a)WhatWhat are the physical, psychological line questionnaire covered details of family consequences were common and and social consequences of whiplash background, previous travel and road neck injury and other types of injury persistent.Whiplash victims and those accident injury, trait worry and emotional in road accidents? with bony injury were more likely to seek problems in the previous month Ehlers etet compensation. Accident and early post- b)b)DoDo psychological and social factors that alal, 1998). A six-question version of the accident psychosocialvariables predicted can be assessed at the time of injury or SF-36 Health Survey Ware et aletal, 1992),1992) at 3-month follow-up predict pain and was used to measure health problems and the pain at1year.Claiming compensation psychiatric outcomes at 1 year for limitation of activities in the month before at 3 months predicted the pain at1year for whiplash victims and are the predictors the accident. Respondents also rated the those with whiplash or bony injury. different from those for other types of accident in terms of how well they injury?injury? remembered it, how frightening they had Conclusions There is no special found it from `very frightening' to `not psychiatry of whiplash neckinjury. METHOD frightening') and whether they felt to Psychologicalvariables and consequences blame. They also rated their emotional Consecutive patients nn1441) aged 17±69 reactions to the accident on five-point are important following whiplash in a years who attended the Accident and rating scales from `not at all' to `extremely' similar manner to other types of injury. Emergency Department of the John on ten specified emotions; these included Radcliffe Hospital, Oxford, following a feeling angry, anxious, shaky, weepy, calm Declaration of interest None.None. road traffic accident vehicle occupants, and dissociative symptoms dazed and motorcyclists, cyclists, pedestrians) over a numb).numb). 1-year period were approached to take part Follow-up questionnaires, which were in the study. sent at 3 months, 1 year and 3 years after Those with head injury who had been the accident, covered physical recovery, unconscious for more than 15 min were further treatment, financial, work and legal excluded. Information from the ambulance problems, return to travelling and cog- and emergency department notes was nitions and cognitive strategies to deal with coded by the research nurse, who unpleasant memories of the accident. The categorised them into three injury types: health and activities questionnaire was no injury, soft-tissue injury only and bony repeated and participants completed the injury. The soft-tissue injury group was Post-Traumatic Stress Symptoms PSS) divided into those with whiplash injury, scale FoascaleFoa et aletal, 1993) and the Hospital {{See editorial, pp. 392^393, thisissue. defined as a diagnosis of whiplash or any Anxiety and Depression HAD) scale
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Zigmond & Snaith, 1983). The 3-year SocialSocial Immediate reactions to the questionnaire was sent only to participants accidentaccident who had also completed either the 3-month Financial and work problem. Three-point Immediate reactions to the accident are or the 1-year questionnaire nn917).917). ratings of `no', `yes, minor' or `yes, major' shown in Table 2. Whiplash subjects were to the questions `Has the accident resulted more likely than other accident victims to in financial problems for you now?' and Cognitive maintaining factors have found the accident frightening and to `Has the accident caused problems for your feel they were not to blame. The whiplash The frequency of cognitions about work situation now e.g. your ability to and uninjured subjects were more likely to memories of the accident was rated by work/the sort of work you can do/lost have a clear memory of the accident. respondents from 0 `never') to 4 `always'): job, etc.)?'.job,etc.)?'. Whiplash subjects also rated themselves as 1,1, ruminationrumination was the mean score of `Why feeling more weepy, anxious and angry did it happen to me?' and `I dwell on and, together with the other soft-tissue memories of the accident'; 2, thoughtthought Limitation in daily activities and limitation in injury group, as more shaky. Anger was suppression was the mean score of `I try social activities. Five-point ratings from more conspicuous in the whiplash group to push them out of my mind' and `I try `not at all' to `extremely' in reply to two than in other groups, even when controlling to distract myself'; 3, negative inter- questions on the health and daily activities for blame for the accident. pretations of intrusive recollections waswas questionnaire. the mean of `I must be going out of my mind' and `I will never get over it'; 4, Outcome anger cognition was the score on `Others RESULTSRESULTS Outcomes at 3 months, 1 year and 3 years have harmed me'. are shown in Table 3. Of the 1441 attenders at the emergency Outcome variables clinic who were given the baseline question- naire 1148 80%) completed it. Of these Psychological outcomes Physical participants, 864 75%) completed the 3- The patterns of psychological consequences month follow-up and 772 67%) completed RecoveryRecovery. A three-point rating of `back to at the 3 month and 1-year follow-ups were the 1-year follow-up. At 3 years, 538 59%) normal', `minor problems only' or `major very similar in all the groups. About one- of the 917 who were sent a questionnaire problems' in reply to the question `How third had psychological complications at 1 completed it. well have you recovered from your accident year.year. In the sample as a whole, men and injuries?'