Psychiatry of Whiplash Neck Injury This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Br J Psychiatry 2002 (May); 180: 441–448 ~ FULL TEXT
RICHARD MAYOU, FRCPsych and BRIDGET BRYANT, MSc
Oxford University Department of Psychiatry,
Warneford Hospital, Oxford
Richard Mayou,
Warneford Hospital,
Oxford OX3 7JX, UK.
Tel: 01865 226477
INTRODUCTION
Whiplash neck injury is the most common type of injury following a road traffic accident (Spitzer et al, 1995) and claims for persistent symptoms make up 85% of all motor accident personal injury claims in the UK. There has been long-standing acrimony about whether complaints are attributable to physical pathology or to psychological mechanisms such as deliberate exaggeration and simulation. We use data from a 1-year consecutive series of all attenders at a hospital emergency department following a road accident (Mayou et al, 2001) in order to consider two questions:
What are the physical, psychological and social consequences of whiplash neck injury and other types of injury in road accidents?
Do psychological and social factors that can be assessed at the time of 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?
DISCUSSION
Few studies have assessed the mental state outcome of whiplash injury and there has been little prospective research on psychological variables (Mayou & Bryant, 1996; Mayou & Radanov, 1996). This study has the major advantage that the whiplash subjects were part of a larger study of all road traffic accident consecutive emergency department attenders over a 1-year period(Ehlers et al, 1998), thereby enabling comparison with outcome following other types of injury. Limitations of the study are that assessment was by self-report, there were non-respondents at each stage and especially at 3 years, and the sample excluded victims who did not attend emergency departments. Validity of the self-report methodology is supported by the similarity of findings with our previous interview study (Mayou et al,1993) and an interviewed sub-sample (details available fromthe author upon request), both of which had high response rates.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 DSM—IV 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 (Mayouet 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:
Immediate physical care should be clear and positive, provide acute symptomatic relief and encourage rapid and progressive mobilisation (Aker et al, 1996).
Persistent pain and psychological complications should be recognised early and access to specialist cognitive—behavioural and psychiatric treatment is essential.
New approaches to medical care are only part of the solution; social and legal procedures also are important.
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
CLINICAL IMPLICATIONS
Psychiatric consequences (post-traumatic stress disorder, travel anxiety, anxiety, depression) are common but their prevalence, course and treatment needs are very similar to those following other types of injury.
Accident-associated and post-accident psychosocial variables are predictors of severity of pain at 1 year.
Whiplash victims are especially likely to seek compensation but this reflects the high proportion of innocent victims, the physical symptoms and the ease of legal definition.
LIMITATIONS
Physical information was based on clinical notes rather than research assessment.
Follow-up was by self-report.
- Response rates decreased over the 3-year follow-up.
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