Acute stress response patterns to accidental injuries

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ELSEVIER

Journal of PsychosomaticResearch,Vol. 45, No. 5, pp. 419424. 1998 Copyright @ 1998El*vier Sciene Inc. All righrsresryed. 0022-3999/98S*e frotrt matter

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ACUTE STRESSRESPONSE PATTERNSTO ACCIDENTAL INJURIES ULRICH SCHNYDER and ULRIK FREDRIK MALT (Received19 August 1997;accepted28 November 1997) Absiract-We examined,by meansof clinical interviewsand severalself-reportmeasures(IES, STAI), 110accidentvictims' primary appraisalof injury during five different timepointsbefore, during, and immediatelyafter the accident.The appraisalswere combinedrvith the correspondingmost dominantemotion in a matrix, revealingsix different acute stressresponsepatterns:ordinary (O: 64 subjects-58%); emotional (E: 19 subjects-17o/o);controlled (C: 9 subjects--{"/o);derealization(D: 15 subjects-14o/"); and denial--elation(DE:3 subjects-3%). The E responsepattern wasassociatedwith being female(RR 3.31).Psychopathologyat the time of the injury or risk of death during the accidentincreasedthe risk for a D or E response(RR 1.61and RR 1.92,respectively).The presenceof psychophysiological symptoms or reducedappetiteduring the hospitalstaywasassociatedwith E, C, or D responsepatternscomparedwith an O pattern (RR 1.76and RR 2.18,respectively).A DE responsewasassociatedwith severe brain injury partly undetectedby the surgeons.We concludethat the identification of different clinical responsepatterns may be a meaningful approach to better tailor response-specific interventions for trauma victims. O 1998Elsevier ScienceInc. Keywords:

Accidents;Acute stressrespons€s;Injury; Posttraumaticstressdisorder;Trauma

INTRODUCTION

Accidental injuries may causeshort- and long-term psychologicalimpairment and distress[1-6]. Despite thesefindings,the resultsof randomizedpsychologicaltreatment studies are far from encouraging[7-9]. The lack of effective therapy may partly be due to insufficientknowledgeof the phenomenologyof the acutepsychological responsesto the physicaltrauma in accidentvictims U0-121.Thus, clinically valid responsepatternsto accidentalinjuries can only be identified by bedsidestudies of a randomsampleof patients.The aim of the presentarticleis to analyzedata from a previous, carefully conducted clinical phenomenologicalstudy to identify clinically meaningful responsepatterns. METHOD Sample One hundred ten patients,15-69yearsof age,were admitted to a surgicaldepartmentfor accidental injuries and includedconsecutivelyfrom an equal number of eachweekdayto avoid samplingbiasesassociatedwith the fact that week-endvictims are psychologicallydifferent from work-day victims. The PsychiatrischePoliklinik, Universitdtsspital,Z0rich, Switzerland. Addresscorrespondenceto: Dr. Ulrich Schnyder,PsychiatrischePoliklinik, Universitdtsspital,Riimistrasse100, 8091 ZUrich, Switzerland.Phone: 41-1-25552 80t Fax: 4l-l-255 43 83: E-mail: uschnvd@ psyp.unizh.ch