.injuries?'. younger people aged under 30 years were less likely to participate at baseline. Those Physical outcomes Subjective pain. A six-point rating from with bony or whiplash injury were more Recovery was worst for the bony injury `none' to `very severe' to the question likely to participate initially than others group and best for the other soft-tissue `How much bodily pain have you had 89%bony, 83%whiplash, 76%other soft and no injury groups, with the whiplash generally during the last 4 weeks?'. tissue, 77%no injury; ww2221.46, d.f. 3, group intermediate. The picture was similar PP550.001).0.001). for those reporting continuous moderate to Psychological very severe pain, but at 3 years slightly more of the whiplash subjects than the Non-participants and drop-outs Phobic travel anxiety. A measure based on bony injury subjects were reporting pain. previous research Mayou & Bryant, There were no relationships between parti- Use of general practice consultation and 1994) combining increased nervousness cipation and vehicle type, driver status or physiotherapy also was similar in the about travelling and avoidance with cut- previous road accident injury. Participants whiplash and bony injury subjects; 48% off points consistent with the DSM±IV who remained in the study were compared in the whiplash group and 56%in the bony American Psychiatric Association, 1994) with those who dropped out at later stages. injury group reported treatment by a criteria for phobia. Dropping out was not related to any of the physiotherapist, osteopath or chiropractor health and psychological measures assessed in the first 3 months, compared with less at baseline. Those in manual occupations Anxiety case. The recommended anxiety than 15%with soft tissue or no injury. were less likely to remain in the study, cut-off of 10 or more on the HAD scale and this was significant for the whiplash Zigmond & Snaith, 1983). and other soft-tissue injury groups. Social outcomes There were some differences in social con- Depression case. The recommended HAD sequences. The whiplash and bony injury depression cut-off of 10 or more. Characteristics of the participants groups were more likely throughout to Characteristics of the participants are report financial and work problems and Post-traumatic stress disorder. The mini-Themini- shown in Table 1. Whiplash sufferers were limitation of daily activities than those with mum number of symptoms on the PSS scale no more likely than other groups to report soft tissue or no injury. At three months FoaFoa et aletal, 1993) required by DSM±IV previous psychological problems or to those with bone injury also reported more criteria.criteria. describe themselves as worriers. limitation in their social life.
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Ta b l e 11Tab Characteristics of participants by type of injury !nn114 7 ) 11 models. These were gender, prior emotional problems, negative emotion, injury severity
Whiplash injury Other soft-tissue No injury Bony injury PP value22 bony injury group only), perceived threat, blame, initial emotional distress, four !!nn278) injury !nn431) !!nn219) !!nn219)219) cognitive maintaining factors and claiming Demographic compensation at 3 months. Age !years) Mean 32.67 32.2030.16 36.6336.63 550.001 Predictors ofany psychological consequences s.d. 11.75 13.53 12.0012.0014.12 In the sample as a whole, significant pre- Gender !nn,%) dictors after adjustment for the effect of Male 108 !39)241!56) 241 !56) 125 125!57) !57)156 !71) 550.001 other variables were female gender, psycho- FemaleFemale 170 !61)!61)170 190 !44)!44)190 94 !43)94!43) 63 !29)!29)63 logical vulnerability and 3-month cognitive Social class !nn,%) factors of rumination, anger and negative Non-manual 171 !71)193 !59) 104 !64)!64)104 99 !54)99!54) 550.010.01 interpretations of intrusive memories of the accident; these accounted for 21%of Manual 71 !29) 136 !41)!41)136 59 !36)86 !47) the deviance. Not knownknownNot 36 102 5634 When predictor variables were entered AccidentAccident singly, there were many similarities Road user group !nn,%) between the injury groups. For all four Driver 193 !69) 175 !41)!41)175 141 !64) 91 !42)!42)91 550.001 groups, emotional distress immediately PassengerPassenger 78 !28)!28)78 75 !17)!17)75 54 !25)!25)54 