Behav. Res. Ther. Vol. 34, No. 10, pp.

775-786, 1996
Pergamon Copyright © 1996 ElsevierScienceLtd
Printed in Great Britain. All rights reserved
S0005-7967(96)@1038-1 0005-7967/96 $15.00 + 0.00

ONE-YEAR PROSPECTIVE FOLLOW-UP OF MOTOR

VEHICLE ACCIDENT VICTIMS

EDWARD B. BLANCHARD *l, EDWARD J. HICKLING 1'2,

KRISTINE A. BARTON 1, ANN E. TAYLOR j, WARREN R. LOOS 2
and JACQUELINE JONES-ALEXANDER ~
tCenter for Stress and Anxiety Disorders, University at Albany-SUNY, 1535 Western Avenue,
Albany, NY 12203, U.S.A. and 2Capital Psychological Associates, Albany, NY, U.S.A.

(Receh,ed 20 April 1996)

Summary--One-hundred and thirty-two victims of motor vehicle accidents (MVAs), who sought medical
attention as a result of the MVA, were assessed at three points in time: 1-4 months post-MVA, 6 months
later, and 12 months later. Of the 48 who met the full criteria for Post-Traumatic Stress Disorder (PTSD)
initially, half had remitted at least in part by the 6-month follow-up point and two-thirds had remitted
by the 1-yr follow-up. Using logistic regression, 3 variables combined to correctly identify 79% of remitters
and non-remitters at the 12-month follow-up point: initial scores on the irritability and foreshortened
future symptoms of PTSD and the initial degree of vulnerability the subject felt in a motor vehicle after
the MVA. Four variables combined to predict 64% of the variance in the degree of post-traumatic stress
symptoms at 12 months: presence of alcohol abuse and/or an Axis-il disorder at the time of the initial
assessment as well as the total scores on the hyperarousal and on avoidance symptoms of PTSD present
at the initial post-MVA assessment. Copyright © 1996 Elsevier Science Ltd

INTRODUCTION

It is well recognized that varying proportions of individuals exposed to a traumatic event which
threatens life or bodily integrity will develop Post-Traumatic Stress Disorder (PTSD) acutely,
and likewise, that varying proportions will remit over time (Green, 1994; Davidson & Foa,
1993; American Psychiatric Association, 1994). Much of the early evidence for the remission was
gathered retrospectively (e.g. NVVRS, Kulka, Schlenger, Fairbank, Hough, Jordan, Marmar &
Weiss, 1988) and represents an inference process, that is, a smaller percentage of individuals
exposed to an earlier trauma are currently positive for PTSD than at some earlier point after
trauma exposure. For example, the NVVRS found about 15% of veterans exposed to combat in
Southwest Asia met the criteria for PTSD when assessed in 1985, whereas almost 30% would have
been positive for PTSD at some time in the past.
In addition to some pioneering prospective studies of natural disaster survivors who were
assessed early after the disaster and then some years later (e.g. Green, Lindy, Grace, Gleser,
Leonard, Korol & Winget, 1990) the past few years have seen an increase in prospective follow-up
evaluations of trauma victims. For example, Rothbaum and Foa (1993) assessed 94 female rape
victims shortly after the assault (average of 12 days) and again at weekly intervals for 3 months.
Initially, 94% of the sample met the symptomatic criteria for PTSD (except for the duration
criteria). By 3 months, the percentage was 47%. Clearly remission is occurring.
Likewise, McFarlane (1988) in Australia, followed up 315 fire fighters exposed to severe, out of
control, brush fires with questionnaire assessments at 3, 8, 11 and 29 months post-exposure to the
trauma. Thirty-two percent met the criteria for PTSD at the initial assessment, while 63 (19.7%)
developed it (as a delayed onset PTSD) over the course of the follow-up. Remission occurred in
64 (20.3%) individuals.
In a large American epidemiologic study, Kessler, Sonnega, Bromet, Hughes and Nelson
(1995) found 459 cases of PTSD out of 5877 individuals assessed. Relying on retrospective report,
they found approximately 28% remission in cases of PTSD from all causes 1 yr after the trauma.

*Author for correspondence.

775
776 Edward B. Blanchard et al.

