Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2017 Sep 21.
Published in final edited form as: Health Psychol. 2016 Mar 21;35(7):742–750. doi: 10.1037/hea0000329

Longitudinal study of mental health and pain-related functioning following a motor vehicle collision

Sarah E Valentine 1,2, Monica W Gerber 1, Carrie J Nobles 1, Derri L Shtasel 1,2, Luana Marques 1,2
PMCID: PMC5031508  NIHMSID: NIHMS772269  PMID: 26998734

Abstract

Objective

Relations between mental and physical health symptoms are well-established in the literature on recovery following motor vehicle collisions (MVCs). To understand the temporal sequencing and evolution of these relations, we examined the bidirectional association between mental and physical health symptoms at 4 and 16 weeks following a MVC.

Methods

The sample consisted of 103 participants recruited through public MVC police reports. The study included self-report assessments for posttraumatic stress symptoms, depressive symptoms, bodily pain, and role limitations due to physical health. A series of multivariable linear regression analyses were conducted to estimate the associations between these mental and physical health outcomes.

Results

The analysis revealed that mental health symptoms at 4 weeks post-MVC were associated with higher bodily pain at 16 weeks post-MVC (PTSD symptoms: β=−0.74, 95% CI: − 1.06, −0.42; depressive symptoms: β= −1.34, 95% CI: −1.90, −0.78), but not higher health-related role limitations. Physical health symptoms at 4 weeks post-MVC were not associated with PTSD or depressive symptoms at 16 weeks post-MVC.

Conclusions

The results indicate the predictive strength of mental health symptoms at 4 weeks post-MVC in identifying individuals at risk for bodily pain at 16 weeks and shed light on the temporal sequencing of how relations between physical and mental health symptoms emerge over time. This suggests that early assessment of mental health symptoms may have significant implications for the treatment of these patients.

Keywords: motor vehicle collisions, posttraumatic stress, depression, pain, physical complaints

Many survivors across different types of potentially traumatic events report co-existing physical difficulties (Ang, Peloso, Woolson, Kroenke, & Doebbeling, 2006; Barry, Guo, Kerns, Duong, & Reid, 2003; Kerns, Otis, Rosenberg, & Reid, 2003; Kuzma & Black, 2006; Litz, Keane, Fisher, Marx, & Monacol, 1992; Mayou & Bryant, 2002; Schnurr & Green, 2004; Shalev, Bleich, & Ursano, 1990; Thomas, Stimpson, Weightman, Dunstan, & Lewis, 2006; Zayfert, Dums, Ferguson, & Hegel, 2002). Given the physical and psychological sequelae of potentially traumatic events, etiological models of adaptation following trauma are increasingly emphasizing the interaction between biological, environment, and intrapersonal (state- & trait- level) factors. For example, Schnurr and colleagues (2004; 1999) posit that psychological distress (posttraumatic stress disorder [PTSD] in particular) (a) mediates the relation between trauma exposure and poor health, and (b) leads to adverse health outcomes via multiple pathways (i.e., biological, attentional, & behavioral). This model has garnered growing empirical support over the past decade (Ramchand, Marshall, Schell, & Jaycox, 2008; Sledjeski, Speisman, & Dierker, 2008; Weisberg et al., 2002).

In a study designed to examine the impact of PTSD symptoms in a sample of pain patients, individuals with trauma symptoms (ranging from a few symptoms to full PTSD criteria) reported higher pain severity and role impairment than individuals reporting no PTSD symptoms (Geisser, Roth, Bachman, & Eckert, 1996). Similar results were obtained from a cross-sectional questionnaire study designed to examine the emotional and physical functioning of pain patients seen in a primary care setting (Seville et al., 2003). Results from these studies suggest that that patients who had experienced at least one traumatic event, and were bothered by it, reported more pain and worse social functioning compared to both those who did not experience a traumatic event and those who experienced a traumatic event, but were not bothered by it (Seville et al., 2003). In a study designed to investigate the patterns of chronic pain among Vietnam veterans, Beckham and colleagues (1997) found that 80% of veterans seen in their outpatient clinic reported suffering from chronic pain, and that those with concomitant chronic pain and PTSD reported significantly more somatization than those with PTSD alone. Other studies have also reported that co-existing pain and PTSD symptoms worsen medical prognosis among combat veterans (Ang et al., 2006; Barry et al., 2003; Kerns et al., 2003; Kuzma & Black, 2006; Thomas et al., 2006).

Relations between PTSD and physical pain are particularly important to consider among motor vehicle collision (MVC) survivors, due to the high prevalence of pain complaints among these individuals (Blanchard & Hickling, 2004; Kuch, Cox, & Evans, 1996; Mayou & Bryant, 2002). A cross-sectional study found that MVC survivors who endorsed chronic pain and high PTSD symptoms, relative to MVC survivors who endorsed chronic pain and low PTSD symptoms, evidenced more physical impairment, greater psychological distress, and poorer coping strategies (Duckworth & Iezzi, 2005). Further, injury- and pain-related limitations in functioning, such as inability to engage in activities of daily living or engage fully in interpersonal relationships, may produce heightened vulnerability for psychological distress, including depression and PTSD (Duckworth, Iezzi, & Shearer, 2012). To explain the specific relations between pain and PTSD, Sharp and Harvey (2001) propose the mutual maintenance model, which emphasizes the contribution of attentional bias and anxiety sensitivity (both conditions that are common among PTSD and pain patients). Attentional bias manifests as hypervigilance to pain or trauma-related stimuli (Defrin et al., 2008; Sharp & Harvey, 2001) whereas anxiety sensitivity manifests as behavioral avoidance of pain or trauma-related stimuli (Asmundson, Coons, Taylor, & Katz, 2002; Defrin et al., 2008). Both of these factors serve to maintain PTSD and pain symptoms. Thus, pain and physical limitations should be considered when examining variables that may impact the longitudinal course of recovery from trauma.

