Psychological Outcome of Whiplash

Psychological issues play a role in the whiplash syndrome—this is well recognized by both physicians and the medical literature. What is still a mystery is the exact relationship between psychological symptoms and pain, disability, and litigation. Most caregivers attribute emotional distress to chronic pain and the stress of litigation (or dealing with insurance companies); insurance companies claim that emotional symptoms are a sign of malingering. Where does the truth lie on this continuum?

A new British study provides some insight. The authors of this study followed 57 whiplash patients for one year. The study began when the patients presented at the emergency room for evaluation immediately after the accident. They were contacted at home soon after this visit, and the authors recorded: demographic data, nature of the accident, previous social adjustment, previous driving behavior, and psychological self-report information. Data were also collected from the emergency department and police reports.

These same patients were again interviewed at three months and at one year after the first evaluation. This interview covered the above topics, as well as current medical symptoms, post-traumatic psychological symptoms, changes in driving behavior, and litigation status. Those with pending litigation at 1 year were contacted again at 2 and 3 years to check on litigation status.

The findings were as follows:

1. "The occurrence of neck symptoms, the core physical symptoms of 'late whiplash', are predicted by the report of physical symptoms at the baseline interview but not by any of our initial psychological and social variables. In contrast, these latter are significant predictors of psychiatric outcome and social impairment..."
2. "There was no association at 1 year between psychological symptoms and physical symptoms but there was a strong correlation between psychiatric status and our global rating of social impairment..."
3. The seven patients who were found to be suffering from mood disorder at 1 year follow-up were also found to have "substantial adverse predisposing and maintaining causes of the psychiatric disorder independent" of the auto accident. These were most commonly serious financial/familial stress or travel anxiety.
4. "It has often been alleged that the prospect of compensation is an important reason why many patients describe persistent symptoms and disability in the absence of abnormal physical findings. Our detailed information about the course and outcome of compensation proceedings is consistent with evidence in relation to neck symptoms from other prospective studies and shows that compensation is not a major determinant of any aspect of outcome:"

• "review of all available information provides no evidence of simulation or gross exaggeration; most subjects returned to work early and made efforts to resume normal activities;"
• "There were no differences in any aspect of outcome between the two-thirds of subjects who were claimants and those who were not;"
• "many claimants had agreed to compensation without dispute within 1 year of injury and well before our 1 year assessment;"
• "delays in settlement were rarely related to disputes about long-term medical outcome;"
• "final settlements were modest in comparison with the distress and financial problems reported to us;"
• "It was also very obvious that the difficulties associated with legal proceedings were a cause of considerable worry, anger and frustration which may have contributed, with many other variables, to determining symptomatic and quality of life outcomes."

The study found that at one year, 49% reported neck pain that they associated with the accident; in most cases these symptoms were mild, but they did interfere with daily activities in 8-25% of patients.

The authors also reported on two kinds of post-traumatic stress problems: post-traumatic stress syndrome (PTSD) in 10% of the patients; and travel anxiety in 19%. Travel anxiety manifested itself as "Limitation and avoidance of social and other activities as a result of travel anxiety, for example reduced excursions, week-ends away and visiting relatives and friends. Anxiety about situations similar to the accident and passing the place of the accident was frequent." The authors state that travel anxiety should be addressed with new patients after whiplash, and that any long-term symptoms may require referral to behavioral therapy to prevent a chronic problem.

Mayou R, Bryant B. Outcome of 'whiplash' neck injury. Injury 1996;27(9):617-623.