This improved to approximately 38% remission by 2 yr and seemed to reach an asymptote of 60%
remission by about 6 yr post-trauma. Interestingly, participation in mental health treatment
(although not necessarily for PTSD) was associated with significantly more rapid remission than
non-participation (about 25% remission among untreated participants at l yr versus 32%
remission among those who received treatment at some point in the follow-up (not necessarily in
the first year post-trauma)).
Within the study of victims of motor vehicle accidents (MVAs), there have been several
prospective follow-up studies. In Oxford (UK), Mayou, Bryant and Duthie (1993) assessed 200
consecutive admissions to the Emergency Room resulting from MVAs. They were able to reassess
174 three months later and 171 (86%) at a 1-yr follow-up. Using the Present State Examination
(Wing, Cooper & Sartorious, 1974), 14 (8%) had developed PTSD by the 3-month follow-up.
Altogether 19 (11%) were positive for PTSD at some point in the 1-yr follow-up study. Five of
the initial 14 had remitted by the 1-yr follow-up. No data were provided on potential predictors
of remission.
Feinstein and Dolan (1991), also in the UK, assessed 48 MVA victims hospitalized for leg
fractures when they were initially hospitalized and at 6 weeks and 6 months post-MVA. Twelve
(25%) met DSM-III-R (American Psychiatric Association, 1987) at the 6-week assessment while
only 7 (14.6%) were still positive at 6 months. From the initial assessment, Impact of Event Scale
(IES) scores (Horowitz, Wilmer & Alvarez, 1979), a measure of intrusion and avoidance symptoms,
predicted clinical status at 6 months as did report of above average alcohol consumption at time
of the initial assessment.
Green, McFarlane, Hunter and Griggs (1993), in an Australian study, examined 24 hospitalized
MVA victims at 4 weeks post-accident and again at 6 months and 18 months post-MVA. Eighteen
(75%) were available at 18 months. Two participants (8.3%) met DSM-III-R criteria for PTSD
at the initial assessment while 7 were subclinical. At 18 months, 5 of the 7 subclinical PTSD
participants now met criteria for full PTSD (the other two cases were not available for
reassessment).
Brom, Kleber and Hofman (1993), in The Netherlands, assessed 151 MVA victims (out of 738
approached) with the Dutch version of the IES (Horowitz et al., 1979). Half received a brief
treatment over the next 6 months, while half (n = 83) constituted a no-treatment control.
Twenty-four percent of the latter dropped out. On average, the reduction in IES scores for the
controls was from 17.4 to 7.4. No specific data on PTSD diagnoses was available but post-traumatic
stress symptoms, as measured by the IES, clearly declined over time.
In a preliminary report from our laboratory (Blanchard, Hickling, Taylor, Loos & Forneris,
1995) we reported on a 6-month prospective follow-up of 98 MVA victims who had sought medical
attention as a result of the accident. Forty (41%) met DSM-III-R criteria for PTSD, based upon
the CAPS (Clinician-Administered PTSD Scale) (Blake, Weathers, Nagy, Kaloupek, Klauminzer,
Charey & Keane, 1990). At 6 months, 20 of the 40 initial PTSDs available for follow-up still met
the full criteria for PTSD. No data on potential predictors of remission were reported.
It is thus clear that relatively little information is available on prospective follow-up of MVA
victims, and the two large-scale reports (Mayou et al., 1993; Brom et al., 1993) did not use a
diagnostic instrument known to be sensitive to the diagnosis of PTSD. Moreover, almost nothing
is known about factors which might be associated with remission of PTSD over the first 12 months
of follow-up. Feinstein and Dolan identified an initial sub-syndromal form of PTSD as a risk factor
among MVA victims with broken legs for developing delayed onset PTSD but gave no hints on
factors related to remission.
In these times of increasing cost consciousness in mental health, it would be of interest to know
what factors (including participation in treatment) would predict the remission of PTSD over the
first year and likewise, what factors are associated with symptom maintenance. With adequate
knowledge on this point and limited treatment resources, one might engage in a triage effort,
sending those at risk to remain ill for early treatment.
In this paper, we report on the 1-yr prospective follow-up of 158 MVA victims who sought
medical attention following the MVA and who were initially assessed 1 4 months post-MVA (thus
allowing enough time for the patient to fully meet the temporal criterion for PTSD). The paper
has three parts, one documents the clinical status of all Ss over the first year and an 18-month
 One-year prospective follow-up o f M V A victims 777

follow-up on the part of the sample who had an initial diagnosis of PTSD. The second part presents
data related to predictors of improvement or remission for 48 participants who initially met the
criteria for full PTSD. The last part examines changes in subjective distress, as measured by
standardized psychological tests, and in role impairment for those participants initially diagnosed
with PTSD.

METHOD
Participants
We initially assessed 158 MVA victims, including 50 males and 108 females. Inclusion
criteria were 17 yr of age or greater and that the individual had sought medical care within 48 hr
of the MVA. The participants were initially assessed from 1-4 months after the MVA. They were
reassessed 6 months and 12 months after the initial interview. Individuals who had met initial
criteria for PTSD and who were still symptomatic at 12 months were also seen for an 18-month
evaluation.
Participants were paid $50 for participating in the initial assessment, $50 for the 6-month
follow-up assessment and $75 for the 12-month follow-up assessment (and $50 for the 18-month
follow-up). All gave written informed consent for all of the procedures.
We were able to obtain data from 132 participants at the 1-yr follow-up representing 83.5% of
the original sample. Of those for whom data are unavailable at 12 months, 12 had moved, left no
forwarding address and were unreachable through family contacts, 13 refused or dropped out of
the study at 6 months or at 12 months, and one had died.
In Table 1 is the basic demographic information on three subsets of 12-month follow-up
participants, subdivided by initial diagnostic status (see below) into full PTSD, sub-syndromal
PTSD, and non-PTSD. Comparable information on the dropouts is also provided. Comparisons
of completers to dropouts revealed that significantly more minority participants discontinued
participation (Z2 (1, n = 158)= 16.63, P = 0.00005); there were no other significant differences.
There was a nonsignificant (P = 0.09) trend for more initial full PTSDs to drop out.

Initial diagnosis
Initial diagnosis for the presence of PTSD was by means of a structured interview developed
by the National Center of PTSD (Boston Branch), the CAPS (Clinician Administered PTSD Scale;
Blake et al., 1990). It has been shown to have adequate reliability and validity (Weathers & Litz,
1994). Four doctoral level assessors, each with over 5 yr of experience in assessing for PTSD in
Vietnam veterans, administered the structured interview. One participated in the development of
the CAPS: he trained the other 3 assessors. All interviews were tape recorded.