Several past studies have investigated a bidirectional predictive relationship between posttraumatic stress symptoms and pain or disability using longitudinal cohorts (Buitenhuis, de Jong, Jaspers, & Groothoff, 2006; Chiarotto, Fortunato, & Falla, 2015; Kongsted et al., 2008; Sterling, Hendrikz, & Kenardy, 2011; Sterling & Kenardy, 2006; Sterling, Kenardy, Jull, & Vicenzino, 2003). One study investigating the one-year trajectory of neck pain-related disability and posttraumatic stress symptoms after experiencing whiplash, found that pain one month after injury was associated with being in a “recovery” or “chronic moderate-severe” (v. “resilience”) trajectory for both posttraumatic stress symptoms and for neck pain-related disability (Sterling et al., 2011). This finding suggests posttraumatic stress symptoms and chronic pain develop along similar trajectories. Similarly, another study found that participants with acute whiplash-associated symptoms who reported moderate to severe stress immediately after an MVC had a greater odds of persistent pain (OR 3.3, 95% CI 1.8, 5.9) and reduced working ability (OR 2.8, 95% CI 1.6, 4.9) as compared to those with lower acute stress (Kongsted et al., 2008). Another study found an association between posttraumatic stress hyperarousal symptoms at one month post-MVC and neck-related pain symptoms at 6 and 12 months post-MVC (Buitenhuis et al., 2006). Findings from these studies suggest that psychological stress post-MVC may produce heightened vulnerability for development of persistent pain and disability over time.

Co-morbid physical and mental health complaints are common in PTSD patient populations (Schnurr & Green, 2004; Shalev et al., 1990; Thomas et al., 2006; Zayfert et al., 2002); however, less is known about the development of these problems in non-patient samples following recent MVC exposure. The present study aims to examine the relations between bodily pain, physical impairment related to health problems, and mental health symptoms (i.e., PTSD, depression) at 4 weeks and 16 weeks post-MVC. We will examine these relations in a non-patient sample (i.e., recruitment is not linked to engagement in medical or mental health care) of men and women who experienced serious MVCs. In our study, a serious MVC was operationalized as an MVC that received a police report documenting that the individual warranted medical attention within 48 hours of the accident (Blanchard & Hickling, 2004). Consistent with previous longitudinal studies, we hypothesize that there is a bidirectional predictive relationship between physical and mental health symptoms following an MVC. Specifically, we hypothesize that pain and physical limitations due to health (4 weeks post-MVC) will predict the PTSD and depressive symptoms (16 weeks post-MVC),and that depressive and PTSD symptoms (4 weeks post-MVC) will predict pain and physical limitations due to health problems (16 weeks post-MVC).

Methods

Participants

The current study reports secondary data analysis from a parent study examining relationship variables in heterosexual couples following a serious MVC (Robinaugh et al., 2011). Study eligibility also included: a) participant report that their emotional response at the time of the MVC included intense fear, helplessness, horror, or the perception that they could die (Criterion A for PTSD; American Psychiatric Association, 2000), and b) participant report of being in an exclusive heterosexual romantic relationship prior to the MVC that had lasted a minimum of 4 months (Kachadourian, Fincham, & Davila, 2004).

Participants were deemed ineligible for participation in the parent study (or excluded prior to data analysis) if they reported any of the following on the police report, during phone screen, or on any of the repeated self-report survey measures (see Figure 1 for detail on number of ineligible and excluded participants by type): 1) age under 18 or over 65 years, 2) non-English speaking, 3) current physical and/or emotional abuse, 4) problematic use or treatment for alcohol or drug abuse/dependence (AUDIT; Saunders, Aasland, Babor, De la Fuente, & Grant, 1993), 5) impaired cognitive functioning (SPMSQ; Pfeiffer, 1975), 6) delusional/psychotic thinking, or that 7) they were in the process of divorce, 8) were involved in driving while intoxicated (DWI) collisions, or 9) were experiencing clear suicidal ideation, intention, and plan warranting the need for immediate psychiatric care.

Figure 1. Flow chart of participants.

Figure 1

Open in a new tab

Note. AUDIT = The Alcohol Use Disorders Identification Test. SPMSQ = Short Portable Mental Status Questionnaire.

*Of the 2373 identified from police MVC records, 1421 were estimated to meet relationship status eligibility criteria.

Response rate = Number of individuals who responded to invitation / number of potentially eligible individuals = 199/2373 or 8.4%.

Procedures

Participants in the current study were men and women between the ages of 18 and 65 who were involved in a serious MVC in the month prior to recruitment. Potentially eligible participants were identified from police MVC records (N = 2373) in the greater Buffalo, New York area. Of those individuals who received the invitation letter, 199 responded (8.4%). Potentially eligible participants who responded to invitation letter were administered a brief phone screen assessing for Criterion A for PTSD related to the MVC (Blanchard & Hickling, 2004) and other inclusion and exclusion criteria. Of the 199 who responded to the invitation letter, 47 were ineligible. Participants eligible based on the phone screen were invited to participate in the survey portion of study. A detailed breakdown of participant enrollment is included in a flow chart (Figure 1).

Eligible participants were asked to complete packets of postal surveys at 4 weeks post-MVC and 16 weeks post-MVC. The 4 week timeframe for the first time point was selected according to the Criterion E for PTSD, which states that only posttraumatic symptoms that endure for more than 30 days can be considered indicators of PTSD symptomatology (American Psychiatric Association, 2000). Of the 152 participants who were eligible and mailed postal surveys, 50 were excluded, yielding a final analytic sample of 102 (Figure 1). Participants received monetary remuneration for their participation (up to $60). Informed consent was obtained from all participants who enrolled in the study. Participants were contacted via the telephone between assessments for a brief suicide assessment. None of the participants endorsed suicidal ideation that would warrant immediate intervention.