32 !15) after the accident and rumination, anger Motorcyclist 3!1)3 !1) 6262!14) !14) 13 !6)!6)13 57 !26)!26)57 and negative interpretations at 3 months CyclistCyclist 4 !1) 86 !20)86!20) 7 !3)7!3) 26 !12)26!12) were significant. For the whiplash, other Pedestrian ^ 33 !8)!8)33 4 !2)4!2) 13 !6)!6)13 soft-tissue and no injury groups, Previous road traffic psychological vulnerability and perceived accident injury !nn,%),%) threat were significant. After adjustment, psychological vulnerability and negative Yes 82 !30)124 !29)58 !27)79 !36)NS interpretations remained significant pre- No 194 !70) 306 !71)306!71)158 !73)140 !64) dictors for the other soft-tissue and no Not knownknownNot 212 133 injury groups. In the whiplash group the PPsychological vulnerability only predictor variable to remain signifi- Emotional problems in cant was rumination. In the bony injury previous 6 months !nn,%) group there were no variables significant Yes 56 !20)56!20) 92 !22)!22)92 46 !21)46!21) 48 !22)!22)48 NS at the 0.005 level Bonferroni correction). No 222 !80)222!80)334 !78)173!79) 173 !79) 170 170!78) !78) Claiming compensation was not significant Not knownknownNot ^5^ 5^^11 after adjustment for any of the groups. Trait worry !nn,%),%) 3+3+ 37 !13) 40 !9)!9)40 21 !10)31 !14)NS Predictors ofpain at 1year 5533 240 !87)!87)240 384 !91)384!91) 198 !90)!90)198 186 !86)!86)186 Subjective pain at 1 year was used as the Not knownknownNot 171 722 main physical outcome variable. The results are shown in Table 4. When variables were 1. Hospital records were missing for one person. 2. Testof significance for age was analysis of variance: FF9.73, d.f.3,3,1143; 1143; for other variables it was ww22,d.f.3; for roadroad3; entered on their own, feeling not to blame user group, d.f.12.12. 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 Compensation been settled within the year; this was for those with other soft-tissue injury. similar to the other soft-tissue and no injury Initial anger or anger cognitions at 3 The whiplash and bony injury groups were groups and compared with very few settle- months were significant predictors for all significantly more likely to claim com- ments among those with bony injury. the groups except the bony injury group. pensation than the other two groups. These In the other soft-tissue group initial high differences remained significant after con- emotional distress and all the cognitive trolling for blame. Among those feeling Predictors of outcome maintaining factors predicted outcome. not to blame, 71%of those with whiplash Logistic regression was used to determine Pre-accident emotional state was not a and bony injury made claims compared predictors of psychological consequences significant predictor except for those in with 53%of those with other soft-tissue and reported pain at 1 year. Twelve the no injury group. injury and 42%of those not injured variables, chosen on the basis of theoretical After adjustment for the effects of the ww2228.6, d.f. 3, PP550.001). Thirty per cent considerations and our previous findings other variables, only claiming compen- of claims made by whiplash sufferers had EhlersEhlers et aletal, 1998), were entered into the sation at 3 months remained significant
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TaTable b l e 2 Reactions to the accident of participants by type of injury !nn114 7 ))114 11
Whiplash injuryOther soft-tissue injuryNo injuryBony injury PP valuevalue22
nn !%) nn !%) nn !%) nn !%)
Memory of accident Clear 217 !79)!79) 282282 !66)!66)155 !72) 143 !65) 550.01 PatchyPatchy 53!19) 119119 !28)!28) 5555 !26)!26)59 !27) NoneNone 6 !2)!2) 2727 !6)!6) 6!3)6 !3) 1717 !8)!8) Not knownknownNot 232 333 Blames self for accident No 231!83) 281281 !66)!66)158 !73) 137 !63) 550.001 PartlyPartly 21!7) 86 !20)!20)32 !15) 44 !20)!20) Yes 25 !9)!9) 6060!14) 27!12) 35 !16) Not knownknownNot 141 42233 Accident frightening Moderate^very 199!72) 283283 !66)!66)142 !66) 123123 !56)!56) 550.01 No^slight 77 !28)!28)147 !34) 7474 !34)!34) 123123 !56)!56) Not knownknownNot 212 133 EmotionsEmotions Angry Moderate^extreme 126!46) 150 !35) 71!33) 6161 !28)!28)0.001 None^slight 150!54) 276 !65)!65)144 !67) 157 !72) Not knownknownNot 252 54411 Anxious Moderate^extreme 127!46) 154 !36) 7474 !35)!35) 8484 !39)!39) 550.050.05 None^slight 147!54) 271 !64)!64)140 !65) 131 !61) Not knownknownNot 464 65544 DazedDazed Moderate^extreme 44!16) 86 !20)!20) 3636!17) 29 !14) NS None^slight 230 !84)!84)338 !80) 178 !83) 186 !87) Not knownknownNot 474 75544 Shaky Moderate^extreme 93 !34)!34)159 !37) 6262 !29)!29) 5454 !25)!25) 550.01 None^slight 181!66) 268268 !63)!63)155 !71) 162 !75) Not knownknownNot 444 42233 Weepy Moderate^extreme 78 !29)!29) 8484 !20)!20) 5050 !23)!23)32 !15) 550.01 None^slight 196!72) 341 !80) 166166!77) 182 !85)!85) Not knownknownNot 464 63355
1. Hospital records were missing for one patient. 2. TestTestof of significance was ww22,d.f.3; for `memory of accident'and `blames self' groups, d.f.6.6.