Table 1. Demographic and diagnostic information on l-yr follow-up completers and drop-outs
Initial diagnostic status of completers
Full PTSD Sub-syndroma[ Non-PTSD Total completer Drop-outs
Characteristic (n = 48) PTSD (n = 42) (n = 42) sample (n = 132) (n = 26)
Sex (M/F) 10/38 14/28 20/22 44/88 6/20
(%F) 79.2% 66.7% 52.4% 66.7% 76.9%
Age
X (SD) 34.8 (10.4) 35.9 (11.8) 38.1 (15.3) 36.2 (12.6) 31.7 (11.8)
Range 19-60 17 65 17-71 17-71 18-73
Ethnici O'
Caucasian/Minority 43/5 40/2 40/2 123/9 17/9
(% Minority) 10.4% 4.8% 4.8% 6.8% 34.6%
Education
Some college/H S 39/9 30/12 31 / 11 100/32 17/9
or less (% college) 81.3% 71.4 73.8% 75.8% 65.4%
Marital status
Married/not married 19/29 19/23 19/23 57/75 8/18
(% married) 39.6% 45.2% 45.2% 43.2% 30.8%
Initial diagnosis of drop-outs
PTSD-% of initial sample 14 (22.6%)
Sub-PTSD~% of initial sample 3 (6.6%)
Non-PTSD--% of initial sample 9 (17.6%)
778 Edward B. Blanchardet al.

MVA victims were initially diagnosed using DSM-III-R (American Psychiatric Association,
1987) criteria. They were termed full PTSD (n = 62, 39.2% of initial sample) if they met the full
criteria. If they met the criteria for Cluster B (one reexperiencing symptom) and either Cluster C
(at least 3 avoidance and psychic numbing symptoms) or Cluster D (at least 2 hyperarousal
symptoms), (but not both) they were termed sub-syndromal PTSD (n = 45, 28.5%). Finally, if they
met the criteria for only one symptom Cluster or no Clusters, they were classified as non-PTSD
(n = 51, 32.3%).
As a local reliability check, an advanced doctoral student in clinical psychology listened to 15
randomly selected tapes and scored the CAPS without knowledge of the initial diagnosis. Kappa
for diagnostic agreement was 0.810 (P < 0.0005). The mean correlation for the CAPS scores on
the 17 individual symptoms used to diagnose PTSD was 0.975 (P < 0.0001).

Follow-up assessment
All participants initially agreed to follow-up assessments 6 and 12 months after the initial
assessment and were given explicit appointments. Approximately one week before the follow-up
appointment, a packet of questionnaires was mailed to the participant with a reminder of his/her
appointment. Follow-up telephone calls were placed to confirm or re-schedule appointments.
Altogether, we were able to gather 6-month data on 145 (91.8%) MVA victims and 12-month
data on 132 (83.5%). For the 18-month follow-up, we attempted to follow-up those initially
diagnosed as PTSD, with special emphasis on those initial PTSDs who still met the full
criteria at 12 months. We obtained 18-month interviews on 35 (73% of those available at
12 months) and on 13 of 16 (81.3%) of those who were still full PTSD at 12 months. We also
followed up the 5 initial sub-syndromal cases who developed delayed onset PTSD during the first
year.
For the most part, follow-up assessments were completed by the same initial assessor and were
conducted face-to-face. In two instances follow-up interviews were completed by telephone.
At the follow-up interviews we adapted the LIFE (Longitudinal Interval Follow-up Evaluation)
methodology to assess week-by-week changes in physical symptoms, effects of the MVA on
driving, and individual symptoms of PTSD. This methodology utilizes personal events (e.g.
birthdays, holidays, etc.) as anchors to help the respondent recall when noticeable changes
occurred in symptoms. We also utilized the LIFE to assess psychosocial status (as a measure of
role impairment) and status of Axis-I co-morbidity as well as any treatment, psychological or
pharmacological, received during the interval. We also noted changes in litigation status and any
new personal or family trauma. Finally, current status of PTSD symptoms was assessed at each
visit using the CAPS-II (Blake et al., 1990).
From the LIFE follow-up of individual symptoms of PTSD, it was possible to make a
week-by-week diagnosis of full PTSD, sub-syndromal PTSD and non-PTSD. These data were
transformed into month-by-month diagnoses on the basis that a participant was called positive for
the month if he/she was positive for at least one week of that month.
Each physical injury was assessed on a 0 to 3 scale as to whether, by the participant's report,
it remained the same (3), was improved but still limited activity (2), was markedly improved but
still noticeable (1) or completely remitted (0). A monthly index of physical injury was calculated
by summing the scores for each injury described by the participant [range 0 to 3 x n (number of
injuries)] and dividing by 3 × n. Thus, a participant who was completely healed would receive a
score of 0 while someone who was not at all improved would receive a score of 1.0
(3xn + 3×n).

Other initial information

The assessors gathered information on the MVA and the participant's reaction to it, including
information on extent of physical injury to the participant and others involved in the MVA, on
subjective reactions to the MVA, the effects on the participant's driving behavior, and status of
legal and insurance issues, using a locally designed structured interview. Participants were asked
about previous MVAs and reactions to them. If anyone was injured, an assessment of possible
PTSD from that earlier accident was made. We also assessed for other previous trauma using the
format of Breslau, Davis, Andreski and Peterson (1991).
 One-year prospective follow-up of MVA victims 779

