Undiagnosed post‐traumatic stress disorder following motor vehicle accidents

To the Editor: The recently reported study of post-traumatic stress disorder (PTSD) following motor vehicle accidents is of great significance.' The authors quite rightly point out that the relationship between physical injury and PTSD had not before been thoroughly studied. Indeed, in recent years a critical exchange of letters about this topic highlighted the controversy involved. 2,3 Lawrence Kolb4 had proposed a neuropsychological hypothesis to explain PTSD. He proposed that this hypothesis "applies to PTSD induced by any intense, life-threatening traumatic experience, including exposure to combat, natural disasters, and the catastrophes of daily life such as automobile, rail, and industrial accidents, fire, assault and rape. All are perceived by the individuals exposed to them as mortal danger associated with fear/terror emotional responses"." Dr Kolb's proposition was vigorously contested, although both sides of the debate recognised the "heterogeneity of PTSD".3 It would seem that the findings of Green and colleagues! are very much in accord with Dr Kolb's hypothesis, and have elegantly demonstrated the development of poet-traumatic stress disorder in a cohort of accident victims over a period of several months. These Australian authors have not only provided an elegant study, but they have suggested that PTSD "has been inadequately detected after other traumatic events, such as natural disasters". One of the reasons, of course, is that the diagnosis is often overlooked. s I have just published a follow-up study of three soldiers who were recognised as having suffered from post-traumatiC stress disorder, well over 40 years after the critical lncident.s In each case, the diagnosis was only arrived at after repeated psychiatric examinations. An attitude of scepticism, mixed with a reluctance to rely on the individual's history, will often explain the failure to diagnose this condition.' The usual coping mechanism of suppression and denial often explains the lack of documentary evidence of traumatic experience and, in particular, the failure to seek treatment or counselling. However, bearing in mind that PTSD is a complex and apparently ubiquitous condition, I would certainly advise caution in adopting the rather simplistic recommendation that "the creation of specially funded programs to develop awareness and early intervention strategies in this area is necessary".' Before it becomes accepted as an article of faith, I would suggest that much research is required to determine whether "primary prevention", that is, early identification, early intervention strategies, and "counselling", is proven to be a helpful or unhelpful approach to PTSD. In my clinical experience, with many hundreds of war veterans over a period of many years, I have found that exploration of memories of traumatic events can often exaggerate and entrench rather than ease emotional distress. It must be emphasised that "individual experience differs and it is mandatory, therefore, to consider each case Advice to correspondents