Measures

Phone Screen

The phone screen was conducted as close to the MVC as possible. During the phone screen, participants were asked several questions pertaining to study inclusion and exclusion criteria. The screener included a standard assessment used in PTSD research related to MVCs. As part of the screening, participants were administered The Motor Vehicle Accident Interview to gather details of the MVC and to evaluate if the MVC met Criterion A for PTSD (Blanchard & Hickling, 2004). Participants were first asked if they had sustained any physical injury during the accident and whether they had received medical attention within 48 hours of the MVC (Criterion A1). If Criterion A1 was satisfied, participants were then asked questions pertaining to Criterion A2. Participants were asked to rate feelings of fear, helplessness, danger and perceptions that they might die during the accident using 0-100 scales (where 0 = not at all and 100 = extreme). In total, 11 participants were ineligible for the study due to responses to Criterion A1 screener; no additional participants were deemed ineligible based on Criterion A2.

Sample Characteristics

Demographics characteristics were measured at 4 weeks post-MVC with a paper questionnaire. Variables included: date of birth, sex, race and ethnicity, and education level. Questions also asked about history of medication use for depression or anxiety, and history of treatment with a counselor, psychologist, or psychiatrist.

Posttraumatic Stress Symptoms

Symptoms of PTSD were assessed with the PTSD-Checklist, Civilian Version (Weathers, Litz, Herman, Huska, & Keane, 1993), a self-report scale designed to assess the frequency of the 17 DSM-IV symptoms of PTSD (American Psychiatric Association, 2000). Participants were asked to rate how much the specific MVC-related post-trauma symptom described in the measure had bothered them over the past month on a five-point scale ranging from 1 (not at all) to 5 (extremely), with total scores ranging from 1 to 75. Among civilian samples, the PCL-C has excellent internal consistency among MVC survivors (Cronbach’s α=.94) as well as other trauma samples (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; Weathers et al., 1993). For the current study, we used this score as a continuous measure, which demonstrated high internal consistency at 4 weeks (α=.94) and 16 weeks (α=.95).

Depressive Symptoms

Depressive symptoms were measured with the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977), a 20-item self-report scale designed to identify depressive symptoms in the community. Participants were asked to rate the frequency of specific depressive symptoms during the past week on a 0 (rarely) to 3 (most of the time) scale. The CES-D has demonstrated high reliability for the general population (α = .85) as well as for clinical samples (α=.90; Radloff, 1977). This scale was used as a continuous measure in the current study, demonstrated an internal consistency of α=.79 (4 weeks) and .77 (16 weeks).

Bodily Pain and Role Limitation due to Physical Health Problems

Both bodily pain and role limitations were measured with the Short Form-36 Health Survey, an expanded version of the Medical Outcomes Study Short-From General Health Survey (Stewart & Ware, 1988). The SF-36 assesses a wide range of health concepts, including personal perceptions of health, and contains subscales that measure eight distinct health concepts. For the current study, two subscales were used: bodily pain, and role limitations due to physical health problems. Possible subscale scores ranges from 0 to 100 with higher scores representing better health. In a study of 3,445 patients with chronic medical or psychiatric conditions, the scale demonstrated adequate reliability for all subscales; internal consistency alphas ranged from .78 to .93 (McHorney, Ware, & Raczek, 1993). In the current study, internal consistency was α=.75 (4 weeks) and α=.90 (16 weeks) for bodily pain and α=.84 (4 weeks) and α=.76 (16 weeks) for role limitations due to physical health problems.

Traumatic Life Events

The Traumatic Life Events Questionnaire (TLEQ) is a 24 question, self-report survey that examines an individual’s exposure to 21 types of traumatic events (e.g., rape, death threats, and physical abuse; Kubany et al., 2000). For this study, we asked participants to indicate whether or not they had experienced each of the 21 types of traumatic events. To characterize our sample, we have reported the number of traumatic events the participant had experience prior to the MVC that met Criterion A for PTSD.

Statistical Analyses

Prior to the main analyses, the data were examined to assess whether statistical assumptions were violated. The data were screened for missing values and no data were missing in excess of 5% (the range of missing values across questionnaires was 0.9-4.0%). Thus, mean imputation was used to prorate missing data, assuming values were missing at random. One observation was dropped in the multivariable regression analyses due to missing data on race and ethnicity. Skewness of all study variables was less than 3 and kurtosis of all study variables was less than 10, suggesting non-normality of the data was not a concern (Kline, 2005). One univariate outlier was found (score on pain severity at 4 weeks, z > 3.29) and was transformed by adding one to the highest value in the pain severity scores (Tabachnick & Fidell, 2000). No multivariable outliers were found using the Mahalanobis distance test.

Descriptive statistics were calculated for demographic and study outcomes variables. Pearson correlation coefficients and corresponding two-sided p-values, using Fisher’s Z transformation, were calculated for the main study variables. Multivariable linear regression analyses were used to examine the linear association between the physical and mental health outcomes of interest. All regression models (8 in total) were adjusted for age, sex, race, education, and the 4-week measure of the dependent variable. First, we estimated the association between PTSD symptoms at 4 weeks post-MVC and bodily pain and role limitations due to physical health at 16 weeks. Second, we estimated the association between depressive symptoms at 4 weeks post-MVC and bodily pain and role limitations due to physical health at 16 weeks. Next, we examined the association between bodily pain at 4 weeks post-MVC and posttraumatic stress symptoms and depressive symptoms at 16 weeks post-MVC. Finally, we examined the association between role limitations due to physical health problems at 4 weeks post-MVC and posttraumatic stress symptoms and depressive symptoms at 16 weeks. Standard errors, standardized estimates, p-values, and 95% confidence intervals were calculated for each parameter estimate. All statistical analyses were performed using SAS 9.3.

Results

Descriptive Statistics

Full descriptive statistics for the study sample are presented in Table 1. The majority of participants identified as white women (75.5% & 74.8%, respectively). Participant mean age was 38 years and 45.7% of participants had a 2-year college degree or higher. A minority of participants reported a history of treatment for anxiety or depression with psychiatric medications (23.3%) or had ever seen a counselor, psychologist, or psychiatrist (18.5%) before the MVC. Nearly all participants self-reported that they had received medical attention for the MVC (96.1%), and most (74.5%) participants defined their injury as “moderate” (i.e., need for medical attention, but not hospitalization). The majority of participants (84.5%) had experienced at least one traumatic event prior to the recent MVC.

Table 1.