We assessed for pre-MVA and current Axis-I psychopathology using the SCID-NP (Spitzer,
Williams, Gibbon & First, 1990a); we also assessed for possible Axis-II psychopathology using the
SCID-II (Spitzer, Williams, Gibbon & First, 1990b). Two of the assessors had been trained in use
of these instruments by personnel from NYS Psychiatric Institute. They, in turn, trained the other
two assessors.
Finally, we assessed for pre-MVA and current psychosocial functioning using the LIFE-Base,
a structured interview developed by Keller, Lavori, Friedman, Nielsen, Endicott, McDonald-Scott
and Andreasen (1987) for this purpose. The four assessors were trained in its use and the use of
the LIFE by personnel at Brown University under Keller's direction.
Using the LIFE-Base participants were assessed for performance in major role functions (work
if employed 30 hr/week or more, school if a full-time student, or homemaking if neither of the
other two applied) on a 1 (no impairment and high level of performance) to 5 (severe
impairment, not able to meet demands of the role) scale. Relationships with all first degree relatives
and spouse or partner on a 1 (very good, very close emotional relationship) to 5 (very poor, no
emotional relationship, avoids family members) scale were assessed. Similar ratings were made for
relationships with friends and participation in recreation. These ratings were repeated prospectively
on a month-by-month basis as part of the LIFE follow-up interviews.
For the purpose of this paper, we used the initial post-MVA assessment ratings and those for
month 12. Furthermore, we used only one role rating (as described above); finally, we averaged
the ratings of family relationships across all first degree relatives plus spouse or partner into a single
family relationship variable.
Psychological tests. We administered the Beck Depression Inventory (Beck, Ward, Mendelson,
Mock & Erbaugh, 1961), the State-Trait Anxiety Inventory, (Spielberger, Gorsuch & Lushene,
1970) and the Impact of Events Scale (Horowitz et al., 1979) at each assessment occasion as
measures of subjective distress. We also made Global Assessment Scale (GAS) ratings on each
occasion.
Degree of initial physical injury was scaled using the Abbreviated Injury Scale (American
Association for Automotive Medicine, 1985) by a physician blind to diagnostic status who had all
of the participant's reports of injury and treatment as well as basic demographic information.
Any patient who had a diagnosable Axis-I disorder, including PTSD, was given an explicit
referral for possible treatment, after the initial assessment.

RESULTS

The first question to be addressed by these results is what happens over time to the MVA victims
in terms of their diagnostic status. Shown in Table 2 is a month-by-month frequency distribution
of diagnoses (full PTSD, sub-syndromal PTSD, and non-PTSD) within each of the initial
diagnostic sub-groups.

Table 2. Month-by-month diagnostic status of M V A victims as a function o f initial diagnosis

12-month
Initial Dx. Initial 1 2 3 4 5 6 7 8 9 10 11 12 CAPS
PTSD (n = 48) NS NS NS ** *** *** *** *** *** *** *** *** ***
PTSD 48 47 45 40 33 27 21 24 22 22 20 20 20 16
Sub 0 0 2 4 7 10 12 9 l0 8 5 6 8 7
Non 0 l 1 4 8 11 15 15 16 18 23 22 20 25
Sub-syndromal (n = 42) * *** *** *** *** *** *** *** *** *** *** *** ***
PTSD 0 1 l 1 0 2 2 3 5 5 4 4 4 3
Sub 42 37 28 21 16 14 12 9 7 8 6 8 7 9
Non 0 4 13 20 26 26 28 30 30 29 32 30 31 30
Non-PTSD (n = 42) * *
PTSD 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sub 0 2 2 2 2 1 2 3 4 4 3 1 1 l
Non 42 40 40 40 40 41 40 39 38 38 39 41 41 41
n = (132)
X2 ~t Critical value
* 0.05 3.841
** 0.01 6.635
*** 0.001 10.827
780 E d w a r d B. B l a n c h a r d et al.

We compared the distribution in each month to the initial distribution using Guilford's Z-'
Test for Difference between Correlated Proportions (Guilford, 1965, p. 242). For those initially
diagnosed with PTSD, by month 3 of the follow-up (approximately 4--7 months post-MVA)
a significant proportion (8/48, 16.7%) had remitted partially or completely. At 7 months the
proportion showing full or partial remission was 50% and by the 1-yr CAPS interview,
two-thirds had remitted partially or in full with slightly over half now meeting the criteria for
non-PTSD.
Examining those initially diagnosed with sub-syndromal PTSD, one sees two phenomena: first,
a generally more rapid rate of remission with significance reached in month 1, and 30 out of 42
(71.4%) fully remitted by month 7. Interestingly, after month 7 there is only limited improvement
on a group basis, since 12 of 42 (28.6%) have not remitted to the non-PTSD level by the l-yr CAPS
interview. The second phenomenon is the deterioration of some initial sub-syndromal PTSD Ss
over time. Altogether, 7 different participants showed enough deterioration (increased symptoms)
to move into the full PTSD category at some point over the 1-yr follow-up. (A detailed analysis
of these participants with delayed onset PTSD is available separately (Buckley, Blanchard &
Hickling, 1996).) At months 8 and 9 the proportion of initial sub-syndromal PTSDs who had
deteriorated is significant. This may coincide with the anniversary of the MVA.
Finally, one sees among those with an initial diagnosis of non-PTSD occasional deterioration
to sub-syndromal PTSD. This became significant in months 8 and 9, mirroring the deterioration
of the sub-syndromal PTSDs, and again perhaps coinciding with an anniversary of the MVA. No
initial non-PTSD deteriorated to the criteria for full PTSD.

18-month jollow-up data

In Table 3 are the month-by-month diagnoses for the 35 initial PTSDs followed from month
12 to month 18 and the 5 initial sub-syndromal PTSD Ss who developed delayed onset PTSD and
who were thus followed for the additional 6 months.
Examining the data on the 35 initial PTSDs, including the 13 of 16 (81.3%) who still met the
full criteria for PTSD based on the CAPS interview at 12 months, the main finding is of stability
of diagnosis. There is very little additional improvement over the next 6 months among those with
full PTSD at the 1-yr follow-up point and some slight deterioration at some points. In no instances
were the change in frequencies significant.
For the 5 sub-syndromal PTSDs who were followed, 2 of the 3 with delayed onset PTSD had
remitted at the 18-month point and one other had become essentially symptom free.
Because of the reduced sample sizes, no analysis of predictors was made on these 12 to 18-month
data.