for those with whiplash and bony injury, DISCUSSION department attenders over a 1-year period with claimants being four times more likely EhlersEhlers et aletal, 1998), thereby enabling com- to report pain at 1 year than non- Few studies have assessed the mental state parison with outcome following other types claimants. In the no injury group only outcome of whiplash injury and there has of injury. Limitations of thestudy are that gender remained significant; women in this been little prospective research on psycho- assessment was by self-report,self-report, there were group were ten times more likely to report logical variables Mayou & Bryant, 1996; non-respondents at each stage and pain at 1 year than men were. Severity of Mayou & Radanov, 1996). This study has especially at 3 years, and the sample injury did not predict pain at 1 year, even the major advantage that the whiplash excluded victims who did not attend in the bony injury group. The total amounts subjects were part of a larger study of all emergency departments. Validity of the of deviance explained were modest. road traffic accident consecutive emergency self-report methodology is supported by
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Ta b l e 33Tab Outcomes !nn, %) at 3 months,1yearmonths, 1year and 3 years by type of injury11
Whiplash injuryOther soft-tissue injury No injuryBony injury PP value22
nn at 3 monthsmonthsat 208 306306 165 185 nn at 1 yearyearat1 187187 285285 138 162 nn at 3 yearsyearsat3 124 200 92 122 Health/treatment Recovery: minor^major problem 3 months 132 !64) 136 !44) 53 !32)!32)53 144 !78) 550.001 11year year 93 !50)!50)93 105 !37)!37)105 35 !25)!25)35 113 !70) 550.001 33years years 55 !44) 56 !28)56!28) 20 !22)20!22)70 !57) 550.001 Bodily pain: moderate^severe^very severe 3 months 77 !37)77!37) 59 !20)!20)59 23 !14)!14)23 79 !43) 550.001 1year1year 50 !27) 56 !20)56!20) 19 !14)!14)19 46 !29)46!29) 550.010.01 33years years 37 !30)!30)37 29 !15) 16 !17) 30 !25)30!25) 550.001 Seeing general practitioner 3 months 117 !57) 141 !46) 47 !29)47!29)116 !63) 550.001 1year1year 28 !15) 36 !13)36!13) 11 !8)!8)11 33 !21) 550.010.01 33years years 16 !13)!13)16 11 !6)!6)11 7 !8)7!8)14 !12)NS Out-patient now 3 months3months 27 !13) 24 !8) 3 !2)3!2) 87 !47)87!47) 550.001 11year year 10 !5) 12 !4) 0 !0)0!0) 37 !24)!24)37 550.001 33years years 6 !5)6!5) 3 !2)3!2) 1!1)1 !1) 9!7) 550.02 Physiotherapy during period 3 months 82 !40) 41 !13)!13)41 14 !9)101 !55) 550.001 1year1year 25 !14) 13 !5)!5)13 3 !2)3!2)18 !12) 550.001 33years years 15 !12) 7!4)7 !4) 3!3) 9!7)9!7) 550.02 Psychological Post-traumatic stress disorder 3 months 50 !24)50!24) 70 !23)!23)70 30 !18)30!18) 48 !26)48!26)NS 1year1year 28 !15) 52 !18) 15 !11)33 !21)NS 33years years 21 !17)!17)21 15 !7) 9!10)9 !10) 15 15!12) !12)NS HAD anxiety or depression 3 months3months 43 !21) 54 !18)54!18) 28 !17)28!17)33 !18)NS 1year1year 48 !25) 58 !21)58!21) 22 !16)22!16) 27 !17)27!17)NS 33years years 29 !24)29!24) 27 !14)27!14) 17 !19)21 !17)NS Phobic travel anxiety 3 months3months 43 !21) 66 !22)66!22) 31 !19)!19)31 45 !25)45!25)NS 1year1year 29 !16) 45 !16)45!16) 22 !16)31 !19)NS 33years years 23 !19) 26 !13)26!13) 9!10)9 !10) 17 17!14) !14)NS Any psychological consequence 3 months3months 