Sample Characteristics (N=103)

Variables n (%)
Age (M, SD) 38.2 (12.9)
Sex, % Female 77 (74.8)
Race, % Non-white 25 (24.5)
Education
  Elementary or Secondary School 24 (23.0)
  Some College 32 (31.1)
  2-Year Degree 19 (18.5)
  4-Year Degree or Higher 28 (27.2)
History of Depression or Anxiety Medication Use 24 (23.3)
History of Treatment with a Counselor, Psychologist, or Psychiatrist 19 (18.5)
Taking Depression or Anxiety Medication while in Study 31 (30.1)
Physical Injuries in MVC 93 (91.2)
Lost Consciousness in MVC 14 (13.6)
Sought Medical Attention for MVC 99 (96.1)
Admitted to the Hospital after MVC 13 (12.8)
Had Surgery due to MVC 7 (7.1)
Type of Injury
  No Injury 1 (1.0)
  Minor Injury (no need for medical attention) 12 (11.8)
  Moderate Injury (need for medical attention, but not hospitalization) 76 (74.5)
  Major Injury (Hospitalization - i.e., overnight, not major surgery) 8 (7.8)
  Severe Injury (Major surgery) 5 (4.9)
Experienced Traumatic Event Before MVCa 87 (84.5)
  If yes, No. of Traumatic Events Before MVC (M, SD) 3.7 (3.3)
Open in a new tab

Note. M= mean. SD=standard deviation. MVC = motor vehicle collision.

a

Per responses on the Traumatic Life Events Questionnaire (TLEQ).

Descriptive statistics for the main study variables are presented in Table 2. On average, scores on the bodily pain and role limitations due to physical health SF-36 subscales increased (higher values represent a more favorable state) between 4 and 16 weeks post-MVC, suggesting reductions in physical symptoms over time. Scores on the PCL-C and CES-D (higher values represent the presence of more symptoms) decreased between 4 and 16 weeks, indicating reductions in mental health symptoms over time.

Table 2.

Properties of the Major Study Variables

Range
Variable M SD Potential Actual
SF-36: Bodily Paina,b
  At 4 weeks 44.4 9.7 0–100 21–75
  At 16 weeks 56.8 27.6 0–100 0–100
SF-36: Role Limitations Due to Physical Healtha,b
  At 4 weeks 32.3 32.1 0–100 0–100
  At 16 weeks 50.5 42.7 0–100 0–100
CES-Da
  At 4 weeks 23.9 8.7 0–60 9–47
  At 16 weeks 19.6 7.5 0–60 8–45
PCL-Ca
  At 4 weeks 38.9 15.4 17–85 14–77
  At 16 weeks 32.4 14.8 17–85 17–80
Open in a new tab

Note: SF-36 = Short Form-36 Health Survey; PCL-C = PTSD-Checklist; Civilian Version; CES-D = Center for Epidemiologic Studies Depression Scale; M = Mean, SD = Standard Deviation.

a

Mean difference between 4 and 16 weeks was tested and is statistically significant (p < .001).

b

Higher scores on this subscale represent higher level of functioning / better health.

Multivariable Linear Regression Models

All adjusted multivariable regression models are presented in Table 3. Regression analyses indicated that a 10-point higher value on the PCL-C at 4 weeks was associated with a 7.4-point lower score on the bodily pain SF-36 subscale (β=-0.74, 95% CI: −1.06, −0.42), but not role limitations due to physical health SF-36 subscale at 16 weeks . Similarly, a 10-point higher score on the CES-D at 4 weeks was associated with a 13.4-point lower score on the bodily pain SF-36 subscale (β= −1.34, 95% CI: −1.90, −0.78), but not the role limitations due to physical health SF-36 subscale at 16 weeks. Together, these four models suggest that initial higher endorsement of mental health problems (i.e., PTSD or depressive symptoms) at 4 weeks post-MVC predicted higher bodily pain severity, but not higher role limitations due to physical health problems at 16 weeks post-MVC.

Table 3.

Multivariable Regression Analyses of Mental and Physical Health Symptoms at 4 weeks Post-Motor Vehicle Collision as Predictors of Mental and Physical Health Symptoms at 16 weeks Post-Motor Vehicle Collision. (N=102)a

Bodily Painb
(16 weeks)
 Role Limitations Due to Physical Healthb
(16 weeks)
B SE(β) β 95% CI B SE(β) β 95% CI
PTSD Symptom (4 weeks) −0.42 0.16 −0.74* −1.06, −0.42 −0.16 0.25 −0.43 −0.93, 0.06
Depressive Symptoms (4 weeks) −0.42 0.28 −1.34* −1.90, −0.78 −0.14 0.43 −0.68 −1.53, 0.18
Posttraumatic Stress Symptoms
(16 weeks)
 Depressive Symptoms
(16 weeks)
B SE(β) β 95% CI B SE(β) β 95% CI
Bodily Pain (4 weeks) −0.11 0.11 −0.17 −0.40, 0.05 −0.01 0.07 −0.01 −0.14, 0.13
Role Limitations Due to Physical
Health (4 weeks)		 −0.07 0.04 −0.03 −0.10, 0.04 −0.06 0.02 −0.01 −0.05, 0.03
Open in a new tab

Note. CI= Confidence Interval.

*

p < .001.

a

One participant was excluded from the analysis because of incomplete information on race.

b

Higher scores on this subscale represent higher level of functioning / better health.

All models adjusted for age (continuous), sex (female vs. male), race (non-White vs. White) and education (4-year degree, 2-year degree, some college vs. elementary or secondary school). All models are also adjusted for the baseline value (4 week post-MVC) of the dependent variable.

No significant associations were found between scores on the bodily pain SF-36 subscale at 4 weeks and either PCL-C or the CES-D scores at 16 weeks. In addition, no significant associations were found between score on the role limitations due to physical health SF-36 subscale at 4 weeks and PCL-C or the CES-D scores at 16 weeks. Overall, we observed no association between bodily pain or role limitations due to physical health problems at 4 weeks and mental health symptoms at 16 weeks post-MVC.