Prediction of rem&sion
There are two prediction problems for this portion of the results. For those participants
with an initial diagnosis of PTSD, we would like to be able to predict two things: (a) their clinical
status (full PTSD or remission) (we have collapsed the sub-syndromal PTSDs (partial remission)
and the non-PTSD (full remission)) and (b) their degree of post-traumatic stress symptoms (PTSS)
as indicated by the 1-yr CAPS score. For the first part, logistic regression is the appropriate
statistic since the criterion is dichotomous. For the second part we have used stepwise multiple
regression.

Table 3. Month-by-month diagnoses for initial PTSDs for months 13 through 18

Month
Dx. initial Dx. 12-month 13 14 15 16 17 18 18-month CAPS
Initially diagnosed with PTSD
PTSD 35 13 14 14 14 13 12 12 12
Sub 0 5 7 6 5 4 5 6 5
Non 0 17 14 15 16 18 18 17 18
Initially sub-syndromal PTSD
PTSD 0 3 3 3 3 2 2 2 I
Sub 5 2 2 2 2 3 3 3 3
Non 0 0 0 0 0 0 0 0 I
 O n e - y e a r p r o s p e c t i v e f o l l o w - u p o f M V A victims 781

Restriction of predictor battery. As is obvious from the description of the initial and
follow-up data gathering efforts, we have a very large potential battery of predictors. (Altogether,
we examined 101 potential predictors since there is almost no data available to guide the selection.)
To help reduce this battery we initially calculated the simple bivariate correlation coefficient
between each predictor and the 1-yr CAPS score and the point biserial correlation between each
predictor and l-yr clinical status (full PTSD or not). Only those predictors which individually
accounted for 4% of variance in one of the two criteria were retained. In addition, we have specified
for the multiple regression analysis that each new variable added to the equation must account
for at least 3% of new variance (AR 2 = 0.03 or higher).

Prediction of l-yr clinical status of initial PTSDs

In Table 4 is the result of logistic regression analysis to identify variables which would predict
who continued to meet the full criteria for PTSD and who had shown full or partial remission.
As indicated in Table 4, using base rates, one would be correct 66.7% of the time if everyone was
predicted to be a remitter. Examining the results in Table 3, one can see that prediction is improved
to 79.2% correctly classified using three variables. Moreover, prediction of who continues to have
PTSD improves from 0 to 62.5%.
To illustrate how these three variables work, one needs to remember that logistic regression yields
coefficients for an equation to predict the natural logarithm (In) of an odds ratio (OR), that is the
probability of a S being classified PTSD or less than PTSD. Using base rates from our data on
initial PTSDs, the O R of PTSD to less than PTSD is 0.333/0.667 or 0.50 to 1; conversely the odds
of being less than PTSD is 2.0 to 1.
As an example, consider the situation in which a S has values for the three predictors of the
mean score for the sample plus one standard deviation (rounded to a whole number for the two
CAPS items). This yields an equation:

In (OR) = -6.6571 + 0.5251(3.85 + 2.43 = 6.28, rounded to 6)

+ 0.4723(1.92 + 2.43 = 4.35, rounded to 4)
+ 0.0379(70.8 + 25 = 95.8, rounded to 96) or
In (OR) = 2.0205
O R = 7.5421.

This means that the likelihood of such an MVA victim, who initially met the criteria for PTSD,
still meeting the criteria 1 yr later is about 7.5 to 1.
As a second example in the opposite direction, consider the case in which the variables are at
the mean score for the sample minus one standard deviation (again rounded to a whole number
for the two CAPS items). This yields a second equation:

In ( O R ) = -6.6571 + 0.5251(3.85 - 2 . 4 3 = 1.42, rounded to 2)

+ 0.4723(1.92 - 2.43 = - 0 . 5 1 , rounded to 0)
+ 0.0379(70.8 - 25 = 45.8, rounded to 46) or
In (OR) = - 1 . 9 7 2 9
O R = 0.1391.

This means that the likelihood of such an MVA victim, who initially met the criteria for
PTSD, still meeting criteria 1 yr later is 0.1391 or about 1 to 7. Turned the other way, such an
individual is about 7 to 1 to have remitted in full or in part.

Table 4. Logistic regression to predict I-yr clinical status among initial PTSDs
Percent correctly identified
Less than
PTSD PTSD Overall B S.E. Wald df Sig. Predictor
0 100 66.7 . . . . . Base rate
50.0 78.1 68.8 0.5251 0.1944 7.294 I 0.0069 Initial CAPS-13, Irritability
56.3 90.6 79.2 0.4723 0.1889 6.254 I 0.0124 Initial CAPS-I1, Foreshortened Future
62.5 87.5 79.2 0.0379 0.0186 4.141 I 0.0419 Vulnerability in Auto. at Initial Assessment
-6.6571 2.0234 10.824 I 0.0010 Constant

BRT 34, tO--B

782 E d w a r d B. B l a n c h a r d et al.

Table 5. Summary of final multiple regression to predict post-traumatic stress symptoms at 1 yr in initial PTSDs
Multiple Change Sig. of F
Variable B 13 t P R R2 in R 2 for change
Alcohol abuse at time of initial assessment 85.53 0.476 4.97 0.000 0.563 0.317 -- --
Sum of initial CAPS hyperarousal symptoms 1.06 0.347 3.62 0.0008 0.712 0.506 0.189 0.0001
Pre-MVA Axis-I! disorder 18.07 0.275 2.91 0.0056 0.770 0.593 0.087 0.0039
Sum of initial CAPS avoidance symptoms 1.12 0.223 2.29 0.0268 0.798 0.637 0.044 0.0268
Constant - 11.64 - 1.51 0.1394