78 !37) 198 !36) 50 !30) 71 !39)!39)71 NS 1year1year 65 !35) 89 !31)89!31) 37 !28)!28)37 57 !35)!35)57 NS 33years years 38 !35)!35)38 41 !23)!23)41 63 !18)!18)63 41 !37) 550.010.01 SocialSocial Financial probem: minor/major 3 months 98 !47) 108 !36) 57 !35)98 !52) 550.001 1year1year 62 !34) 59 !21)!21)59 23 !17)!17)23 61 !38)!38)61 550.001 33years years 20 !16)20!16) 15 !8)!8)15 6 !7)6!7)23 !19) 550.02 Work problem: minor/major 3 months3months Not available 1year1year 46 !25) 47 !17)47!17) 20 !15)20!15) 60 !38)60!38) 550.001 33years years 28 !23)28!23) 24 !12) 10 !11)32 !26)0.02
!!continued overleaf ))
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TaTable b l e 3 !!continued))
Whiplash injuryOther soft-tissue injury No injuryBony injury PP valuevalue22
Daily activities limited in previous 4 weeks: moderate^extremely 3 months3months 32 !15) 27 !9)27!9) 6 !4)6!4) 59 !32)!32)59 550.001 1year 21 !11) 23 !8)!8)23 7 !5)7!5) 26 !16)26!16) 550.010.01 3years 19 !15) 10 !5) 5 !5)18 !15) 550.010.01 Legal Claiming compensation 3 months3months 128 !62) 115!38)115 !38) 55 55!34) !34)94 !51) 550.001 11year year 111 !60)!60)111 103 !37) 43 !31)83 !52) 550.001 33years years 67 !54)!54)67 72 !36) 32 !35) 53 !42)!42)53 550.010.01 Claim settled 3 months3months ^^^ ^^^^^ 1year!nn340) 33 !30)!30)33 31 !30)!30)31 13 !30)!30)13 7 !8)7!8) 550.050.05 3 years !!3years nn224)224) 50 !75)50!75) 63 !88)!88)63 26 !81)26!81) 30 !57)30!57) 550.001
1. Numbers and percentages are shown for only one category of the dichotomous variables. 2. TestTestof of significance: ww22,d.f.3. HAD, Hospital Anxiety and Depression scale. TaTable b l e 4 Rate ratios of pain at1year, before and after adjustment for all other baseline and 3-month factors, by injury group
FactorFactor Pain at 1 year11 95% CI for adjusted rate ratio
Unadjusted rate ratio22 Adjusted rate ratio22
Whiplash !nn156) BaselineBaseline Blames self !no) 3.70* Anger !high) 2.14* 3months Claimant !yes) 4.81** 4.27*** 1.6^11.1 Anger cognition !high) 2.68** 2.222.22 1.0^4.8 Deviance explained: 9.69%
Other soft-tissue injury !nn232)232) BaselineBaseline Frightening !very) 2.32* Negative emotion !high) 2.81** 2.25 1.07^4.74 3months Negative interpretation !high) 3.38** 2.90*** 1.41^5.96 Claimant !yes) 2.33* Rumination !high) 2.37* Thought suppression !high) 2.31* Anger cognition !high) 2.42* Deviance explained: 7.50% No injury !No !nn119) BaselineBaseline Gender !female) 9.22**9.22** 9.93*** 1.99^49.59 Frightening !very) 3.70* Prior emotional problem !yes) 3.67* 4.08 1.10^15.04 3months Anger cognition !high) 2.75 !NS) 5.67 1.28^24.88 Deviance explained: 22.6% Bony injury !nn146) BaselineBaseline Blames self !no) 3.31** 3months Claimant !yes) 4.76** 4.63***4.63*** 1.91^11.23 Negative interpretation !high) 3.16** 3.05 1.37^6.76 Deviance explained: 13.20%
1. The dichotomous dependent variable is the logit of the probability of moderate to very severe pain at1year. 2. Each rate ratio is compared with a reference category that has the value1.00. For each dichotomous factor the reference category !not shown) is the remainder,remainder, with presence/ absence or high/low score as appropriate. **PP550.05, **PP550.01, ******0.01, PP550.0042 compared with reference category !Bonferroni correction 0.05/12).