Discussion

In this study we examined the bidirectional relations between physical health problems (pain, role limitation due to physical health) and mental health problems (PTSD, depression) at 4 and 16 weeks after a MVC. Our sample consisted of 102 women and men who had experienced a recent serious MVC and reported substantial negative emotional response to this MVC. Overall, we found that PTSD and depressive symptoms, as well as bodily pain and role limitations due to health problems, decreased in severity over time. Our main regression analyses revealed that mental health symptoms related to PTSD and depression at 4 weeks post-MVC predicted severity of bodily pain, but not role limitations due to physical health problems at 16 weeks post-MVC. These findings partially support our hypothesis that poor mental health adjustment following an MVC is associated with poor physical health adjustment over time. Our second hypothesis, that physical health problems at 4 weeks would be associated with mental health problems at 16 weeks, was not supported. Although most of our hypotheses were not supported, our results indicate associations between mental health symptoms at 4 weeks post-MVC in bodily pain at 16 weeks. It appears that within this 16 week window, mental health symptoms may present as early indicators of complicated recovery.

Our findings lend support to the notion that poor mental health adjustment following trauma can place individuals at risk for persistent bodily pain. These results are consistent with the MVC literature, which suggests that there is a negative association between PTSD symptoms and pain severity (for a review see Sharp & Harvey, 2001). Our findings at 16 weeks are also consistent with the depression literature which suggests a strong relation between depressive and pain symptoms (Seville et al., 2003), and our findings extend the MVC literature by documenting the progression of these associations over time. Overall, our finding fit the model proposed by Schnurr and colleagues (2004; 1999), whereby the presence PTSD symptoms following exposure to a traumatic event, predicts pain severity over time. Our findings bolster the growing empirical support for this model (Ramchand et al., 2008; Sledjeski et al., 2008; Weisberg et al., 2002).

Previous pain models have theorized that the acute stress response triggered by the MVC interacts with central pain processing pathways, resulting in persistent pain, disability, and mental health problems (McLean, Clauw, Abelson, & Liberzon, 2005). However, there is little empirical evidence to support the relation between acute stress symptoms (that is psychological stress symptoms persisting for less than 30 days in duration following a traumatic event; these symptoms qualify as posttraumatic stress symptoms only if they persist beyond 30 days) and long-term mental health. Our findings do not support this proposed pathway model, from pain to mental health outcomes. Although our multivariable regression analyses are consistent with the well-documented relations between physical difficulties and mental health problems (Ang et al., 2006; Thomas et al., 2006), our longitudinal approach suggests a more nuanced and, perhaps time-sensitive, relation. Our findings may not adequately compare to the broader literature suggesting that pain (by way of disrupting daily activities and the quality of interpersonal relationships) may be a vulnerability for the development of depression and PTSD (Duckworth et al., 2012), given that our assessments may not have captured onset or chronicity of pain symptoms. We did not find a relationship between bodily pain at 4 weeks and PTSD or depressive symptoms at 16 weeks. In fact, bodily pain at 4 weeks was not associated with any mental health or physical health outcomes observed in this study. It is possible that our assessment of 4 week bodily pain captured a construct closely related to biological recovery from a serious MVC (i.e., expected pain levels akin to healing), which was not a precursor to complicated adjustment.

Previous studies that have identified synchronized trajectories of PTSD and pain symptoms over the course of a 12 month period following an MVC, where individuals track onto recovery, chronic, or resilience pathways (Sterling et al., 2011). It is plausible that our null findings, particularly related to pain and role limitations due to health problems did not emerge due the brief duration of the study. For example, the fact that 4 week bodily pain was not associated with other variables of interest may suggest that early bodily pain captures individuals who may go on to any of three trajectories—thus early indicators of pain may have weak predictive ability. Given that the majority of previous research has examined relations between mental health symptoms and chronic pain (i.e., pain enduring beyond 6 months after an injury), rather than pain during the early physical recovery process, the previous literature may not be a sound comparator for the pain experiences captured in our sample. Together, these findings suggest the need for future research to fully understand the etiology of pain-mental health relations and how these emerge and evolve over time.

Our study sheds light on the temporal sequencing of how relations between physical and mental health symptoms emerge following a serious MVC. Early detection of mental health symptoms may help providers to identify a group of MVC survivors who are at risk of developing prolonged physical health problems, such as chronic pain. Future studies should investigate the need for early and repeated assessment of mental health problems following MVCs, including the integration of mental health services with pain care settings. Although researchers have recommended a three-step service model detailed by O’Donnell, et al. (2008), which highlights the importance of (a) screening injured (or trauma-exposed) persons for vulnerability to progression mental health problems (i.e., depression, PTSD), (b) following patients who have been identified at risk of developing mental or physical health problems, and (c) inviting at-risk patients for return face-to-face assessments, further research is needed to determine the value of integrated models of care.

Limitations and Future Directions

The findings of the current study must be interpreted in light of several limitations. It is important to note that most of the aforementioned work on relations between pain and trauma has been conducted among chronic pain patients. An individual is categorized as having chronic pain when physical pain has lasted for longer than six months, or in excess time beyond healing (Breen, 2002; Turk & Rudy, 1988). Given that the majority of participants in the current study developed pain symptoms prior to enrolling in the study (96% endorsed current pain related to MVC at time of phone screen). Therefore, we cannot report on chronicity of pain in our sample. For example, for pain with onset at the time of the MVC, our 4 month time point would still be too early to detect chronic pain.

Our assessment of participants’ symptoms at 4 and 16 weeks post-MVC is unlikely to have captured the full relevant timeframe in which pain and trauma symptoms interact after experiencing an accident. Although beyond the scope of this study, symptoms experienced in the immediate days and weeks after the MVC may be important precursors to the interplay between pain and trauma, and although our study design precluded evaluation of symptoms prior to 4 weeks post-MVC, future research would benefit from incorporating short-term measures of pain and trauma following a MVC. Despite this limitation, our 4- and 16-week measures did capture meaningful changes in symptom severity, and the interplay between mental and physical symptoms, in the months following an MVC.