One-year post-traumatic stress symptoms of initial PTSDs

Shown in Table 5 is the final multiple regression equation for predicting l-yr CAPS scores as
indication of PTSS for those participants initially diagnosed with PTSD.
One can determine from Table 5 that with four variables we are able to account for 64% of
variance in 1-yr CAPS scores, representing a multiple R of 0.798.
Cross-validation. As is well-known, any multiple regression equation capitalizes to some degree
on chance associations present in the sample. One way to correct for these chance associations is
through cross-validation. We have approached this issue in the following way: we randomly
selected half (n = 24) of our original sample of initial PTSDs, leaving a second randomly selected
sub-sample of 24. We then calculated multiple regression equations, using the steps described
above, with the criterion of total CAPS score. This yielded two sets of significant predictors and
two multiple Rs (one for each half). This whole process was repeated three times to yield a total
of six sets of predictors and six multiple Rs. Those predictors which regularly appear in the various
regression equations are probably the ones in which one should have the most faith.
A summary of these six cross-validations, and of the variables selected in the initial analysis
(Table 5), is presented in Table 6.
Examining Table 6, one can see that three of the variables identified in the stepwise multiple
regression analysis of the entire sample (Table 5), namely presence of alcohol abuse at the time
of the initial assessment, presence of any Axis-II Personality Disorder at the initial assessment, and
sum of CAPS scores on the Cluster D (Hyperarousal) symptoms, all load regularly in the cross
validation. Four other potential predictors also emerge two or more times in the cross validation.
Among the four are the CAPS score on Symptom 11, sense of foreshortened future, the CAPS
score on Symptom 13, irritability, and the perceived vulnerability when driving or a passenger in
a vehicle, all three of which load in the logistic regression, and the initial AIS score as an indication
of degree of physical injury. The one variable from the regression equation in Table 5 which does
not show up in the cross-validation is initial CAPS score on Avoidance symptoms. Thus, it may
be a less important indicator of 1-yr status. Finally, all of the cross-validation regressions yield
multiple R values in the same range as that in Table 5, or higher.
The role of treatment in remission of PTSD. Given the results from Kessler et al.'s (1995)
retrospective survey on the apparent early importance of treatment in remission of PTSD, we
entered treatment participation (pharmacological, psychological, both pharmacological and
psychological) as a potential predictor. Of the 48 participants with an initial diagnosis of
PTSD, 23 entered some form of treatment. None of the treatment participation predictors was a

Table 6. Summary of predictors identified in cross-validation analysis

Cross-validation sample Number Variables
of times found in
Predictor variable 1 2 3 4 5 6 appears Table 5
Alcohol abuse at time of initial assessment + + + 3 *
Pre-MVA Axis-II disorder + + + 3 *
Sum of initial CAPS hyperarousal Sxs. + + 2 *
Sum of initial CAPS avoidance Sxs. 0 *
Relations with family, post-MVA (social support) + 1
Initial CAPS, Symptom 11, Foreshortened Future + + + 3
Initial CAPS, Symptom 13, Irritability + + 2
Abbreviated Injury Scale score + + + 3
Vulnerability in auto at initial assessment + + 2
Subjective estimate of functioning at initial assessment + 1
Final multiple R 0.949 0.826 0.927 0.838 0.785 0.800 0.798
 O n e - y e a r prospective follow-up o f M V A victims 783

Table 7. Ratings of role performance variables for participants with initial PTSD based on 12-month clinical status
Initial 12-month
12-month assessment value assessment value
Variables diagnosis ~" (SD) ~" (SD)
Major role PTSD 3.4 (1.2) 2.8 (1.7)
(n = 16)
Function ~ (work, school homemaking) Sub-PTSD 2.7 (1.6) 1.4 (0.8)
(n = 7)
Non-PTSD 3.0 (1.4) 2.2 (1.6)
(n = 25)
Relations with family2 (average of all 1st degree relatives plus spouse/partner) PTSD 2.2 (0.8) 2.5 (0.7)
Sub-PTSD 2.3 (1.0) 2.1 (0.6)
Non-PTSD 2.3 (1.0) 2.2 (I.0)
Relations with friends PTSD 2.0 (1.3) 2.6 (1.4)
Sub-PTSD 2.4 (1.6) 2.1 (1.1)
Non-PTSD 2.3 (1.2) 2.0 (I.2)
Recreation participation PTSD 3.9 (0.8) 3.3 (1.2)
Sub-PTSD 3.1 (1.9) 2.1 (1.3)
Non-PTSD 3.0 (1.4) 2.3 (1.3)
JRating l - - n o impairment, high level of performance; 3--mild impairment; 5--severe impairment;
2Rating l--very good, very close emotional relationship; 3--fair, believes relationship needs to be closer; 5--very poor. no emotional
closeness, avoids family member.

significant correlate of 12-month clinical status or 12-month CAPS score. For example, the
correlations of any treatment with 12-month clinical status was 0.030 and with 12-month CAPS
score was 0.149 (P = 0.313). These results seem to justify combining treated and untreated
participants in all of the analyses.