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meanInjury SeverityScore[13, 14] was8.6 (so 4.9,range1-35). Forty-six percentwere injured in motor vehicleaccidents.The majority of patientswere males(77.3olo)and about half the patientswere lessthan 30 yearsof age.Twenty-sevenpatientshad been unconsciousfor severalminutes up to 24 hours and 18 patients had possiblybeen unconsciousfor a few seconds.Twenty-threepatients had a definite retrogtade amnesiaand 13 patientsa probable retrogradeamnesia.The mean tirne from the injury to the interview in the whole group was 84 hours (so 19.2hours). Twenty-fivepercentof the patientswere seen within 24 hours following the accidentand 78.5olo within 96 hours.Details about the samplingprocedure, backgroundof the patients,and the injuries sustainedhave been presentedelsewhere[1, i5, 16]. Assessments Assessmentsincluded clinical interviews and the ComprehensivePsychopathologicalRating Scale (CPRS) [17]. To cover all symptomsneededfor the diagnosisof anxiety disordersand stress.eiponse syndromes,severalitems were added to the CPRS interview: startle reactions;intrusive thoughts;bad dreams;rituals related to the injury or the place of the injury; isolation;phobia related to the accident; pessimisticthoughtsabout the injury; survivor guilt; and vigilance.The patientsalsofilled out the General Health Questionnaire(GHQ) regardingthe last fortnight prior to the injury [18]. For valid assessment of preaccidentpsychopathologyand distress,we considerid information from severaldifferent sources,partly patient-independent(e.g.,health registers,prior medicalrecords),when preaccidentpsychopathologywasassessed [1, 16]. If all this information gaveany indication of a mental disorderin the past,or problemsrelated to socialor occupationalfunctioning,includingpoor object relations, items from the Scheduleof Interviewing Borderlines [19] coveringDSM-III perionality disorders were_applied.Extensivecasehistorieswere written for eachpatient and reviewedby a secondpsychiatrist [1], to have a quality control of the diagnosticprocess. Assessment of clinical responsepatterns The assessment of the clinical responsepatternswasbasedon Lazarusand coworkers'theory of coping and appraisaland Horowitz's studiesof stressresponsepatterns.The interview assessed the patients' reactionsat five different timepoints (l-the period from when the patient becameaware of tlie threat until the moment of the injury; 2-the immediateresponseto the injury; 3-the period betweenthe immediatereaction and admissionto hospital;4-the period when the patient wasadmitted to the surgical ward; and 5-the time of the interview). For eachtimepoint, the interview independentlyassessed the patient's appraisalof the situation,the focus of the cognitive activities,the concomitant emotional experience(eg., anxiety, sadness,anger), ald the behavior (e.g.,no action, shouting,running around). The appraisalresponsesat each point in time were classifiedas death, disability, threatftrarm,no waming/harm,or amnesia.The primaiy focus of the cognitiveactivitieswas mostly the injury, but there was alsosomefocuson the impliiationi of the injury, responsibilityissues,and non-personalrelated damage,particularly at time 2 [15]. The concomitant emotionswere classifiedas anxiety,severeanxiety closeto panic, dissociativereiponses(derealization/depersonalization),irritability, depressionor sadness,guili, relief, elated mood, or no particular dominating emotion. Dissociativeresponseswere assessed by item 27 (derealization)and item 28 (depersonalization)on the CPRS. The typ_eand severityof the injury was assessed by two experiencedtrauma surgeonsusing the Ab-breviatedInjury Scale(AIS) and Injury Severity Score(ISS) 11,20,21).The ISS is i very welfaccepred index for severity of physicaltrauma. An ISS score >10 usually definespatients with multiple injuries or a severesingle_injury.A 12-itemversionof the SpielbergerStateAnxiety Inventory (STAi) wai used to-assess anxiety [22]and the Impact ofEvent Scale(IES) to assess intrusion and avoidance[23].a score of G8 was consideredto reflect a low level of distress,a scoreof 9-19 a medium level, and i scoreof >20 a high level of distress[11]. The interrater reliabilities of all variableswere assessed in a random sampleof 18 interviews.These analysesdemonstratedacceptableto very good interrater reliability for all assessments [15, 16]. Identifying and validating stressresponse pafterns First, the reports about appraisals,focusof cognitiveactivities,prominent emotions,and behavior at the five different timepoints were combinedfor eachof the 110 patients to identify the unique pattern of-responseof eachpatient over time. It turned out that the combinationof appraiial and emotibn best differentiatedthe responsesand gavethe most meaningfulclinical responsepatterns.Second,theseresponsepatterns were comparedwith sociodemographicand preaccidenthealth variablesand patient scoreson self-reportedstressmeasures. Statisticalprocedure Chi-squaretestswere usedto analyzecontingencytables.A value ofp
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