Our low response rate of 8.4% initially contacted raises concerns about whether our cohort is representative of the population. With such a highly selected cohort, it is possible that selection bias may have been introduced if factors related to the selection of participants were associated with both physical symptoms (pain or role limitations) and mental health symptoms (PTSD or depression). For example, our sample may have been biased by domains related to all variables of interest, such as housing stability—and it is also possible that highly symptomatic individuals may be over- or underrepresented in the sample. Therefore, our findings should be interpreted with these potential selection biases in mind.

Although it is plausible that the shared variance among constructs of interest may drive some of the findings, it is unlikely that this accounts for all of the results of this study. Future research should attempt to decipher these constructs in order to better understand the unique contributions of relationship distress to post-trauma and depressive symptoms among MVC survivors. One way to pursue such an endeavor would be to conduct diagnostic interviews, where a clinician might be able to discriminate these constructs. Specifically, including a mix of clinician administered and self-report measures assessing for diagnosis, acuity, and functionality would yield important data for conceptualizing exactly how (i.e., what symptoms, or clusters of symptoms) are associated with pain. However, a longer design might capture a better picture of additional variables that impact trauma development, such as pain. Specifically, a longer timeframe might be needed to assess other variables such as pain severity, as these symptoms might have not become chronic by 4 months.

We believe our results should be generalized to all individuals who experienced a recent MVC with caution. It is possible that the bidirectional association between mental health and physical health symptoms may be moderated by relationship status or by the traumatic nature of the MVC, such that those with more social support may have buffered participants from more severe mental and physical health problems. In this case, the bidirectional association between mental health and physical health symptoms may differ among those not in ongoing romantic relationships, or based on the quality of these relationships. Although beyond the scope of this study, future studies should systematically investigate the role of social support from romantic partners on the trajectory of physical and mental health problems post-MVC.

Conclusion

In conclusion, this study offers support for the hypothesis that depressive and posttraumatic symptoms at 4 weeks post-MVC are associated with the progression of pain symptoms, but not role limitations due to health problems, at 16 weeks post-MVC. Neither pain symptoms nor role limitations due to health problems at 4 weeks post-MVC were associated with the progression of depressive or posttraumatic symptoms at 16 weeks post-MVC. Our findings provide preliminary support for an association between early mental health symptoms and risk for developing physical health problems over time. Thus, our findings may suggest the potential benefit for early detection among individuals at risk for pain. Further research is needed to test the potential effects of early screening and repeated assessments of mental health symptoms post-MVC on pain outcomes.

Acknowledgments

Conflicts of Interest and Source of Funding

This project was supported by grants from the National Institute of Mental Health ([NIMH] MH075383-02) and by the Mark Diamond Research Award (State University of New York) awarded to Dr. Marques and mentored by J. Gayle Beck, Ph.D. Dr. Marques’ time is supported by a K23 Mentored Patient-Oriented Research Career Development Award from the NIMH (K23MH096029).