Collateral changes in participants initially diagnosed with PTSD

Shown in Table 7 are the mean ratings on role performance from the initial and 12-month
follow-up assessments for those participants initially diagnosed with PTSD. They are subdivided
by 12-month clinical status into full PTSD (no remission), sub-syndromal PTSD (partial remission)
and non-PTSD (full remission). The mean scores from the psychological tests, as measures of
subjective distress, from the initial and 12-month assessments are shown in Table 8. Each set of
scores was initially subjected to a 2-way (Sub-group x Time) M A N O V A which was followed as
appropriate by univariate repeated measures ANOVAs. Since no comparable data are available,
in the interest of fully exploring the data set, we calculated correlated t-tests for each diagnostic
sub-group for each measure. These results are shown in Tables 7 and 8.
Examining the role performance ratings, we found an overall main effect of Time [F(4,41) = 4.90,
P = 0.003] but no main effect of Sub-group or interaction of Sub-group x Time. Univariate

Table 8. Psychological test scores for participants with initial PTSD based on 12-month clinical
status
Initial assessment 12-month assessment
12-month
Measure diagnosis X (SD) k (SD)
Beck Depression Inventory
PTSD 20.6 (11.4) 20.3 00.5)
Sub 13.4 (2.2) 10.9 (7.2)
Non 13.0 (8.1) 9.6 (10.3)
Impact of Events
PTSD 41.7 (14.2) 39.5 (17.4)
Sub 36.4 (16.2) 29.0 (9.7)
Non 30.2 (17.4) 10.5 (9.5)
State-Anxiety
PTSD 75.0 (18.3) 77.1 (16.0)
Sub 64.4 (18.6) 59.7 (18.8)
Non 58.3 (16.2) 50.4 (16.4)
Trait-Anxiety
PTSD 64.4 (18.6) 76.3 (16.3)
Sub 58.1 (9.1) 60.7 (12.5)
Non 57.4 (10.9) 53.4 (16.1)
Global Assessment Scale
PTSD 57.0 (8.9) 56.8 (11.6)
Sub 55.0 (13.2) 63.0 (7.1)
Non 57.0 (12.7) 70.4 (14.8)
784 Edward B. Blanchardet al.

ANOVAs revealed significant improvement over time (Time main effects) on Major Role Function
[F(1,41)=9.27, P = 0 . 0 0 4 ] and participation in Recreation [F(I,41)= 11.83, P = 0 . 0 0 1 ] but
no effects on Relationships with Family or Friends. There were no significant differential
improvements among the 3 sub-groups on any of the role performance variables.
Turning to Table 8, we find a significant overall main effect of Sub-group [F(10,80) = 2.87,
P = 0.004, Pillais], of Time, [F(5,39) = 22.6, P < 0,001] and of the interaction of Sub-group x
Time [F(10,80)= 3.09, P = 0.002, Pillais]. Follow-up univariate tests revealed significant main
effects of Sub-group for the BDI, State-Anxiety, Trait-Anxiety and IES (all Ps < 0.006), significant
main effect of Time for only the IES [F(1,43) = 18.7, P < 0.001] and GAS [F(1,43) = 10.72,
P = 0.002] and significant interactions for the IES [F(2,43)- 8.27, P = 0.001], Trait-Anxiety
[F(2,43) = 7.02, P = 0.002] and GAS [F(2,43) = 5.24, P = 0.009].
Using orthogonal contrasts, we find the group who remained PTSD at 12 months was higher
than the other 2 groups combined for the BDI ( P = 0.002), State-Anxiety (P<0.001),
Trait-Anxiety (P = 0.005), and IES (P = 0.002).
The correlated t-test reveal that those who remained with PTSD increased significantly on
Trait-Anxiety [t(14)= 3.89, P=0.002]. Those initial PTSDs who had fully remitted had
significantly lower IES scores [t(23) = 10.1, P < 0.001] at 12 months their GAS score increased
significantly [t(23) = 4.53, P < 0.001].
The overall picture on the measures of psychological distress is that those with initial PTSD who
remitted fully or in part were less distressed initially than those who continue with PTSD and that
those with continuing PTSD continue to be as distressed 12 months later as they were at the initial
assessment (and on Trait-Anxiety score significantly higher at the 12-month follow-up).

DISCUSSION

As with the PTSD from other trauma, the PTSD resulting from MVAs shows a sizable degree
of remission in the year plus (13-17 months) following the accident. Of the 48 individuals with
PTSD at the initial assessment, 1-4 months post-trauma, about half have shown full or partial
remission (to sub-syndromal PTSD) by 6 months and two-thirds by the 12-month follow-up point.
Among those who have not remitted, at least in part, by 12 months (n = 13), there was very little
additional improvement over the next 6 months (out to 18 months post-initial assessment).
Rothbaum and Foa (1993) have shown a similar (and possibly steeper) remission curve in their
prospective follow-up study of sexual assault victims, whereas McFarlane's (1988) report on
Australian fire fighters seemed to show a more gradual remission curve, and considerable delayed
onset PTSD. Other prospective follow-up studies of MVA victims have shown some degree of
remission: Mayou et al. (1993) found 5 of 13 (38.5%) MVA victims, who initially met criteria for
PTSD at a point 3 months post-MVA, had remitted by a 12-month follow-up. By contrast, in
Feinstein and Dolan's (1991) 6-month follow-up of MVA victims hospitalized for leg fractures,
5 of 10 (50%) with PTSD had remitted by the 6-month follow-up point, a remission rate
comparable with ours.
These prospectively determined rates of remission, approximately 40-70% by 1 yr, are much
higher than the average for all PTSD cases in the study by Kessler et al. (1995). This latter study
has a much larger sample (459 cases from all causes) and thus could represent a more stable
estimate. However, the difference could also arise as a difference between retrospective follow-up
(Kessler et al., 1995) and prospective follow-up (our study and all of the others reviewed).
Also, like other prospective studies of MVA victims, we find some delayed onset PTSD. Mayou
et al. (1993) found 6/171 (3.5%) cases of delayed onset, whereas Green et al. (1993) found 5/24
(20.8%) cases developed delayed onset PTSD over their 18-month follow-up. Our rate was 7 cases
in 132 (5.3%) at 12 months. Like Green et al. (1993) all of our delayed onset cases emerged from
MVA victims who initially met the criteria for sub-syndromai ('sub-clinical' in Green et al.'s
terminology) PTSD. One cannot tell from Mayou et al.'s (1993) report what the initial status of
their delayed onset cases would be.
Examining the existing literature of MVA victims, one finds almost no attention paid to factors
associated with remission of PTSD. The logistic regression (Table 4) identified 3 variables which
predict remission: relatively lower scores on 2 of the 17 symptoms which make up the syndrome
 One-year prospective follow-up of MVA victims 785

