Posttraumatic disorders following injury: an empirical and methodological review

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Abstract

Although there has been a marked increase in research on psychological disorders following physical injury in recent years, there are many discrepancies between the reported findings. This paper reviews the prevalence outcomes of recent studies of the mental health sequelae of physical injury with a focus on posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and depression. The review critically outlines some of the methodological factors that may have contributed to these discrepancies. The phenomenological overlap between organic and psychogenic symptoms, the use of narcotic analgesia, the role of brain injury, the timing and content of assessments, and litigation are discussed in terms of their potential to confound findings with this population. Recommendations are proposed to clarify methodological approaches in this area. It is suggested that a clearer understanding of the psychological effects of physical injury will require the widespread adoption of more rigorous, standardized and transparent methodological procedures.

Introduction

In recent years, increasing attention has been devoted to psychological morbidity that can develop following traumatic physical injury. This attention is understandable considering that physical injury is a very frequent phenomenon. For example, in 2000, 11% of the U.S. population (approximately 30 million people) were treated in emergency departments following nonfatal injuries (National Centre for Injury Prevention and Control, 2000). The high prevalence of physical injury partly explains why the psychological effects of physical injuries, such as those resulting from motor vehicle accidents (MVAs), industrial accidents, and related events, represent one of the major causes of psychological injury (Norris, 1992). Considerable research has attempted to investigate the nature and prevalence of psychiatric sequelae either by directly examining physically injured populations or by examining other traumatized populations where injury may be a component of the experience. Despite increasing data on this topic, there is marked variability in the findings concerning the prevalence of psychological disorders associated with traumatic injury.

The purpose of this paper is to provide an overview of the psychiatric prevalence data for this population and to highlight the methodological problems inherent in much of this research. We suggest that many of the inconsistent findings in this field may be attributed to variability in methodological approaches. An underlying premise is that future developments in our understanding of psychological effects of traumatic injury depend on these methodological issues being resolved. While we recognize that factors other than methodology may also contribute to differences in prevalence rates between studies (e.g., cross-national differences in populations), addressing these issues is beyond the scope of this paper. This article critically reviews some of the significant procedural issues underpinning much of the prevalence research on this topic and, where possible, suggests recommendations regarding a consistent approach to assessing severely injured survivors. We commence with a summary of the current evidence concerning psychological morbidity following physical injury, before discussing the major methodological problems that confront researchers in this area. The paper concludes with a series of recommendations for future research methodologies utilizing injured populations. The key focus of this paper is on prevalence of psychopathology following injury, with particular reference to posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and depression, although most of the methodological issues have relevance also for other research designs utilizing this population. While methodological issues have been noted by previous authors (e.g., Blaszczynski et al., 1998), little attempt has been made to provide a comprehensive and integrated review of the key methodological dilemmas confronting researchers in this area. This paper is not intended to be overly prescriptive, nor does it claim to identify and solve all methodological problems. Rather, it is hoped that by raising some of the key issues, an increase in methodological transparency and improved reporting of research methodology details with this population will occur.

Section snippets

Posttraumatic stress disorder

The diagnosis of PTSD was introduced to the diagnostic nomenclature in 1980 with the advent of DSM-III (American Psychiatric Association, 1980). Although the diagnostic criteria have been modified a little over the years, the disorder is now thought to comprise three primary symptom clusters: re-experiencing of the traumatic memories, active and passive avoidance of reminders, and persistent hyperarousal. Symptoms from each of these clusters are required for a diagnosis of PTSD, but they must

Methodological issues

In the above literature review, we have briefly highlighted some potential methodological difficulties in many studies utilizing an injured population. The following section elaborates on these and other methodological issues which may potentially be associated with the variability in reported prevalence rates of posttraumatic conditions and impact on prediction studies. In this section, methodological issues pertaining to physical injury, TBI, subsequent traumatization, use of narcotic

Recommendations for future research

We now turn to a number of recommendations for future research into psychological disorders following traumatic injury. The following recommendations are made with the aim of providing a guide that will permit some uniformity in approach and comparability between studies. We emphasize that while we suggest operational definitions where possible, we recognize in many cases operational definitions are not available and as a result decisions are made on clinical judgement. At a minimum, we suggest

Conclusion

The evidence pertaining to psychological consequences of physical injury has expanded markedly in recent years. The extent to which the increasing evidence accurately develops our understanding of postinjury psychological functioning depends, however, on consistent and empirically defensible methodologies. This review has highlighted several issues that researchers need to consider if the current discrepancies between research outcomes are to be clarified. At the very least, recognizing and

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