References

  1. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders. 4th American Psychiatric Association; Washington, DC: 2000. pp. 553–557. [Google Scholar]
  2. Ang DC, Peloso PM, Woolson RF, Kroenke K, Doebbeling BN. Predictors of Incident Chronic Widespread Pain Among Veterans Following the First Gulf War. The Clinical Journal of Pain. 2006;22(6):554–563. doi: 10.1097/01.ajp.0000208907.42506.21. doi: 10.1097/01.ajp.0000208907.42506.21. [DOI] [PubMed] [Google Scholar]
  3. Asmundson GJG, Coons MJ, Taylor S, Katz J. PTSD and the experience of pain: research and clinical implications of shared vulnerability and mutual maintenance models. Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie. 2002;47(10):930–937. doi: 10.1177/070674370204701004. [DOI] [PubMed] [Google Scholar]
  4. Barry LC, Guo Z, Kerns RD, Duong BD, Reid MC. Functional self-efficacy and pain-related disability among older veterans with chronic pain in a primary care setting. Pain. 2003;104(1-2):131–137. doi: 10.1016/s0304-3959(02)00471-2. doi: 10.1016/S0304-3959(02)00471-2. [DOI] [PubMed] [Google Scholar]
  5. Beckham JC, Crawford AL, Feldman ME, Kirby AC, Hertzberg MA, Davidson JRT, Moore SD. Chronic posttraumatic stress disorder and chronic pain in Vietnam combat veterans. Journal of Psychosomatic Research. 1997;43(4):379–389. doi: 10.1016/s0022-3999(97)00129-3. doi: 10.1016/S0022-3999(97)00129-3. [DOI] [PubMed] [Google Scholar]
  6. Blanchard EB, Hickling EJ. After the Crash: Psychological Assessment and Treatment of Survivors of Motor Vehicle Accidents. Second American Psychological Association; 2004. [Google Scholar]
  7. Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD checklist (PCL) Behaviour Research and Therapy. 1996;34(8):669–673. doi: 10.1016/0005-7967(96)00033-2. doi: 10.1016/0005-7967(96)00033-2. [DOI] [PubMed] [Google Scholar]
  8. Breen J. Transitions in the concept of chronic pain. ANS. Advances in nursing science. 2002;24(4):48–59. doi: 10.1097/00012272-200206000-00009. [DOI] [PubMed] [Google Scholar]
  9. Buitenhuis J, de Jong PJ, Jaspers JP, Groothoff JW. Relationship between posttraumatic stress disorder symptoms and the course of whiplash complaints. J Psychosom Res. 2006;61(5):681–689. doi: 10.1016/j.jpsychores.2006.07.008. doi: 10.1016/j.jpsychores.2006.07.008. [DOI] [PubMed] [Google Scholar]
  10. Chiarotto A, Fortunato S, Falla D. Predictors of outcome following a short multimodal rehabilitation program for patients with whiplash associated disorders. Eur J Phys Rehabil Med. 2015;51(2):133–141. [PubMed] [Google Scholar]
  11. Davila J, Bradbury TN, Cohan CL, Tochluk S. Marital functioning and depressive symptoms: Evidence for a stress generation model. Journal of Personality and Social Psychology. 1997;73(4):849–861. doi: 10.1037//0022-3514.73.4.849. [DOI] [PubMed] [Google Scholar]
  12. Defrin R, Ginzburg K, Solomon Z, Polad E, Bloch M, Govezensky M, Schreiber S. Quantitative testing of pain perception in subjects with PTSD--implications for the mechanism of the coexistence between PTSD and chronic pain. Pain. 2008;138(2):450–459. doi: 10.1016/j.pain.2008.05.006. doi: 10.1016/j.pain.2008.05.006. [DOI] [PubMed] [Google Scholar]
  13. Duckworth MP, Iezzi T. Chronic pain and posttraumatic stress symptoms in litigating motor vehicle accident victims. The Clinical Journal of Pain. 2005;21(3):251–261. doi: 10.1097/00002508-200505000-00008. [DOI] [PubMed] [Google Scholar]
  14. Duckworth MP, Iezzi T, Shearer EM. Retraumatization associated with disabling physical injuries. In: Duckworth MP, Follette VM, Duckworth MP, Follette VM, editors. Retraumatization: Assessment, treatment, and prevention. Routledge/Taylor & Francis Group; New York, NY, US: 2012. pp. 377–421. [Google Scholar]
  15. Geisser ME, Roth RS, Bachman JE, Eckert TA. The relationship between symptoms of post-traumatic stress disorder and pain, affective disturbance and disability among patients with accident and non-accident related pain. Pain. 1996;66(2–3):207–214. doi: 10.1016/0304-3959(96)03038-2. doi: 10.1016/0304-3959(96)03038-2. [DOI] [PubMed] [Google Scholar]
  16. Kachadourian LK, Fincham F, Davila J. The tendency to forgive in dating and married couples: The role of attachment and relationship satisfaction. Personal Relationships. 2004;11(3):373–393. doi: 10.1111/j.1475-6811.2004.00088.x. [Google Scholar]
  17. Kerns RD, Otis J, Rosenberg R, Reid MC. Veterans' reports of pain and associations with ratings of health, health-risk behaviors, affective distress, and use of the healthcare system. Journal of Rehabilitation Research and Development. 2003;40(5):371–379. doi: 10.1682/jrrd.2003.09.0371. [DOI] [PubMed] [Google Scholar]
  18. Kline RB. Principles and practice of structural equation modeling. 2nd Guilford Press; New York, NY, US: 2005. [Google Scholar]
  19. Kongsted A, Bendix T, Qerama E, Kasch H, Bach FW, Korsholm L, Jensen TS. Acute stress response and recovery after whiplash injuries. A one-year prospective study. Eur J Pain. 2008;12(4):455–463. doi: 10.1016/j.ejpain.2007.07.008. doi: 10.1016/j.ejpain.2007.07.008. [DOI] [PubMed] [Google Scholar]
  20. Kubany ES, Leisen MB, Kaplan AS, Watson SB, Haynes SN, Owens JA, Burns K. Development and preliminary validation of a brief broad-spectrum measure of trauma exposure: The Traumatic Life Events Questionnaire. Psychological Assessment. 2000;12(2):210–224. doi: 10.1037//1040-3590.12.2.210. doi: 10.1037/1040-3590.12.2.210. [DOI] [PubMed] [Google Scholar]
  21. Kuch K, Cox BJ, Evans RJ. Posttraumatic stress disorder and motor vehicle accidents: a multidisciplinary overview. Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie. 1996;41(7):429–434. doi: 10.1177/070674379604100707. [DOI] [PubMed] [Google Scholar]
  22. Kuzma JM, Black DW. Chronic widespread pain and psychiatric disorders in veterans of the first Gulf War. Current Pain and Headache Reports. 2006;10(2):85–89. doi: 10.1007/s11916-006-0017-z. [DOI] [PubMed] [Google Scholar]
  23. Litz BT, Keane TM, Fisher L, Marx B, Monacol V. Physical health complaints in combat-related post-traumatic stress disorder: A preliminary report. Journal of Traumatic Stress. 1992;5(1):131–141. doi: 10.1002/jts.2490050114. [Google Scholar]
  24. Mayou R, Bryant B. Outcome 3 years after a road traffic accident. Psychological Medicine. 2002;32(4):671–675. doi: 10.1017/s0033291702005470. doi: 10.1017/S0033291702005470. [DOI] [PubMed] [Google Scholar]
  25. McHorney CA, Ware JE, Lu JFR, Sherbourne CD. The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Medical Care. 1994;32(1):40–66. doi: 10.1097/00005650-199401000-00004. doi: 10.1097/00005650-199401000-00004. [DOI] [PubMed] [Google Scholar]