(irritability and sense of foreshortened future) and relatively lower score on the degree of
vulnerability the participant felt when either a passenger or driver in a vehicle at the time of the
initial assessment. Different predictors emerge if one is interested in how symptomatic (degree of
PTSD as measured by the 12-months CAPS) an individual is at 12 months. Among the stable
predictors of higher PTSD scores (less remission) are two variables which could be considered
predisposing factors (in that they were present prior to the MVA), a history of having met the
criteria for alcohol abuse at the time of the initial assessment and a history of meeting the criteria
for any Axis-II disorder. Other relatively stable predictors (of less remission) are higher scores on
the hyperarousal (Cluster D) symptoms (especially including irritability), higher scores on the
foreshortened future symptom, initial degree of physical injury as measured by the AIS, and
perceived vulnerability in a vehicle after the MVA. (Three of these entered the logistic regression
equation as described above.)
Interestingly, the initial reexperiencing symptoms and avoidance symptoms (tapped by the IES
scale) do not predict nor does the initial degree of fear, terror or helplessness. These latter variables
have been shown to predict who initially develops PTSD in other studies of MVA victims (Mayou
et al., 1993; Feinstein & Dolan, 1991; Blanchard, Hickling, Taylor, Loos & Forneris, 1996) but do
not predict remission.
Although there is scant literature on the topic, we do not find that the presence of personality
disorder and/or previous alcohol abuse are associated with poor outcome, surprisingly. Certainly,
diverse treatment studies have shown that the presence of either of these two can be associated
with poorer responses to treatment.
In terms of the physical injury variable, we would have expected, based on the simple bivariate
correlations, one of the physical injury quotient variables to have predicted remission (or lack
thereof). Instead, the sheer extent of initial physical injury is the predictor. This stands in contrast
to reports by Feinstein and Dolan (1991) who did not find such an association nor did Mayou
et al. (1993).
We did not find that participating in any form of mental health treatment in the first year
post-trauma was differentially associated with remission or with a reduction in PTSD symptoms.
This finding would be consistent with the results from MVA victims reported by Brom et al. (1993).
These results are contrary to the highly significant effect of treatment reported in Kessler et al.'s
(1995) retrospective follow-up. Our findings may be trauma-specific. Alternatively, the retrospective
(Kessler) versus prospective (present study) difference may account for the difference.
We do not wish to emphasize the lack of a treatment response because: (i) there was not random
assignment to treatment versus no treatment, participants self-selected; and (ii) we cannot evaluate
the adequacy of either the drug or psychological treatment our participants received.
Our results, which show an apparent asymptote in recovery after 1 yr, and a less rapid rate of
recovery from PTSD after about 7 months, suggest that these individuals might benefit from a very
focused, PTSD specific treatment. We are currently trying to develop such a treatment program.
The collateral psychosocial results (impairment in role functioning and subjective distress)
suggest two things: those MVA victims who develop PTSD initially but who are relatively less
impaired and less distressed initially are more likely to improve on clinical status over the year.
Likewise, those who initially meet the criteria for PTSD after the MVA, and who continue to meet
the full PTSD criteria a year later are noticeably impaired in major role function and participation
in recreational activities initially and remain impaired. Their relationships with friends even
deteriorate (albeit not significantly) over the year follow-up. This suggests that some friends may
have difficulty remaining supportive of a symptomatic individual over time. Their level of subjective
distress, as measured by standardized psychological tests, remains fairly stable over the year (and
they actually increase significantly on trait-anxiety).
There are, of course, certain limitations to this research. Our initial MVA sample is not a random
sample of all MVA victims or even of all injured MVA victims. While such a sample would be
desirable in terms of generalizing the results, human Ss constraints restrict us to studying those
MVA victims who were willing to be studied, namely volunteers. We lost 16% of our initial sample;
roughly half refused and half disappeared despite our efforts to maintain contact. The retention
rate is comparable with other reports on MVA victims. The one significant difference between
dropouts and our sample was in terms of ethnicity. We did a poorer job of retaining minorities
786 Edward B. Blanchard et al.

a n d h a v e n o r e a d y e x p l a n a t i o n for this. T h e s e losses w e r e m o r e o w i n g to i n a b i l i t y to t r a c k

p a r t i c i p a n t s t h a n to o u t r i g h t refusals. D e s p i t e these l i m i t a t i o n s we believe we p r o v i d e a useful
p i c t u r e o f the s h o r t t e r m n a t u r a l h i s t o r y o f A m e r i c a n M V A v i c t i m s w i t h initial P T S D .

Acknowledgements--This research was supported in part by a grant from NIMH, MH-48476. We acknowledge the
statistical assistance of Dr James Jaccard.

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