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the similarity of findings with our previous interview study Mayou et aletal, 1993) and an CLINICAL IMPLICATIONS interviewed sub-sample details available from the author upon request), both of && Psychiatric consequences !post-traumatic stress disorder, travel anxiety, anxiety, which had high response rates. depression) are common but their prevalence, course and treatment needs are very similar to those following other types of injury.
What are the physical, && Accident-associated and post-accident psychosocial variables are predictors of psychological and social severity of pain at1year. consequences of whiplash neck injury and other types && Whiplash victims are especially likely to seek compensation but this reflects the of injury in road accidents? high proportion of innocent victims, the physical symptoms and the ease of legal definition. Whiplash sufferers differ from those with no injury and those with other soft-tissue LIMITATIONS injury in that they report more pain and use of health care and more effects on && Physical information was based on clinical notes rather than research assessment. finances, work and leisure activities, and && Follow-up was by self-report. in these respects their outcome resembles the outcome for those with bony injury. && Response rates decreased over the 3-year follow-up. 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 RICHARD MAYOU,FRCPsych, BRIDGET BRYANT,MSc,Oxford University Department of Psychiatry, of a standard instrument that enabled Warneford Hospital,OxfordHospital, Oxford DSM±IV diagnosis), they were also similar to those that we have described for CorrespCorrespondence:Richardondence:Richard Mayou,Warneford Hospital,Oxford OX3 7JX,UK.Tel: 01865 226477 whiplash victims in an earlier prospective FirstFirstreceived28November2000,finalrevision1June2001,accepted8June2001) received 28 November 2000, finalrevision1June 2001,accepted 8 June 2001) study Mayou & Bryant, 1996).
Do psychological and social factors Is there a psychiatry of whiplash? legal processes may perpetuate difficulties. that can be assessed at the time Our findings demonstrate that these issues of the injury or at 3-month follow- The findings show that there is no special are important for the outcome of all types up predict pain and psychiatric psychiatry of whiplash. Psychiatric out- of road accident injury, not whiplash alone. outcomes at 1 year for whiplash comes are entirely comparable to those Indeed, these conclusions are fully con- victims and are the predictors following other types of road traffic sistent with wider literature on back and different from those for other accident. Predictors of pain generally are other chronic pain Linton, 1998, 2000) types of injury? very similar to those identified after other and medically unexplained symptoms There were a number of factors that pre- types of injury. MayouMayou et aletal, 1995).,1995). dicted psychological outcome in the sample Most writers on whiplash have con- as a whole, with few major differences sidered physical and psychological explana- between the injury categories. As in our tions of physical symptoms as separate The significance of compensation previous study Mayou et aletal, 1993),,1993), alternatives. This is incorrect; they are There are several reasons why whiplash evidence of previous psychological vulner- interacting, with both physical and psychi- neck injury is so prominent a cause of com- ability predicted the outcome of whiplash atric factors contributing to the overall pensation claims. It is the most common neck injury. Claiming compensation was impairment of the quality of everyday life. type of road traffic accident injury 24% not a predictor of psychological outcome It is to be expected that the psychological of this series) and, compared with other in any of the injury groups. consequences may influence perception of injury categories, it is much more likely that Physical outcome was not predicted physical symptoms and that physical symp- the sufferer is an innocent victim and that by measures of pre-accident psycho- toms may maintain psychological prob- the liability of the other driver will not be logical status and the principal predictors lems. Behavioural reactions may have disputed. The proportion of victims who were variables relating to the accident effects on posture and movement, with sub- claim compensation is higher than for itself, initial psychological response, stantial effects on the course of recovery; innocent victims with either no injury or subsequent cognitions and claiming com- anxiety and depression will affect the other soft-tissue injuries mainly abrasions, pensation. It was notable that, even in perception of physical symptoms; in- bruises and lacerations). It is similar to the those who had suffered fracture, injury consistent or over-cautious medical advice proportion of claimants among those with severity did not contribute to the is likely to exacerbate problems; slow, bony injuries and this perhaps reflects the regression.regression. bewildering and apparently unsympathetic unpleasantness of the acute symptoms and