  26. McHorney CA, Ware JE, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medical Care. 1993;31(3):247–263. doi: 10.1097/00005650-199303000-00006. doi: 10.1097/00005650-199303000-00006. [DOI] [PubMed] [Google Scholar]
  27. McLean SA, Clauw DJ, Abelson JL, Liberzon I. The development of persistent pain and psychological morbidity after motor vehicle collision: integrating the potential role of stress response systems into a biopsychosocial model. Psychosomatic medicine. 2005;67(5):783–790. doi: 10.1097/01.psy.0000181276.49204.bb. [DOI] [PubMed] [Google Scholar]
  28. O'Donnell ML, Bryant RA, Creamer M, Carty J. Mental health following traumatic injury: Toward a health system model of early psychological intervention. Clinical Psychology Review. 2008;28(3):387–406. doi: 10.1016/j.cpr.2007.07.008. doi: 10.1016/j.cpr.2007.07.008. [DOI] [PubMed] [Google Scholar]
  29. Pfeiffer E. A Short Portable Mental Status Questionnaire for the Assessment of Organic Brain Deficit in Elderly Patients†. Journal of the American Geriatrics Society. 1975;23(10):433–441. doi: 10.1111/j.1532-5415.1975.tb00927.x. [DOI] [PubMed] [Google Scholar]
  30. Radloff LS. The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement. 1977;1(3):385–401. doi: 10.1177/014662167700100306. [Google Scholar]
  31. Ramchand R, Marshall GN, Schell TL, Jaycox LH. Posttraumatic distress and physical functioning: A longitudinal study of injured survivors of community violence. Journal of Consulting and Clinical Psychology. 2008;76(4):668–676. doi: 10.1037/0022-006X.76.4.668. doi: 10.1037/0022-006X.76.4.668. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Robinaugh DJ, Marques L, Traeger LN, Marks EH, Sung SC, Beck JG, Simon NM. Understanding the relationship of perceived social support to post-trauma cognitions and posttraumatic stress disorder. Journal of anxiety disorders. 2011;25(8):1072–1078. doi: 10.1016/j.janxdis.2011.07.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Saunders JB, Aasland OG, Babor TF, De la Fuente JR, Grant M. Development of the alcohol use disorders identification test (AUDIT). WHO collaborative project on early detection of persons with harmful alcohol consumption-II. ADDICTION-ABINGDON- 1993;88:791–791. doi: 10.1111/j.1360-0443.1993.tb02093.x. [DOI] [PubMed] [Google Scholar]
  34. Schnurr PP, Green BL. In: Trauma and health: Physical health consequences of exposure to extreme stress. Schnurr PP, Green BL, editors. American Psychological Association; Washington, DC, US: 2004. [Google Scholar]
  35. Schnurr PP, Jankowski MK. Physical health and post-traumatic stress disorder: review and synthesis. Seminars in Clinical Neuropsychiatry. 1999;4(4):295–304. doi: 10.153/SCNP00400295. doi: 10.153/SCNP00400295. [DOI] [PubMed] [Google Scholar]
  36. Seville JL, Ahles TA, Wasson JH, Johnson D, Callahan E, Stukel T. Ongoing Distress from Emotional Trauma Is Related to Pain, Mood, and Physical Function In a Primary Care Population. Journal of Pain and Symptom Management. 2003;25(3):256–263. doi: 10.1016/s0885-3924(02)00646-2. doi: 10.1016/S0885-3924(02)00646-2. [DOI] [PubMed] [Google Scholar]
  37. Shalev A, Bleich A, Ursano RJ. Posttraumatic stress disorder: Somatic comorbidity and effort tolerance. Psychosomatics: Journal of Consultation and Liaison Psychiatry. 1990;31(2):197–203. doi: 10.1016/S0033-3182(90)72195-0. doi: 10.1016/S0033-3182(90)72195-0. [DOI] [PubMed] [Google Scholar]
  38. Sharp TJ, Harvey AG. Chronic pain and posttraumatic stress disorder: mutual maintenance? Clinical Psychology Review. 2001;21(6):857–877. doi: 10.1016/s0272-7358(00)00071-4. doi: 10.1016/S0272-7358(00)00071-4. [DOI] [PubMed] [Google Scholar]
  39. Sledjeski EM, Speisman B, Dierker LC. Does number of lifetime traumas explain the relationship between PTSD and chronic medical conditions? Answers from the National Comorbidity Survey-Replication (NCS-R) Journal of Behavioral Medicine. 2008;31(4):341–349. doi: 10.1007/s10865-008-9158-3. doi: 10.1007/s10865-008-9158-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Sterling M, Hendrikz J, Kenardy J. Similar factors predict disability and posttraumatic stress disorder trajectories after whiplash injury. Pain. 2011;152(6):1272–1278. doi: 10.1016/j.pain.2011.01.056. doi: 10.1016/j.pain.2011.01.056. [DOI] [PubMed] [Google Scholar]
  41. Sterling M, Kenardy J. The relationship between sensory and sympathetic nervous system changes and posttraumatic stress reaction following whiplash injury--a prospective study. J Psychosom Res. 2006;60(4):387–393. doi: 10.1016/j.jpsychores.2005.08.016. doi: 10.1016/j.jpsychores.2005.08.016. [DOI] [PubMed] [Google Scholar]
  42. Sterling M, Kenardy J, Jull G, Vicenzino B. The development of psychological changes following whiplash injury. Pain. 2003;106(3):481–489. doi: 10.1016/j.pain.2003.09.013. [DOI] [PubMed] [Google Scholar]
  43. Stewart R, Ware J. The MOS Short Form General Health Survey: reliability and validity in a patient populations. Medical Care. 1988;26:724–735. doi: 10.1097/00005650-198807000-00007. [DOI] [PubMed] [Google Scholar]
  44. Tabachnick BG, Fidell LS. Using Multivariate Statistics. 4 Allyn & Bacon; Boston, MA: 2000. [Google Scholar]
  45. Thomas HV, Stimpson NJ, Weightman A, Dunstan F, Lewis G. Pain in veterans of the Gulf War of 1991: a systematic review. BMC Musculoskeletal Disorders. 2006;7(1):1–12. doi: 10.1186/1471-2474-7-74. doi: 10.1186/1471-2474-7-74. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Turk DC, Rudy TE. Toward an empirically derived taxonomy of chronic pain patients: integration of psychological assessment data. Journal of Consulting and Clinical Psychology. 1988;56(2):233–238. doi: 10.1037//0022-006x.56.2.233. [DOI] [PubMed] [Google Scholar]
  47. U.S. Bureau of the Census . Statistical Abstract of the United States. Washington, D.C.: 2000. [Google Scholar]
  48. Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM. The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies. 1993 [Google Scholar]
  49. Weisberg RB, Bruce SE, Machan JT, Kessler RC, Culpepper L, Keller MB. Nonpsychiatric illness among primary care patients with trauma histories and posttraumatic stress disorder. Psychiatric Services. 2002;53(7):848–854. doi: 10.1176/appi.ps.53.7.848. doi: 10.1176/appi.ps.53.7.848. [DOI] [PubMed] [Google Scholar]
  50. Zayfert C, Dums AR, Ferguson RJ, Hegel MT. Health functioning impairments associated with posttraumatic stress disorder, anxiety disorders, and depression. Journal of Nervous and Mental Disease. 2002;190(4):233–240. doi: 10.1097/00005053-200204000-00004. doi: 10.1097/00005053-200204000-00004. [DOI] [PubMed] [Google Scholar]

RESOURCES