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the significant limitations of valued every- b)b)PersistentPersistent pain and psychological __ &&Clarke,D.M. Clarke, D. M. 2000) 2000) Acognitivemodelof day activities associated with continuing complications should be recognised posttraumatic stress disorder. Behaviour Research and TherapyTherapy,, 3838, 319^345.,319^345. whiplash symptoms. early and access to specialist cognitive±cognitive± The influence of compensation on behavioural and psychiatric treatment Foa, E. B., Riggs, D. S., Dancu, C.V., et aletal 19 93) is essential.isessential. Reliability and validity of a brief instrument for assessing course and outcome is complex, partly posttraumatic stress disorder. Journal of Traumatic Stress,, because proceedings are more likely, and c)c)NewNew approaches to medical care are 66, 459^473. also more likely to be prolonged, in those only part of the solution; social andsocialand Linton, S. J. 19 1998) 9 8) The socioeconomic impact of with the most distressing physical symp- legal procedures also are important. chronic back pain: is anyone benefiting? PainPain,, 7575,, toms. Our findings are consistent with our 163^168.163^168. 6-year follow-up of claimants Bryant etet Better clinical understanding of psycho- __ 2000) 2000) A review of psychological risk factors in back alal, 1997). We believe that the practical logical and behavioural issues would have and neck pain. SpineSpine,, 25,1148^1154. difficulties, the anger associated with being benefits for patients and also could be Mayou, R., Bryant, B. & Duthie, R. 19 1993) 93) PsychiatricPsychiatric an innocent victim and the slowly progres- expected to reduce the demands on medical consequences of road traffic accidents. BMJBMJ,, 307307,, sing litigation mean that it is one of several resources. It would further enable changes 647^651. social variables influencing overall quality in legal and compensation proceedings that __ && __ 19 1994) 94) Effects of road accidents on travel. of life following the accident. It is probable would minimise their role in exacerbating InjuryInjury,, 2525,,457^460. 457^460. that post-traumatic stress disorder and the subjective severity of pain and other __ ,Bass,C.&Sharpe,M. 1995), Bass, C. & Sharpe, M. 19 95) Treatment of other psychiatric complications are main- physical symptoms. Functional Somatic Symptoms.Oxford: Oxford University tained by psychological variables such as Press. reminders of the accident, continuing REFERENCES __ & Bryant, B. 19 1996) 9 6) Outcome of `whiplash'neck`whiplash' neck physical problems, further accidents and injury.injury. InjuryInjury,, 2727, 617^623.,617^623. disability Ehlers et aletal, 1998; Ehlers & Aker, P.D.,P. D., Gross, A. R., Goldsmith, C. H., et aletal __ &Radanov,B.P. 1996)& Radanov, B. P. 19 9 6) Whiplash neck injury. Clarke, 2000), and that seeking compen- 19 9 6)6) 19 Conservative management of mechanical neck Journal of Psychosomatic Research Research,, 40,,461^474. 461^474. pain: systematic overview and meta-analysis. BMJBMJ,, 313313,, sation acts in a similar manner in relation 1291^1296.1291^1296. __ & Bryant, B. 2001) 2001) Outcome in consecutive to pain.topain. emergency department attenders following a road American Association for Automotive Medicine traffic accident. British Journal of Psychiatry,, 179179,, 19 1990) 9 0) The Abbreviated Injury Scale. Des Plaines, IL: 528^534. Implications American Association for Automotive Medicine. Spitzer,W.O., Skovron, M. L., Salmi, L. R., et aletal An understanding of the multi-causal American Psychiatric Association 1994) Diagnostic 19 95) Scientific monograph of the QuebecTask Force aetiology of the consequences of trauma, and Statistical Manual of Mental Disorders 4th edn) on Whiplash-Associated Disorders: redefiningredefining`whiplash' `whiplash' especially post-accident variables, leads to DSM^IV).Washington, DC: APA. and its management. SpineSpine,, 20 suppl. 8), 1S^73S.
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