PTSD After a Car Accident

Trauma and the PTSD Diagnosis

Post-traumatic stress disorder can only develop after a person goes through or sees a life-threatening event, according to the VA National Center for PTSD. Car accidents appear by name on the MedlinePlus list of events after which PTSD can occur, and Cleveland Clinic gives serious accidents, like car crashes, as one example of a traumatic event.

For diagnosis, the DSM-5-TR defines trauma as exposure to actual or threatened death, serious injury, or sexual violence, StatPearls explains. That exposure can come from directly experiencing the event, witnessing a person experiencing trauma, or learning that the event occurred to a close family member or friend.

Most people who go through a traumatic event will not develop PTSD, the National Center for PTSD reports. Its best estimates are that about 6 of every 100 people will have PTSD at some point in their lives and about 5 of every 100 adults in the U.S. have it in any given year. Women are more likely to develop it than men, at about 8 of every 100 women and 4 of every 100 men over a lifetime.

The condition outlasts the danger. People who have PTSD may continue to feel stressed or frightened even though they are not in danger, the National Institute of Mental Health (NIMH) says.

Fear Response During a Crash

Fear is part of the body’s built-in alarm system, which helps people avoid or respond to potential danger, according to NIMH. NIMH calls it natural to feel afraid during and after a traumatic situation.

The first response to trauma is a surge of adrenaline from sympathetic nervous system stimulation, StatPearls explains, which can lead to a fast heart rate, rising blood pressure, and the release of cortisol and catecholamines. When the trauma stimulus is prolonged or repeated, StatPearls says, a conditioned behavioral response leading to acute stress disorder or PTSD can occur.

Normally the body recovers after the event. The stress hormones and chemicals released during the event go back to normal levels, MedlinePlus explains, but for some reason the body of a person with PTSD keeps releasing them.

Brain circuits that handle threat are part of the picture. The amygdala has significant responsibility for threat detection and fear response, according to StatPearls, and in patients with PTSD the frontal lobe’s capacity to tone that response down is dysregulated. Changes in brain chemicals may keep the body in that alarm state and raise heart rate, blood pressure, and startle response, Cleveland Clinic notes.

Why one crash survivor develops PTSD and another does not is still unknown. MedlinePlus says health care providers do not know why traumatic events cause PTSD in some people but not in others, and that genes, emotions, and family setting may all play roles.

Acute Stress in the First Month

Upsetting memories, feeling on edge, and trouble sleeping are normal after a traumatic event, the VA National Center for PTSD says, and most people start to feel better after a few weeks. NIMH likewise reports that most people recover from these symptoms and that their reactions lessen over time.

Heavier distress in that window has its own name. The National Center for PTSD describes acute stress disorder (ASD) as heightened distress that takes place from 3 days to one month following trauma, with a requirement of 9 of 14 symptoms across reexperiencing, dissociation, avoidance, and hyperarousal.

Accidents produce ASD less often than interpersonal events do. A meta-analysis of 70 studies, described by the VA, found ASD in an average of 20.4% of people after a traumatic event, with a rate of 15.9% after accidents and 36.0% after interpersonal events. A 2018 meta-analysis cited by StatPearls found an overall ASD prevalence of 15.8% in people involved in road traffic accidents.

An early diagnosis does not settle the later one. ASD has not been shown to effectively predict PTSD, the VA says, though people with ASD are at higher risk of later developing PTSD. StatPearls adds that many patients who later develop PTSD do not meet full ASD criteria during the first month after trauma.

Physical injuries compete for attention in those weeks. The VA gives managing acute physical pain after a car accident as an example of an immediate concern in the first days and weeks, and says it is possible that treatment for ASD will not be a high priority.

Four Symptom Clusters

There are 4 types of PTSD symptoms, and a diagnosis requires each type, according to the VA National Center for PTSD. For adults, NIMH sets the threshold at all of the following for at least 1 month: at least one re-experiencing symptom, at least one avoidance symptom, at least two arousal and reactivity symptoms, and at least two cognition and mood symptoms.

Re-experiencing includes flashbacks, in which a person relives the event with physical symptoms such as a racing heart or sweating, along with recurring memories or dreams and distressing thoughts, NIMH explains. The VA lists news reports and seeing an accident among examples of trauma reminders that can bring the event back.

Avoidance means staying away from places, events, or objects that are reminders of the experience, or avoiding thoughts or feelings related to it, according to NIMH.

Arousal and reactivity symptoms, on the NIMH list, include being easily startled, feeling tense or on edge, difficulty concentrating, difficulty falling or staying asleep, irritability or angry outbursts, and risky or reckless behavior. NIMH says these symptoms are often constant.

Cognition and mood symptoms include trouble remembering key features of the event, negative thoughts about oneself or the world, exaggerated blame, ongoing fear, anger, guilt, or shame, and loss of interest in previous activities, per NIMH. MedlinePlus adds constant guilt about the event, including survivor guilt, and lists related symptoms of anxiety and tension such as dizziness, fainting, headache, and feeling the heart beat in the chest.

Timing varies from person to person. Symptoms usually begin within 3 months of the traumatic event but sometimes emerge later, NIMH says, and the VA notes they may not appear until months or years later and may come and go over many years. StatPearls describes a delayed expression specifier for cases in which full criteria are not met until at or after 6 months.

Some reactions call for prompt attention. MedlinePlus advises seeking help right away for the first four signs below, and StatPearls lists head injury signs, such as worsening headache, repeated vomiting, seizure, unequal pupils, slurred speech, and confusion, that should prompt neurologic assessment. Anyone struggling or having thoughts of suicide can call or text the 988 Suicide and Crisis Lifeline, according to NIMH.

Driving Avoidance and Travel Anxiety

Avoidance can rewrite a daily routine. Some people may avoid driving or riding in a car after a serious car accident, NIMH notes, and the VA National Center for PTSD uses the same example of a person who avoids driving after a car accident.

Triggers can include sights, sounds, smells, places, or situations, according to Cleveland Clinic, and even certain dates or times of year can cause symptoms to flare. When a trigger happens, Cleveland Clinic says, anxiety, flashbacks, or strong emotions may return even after a person was feeling better.

Avoidance can reach medical care itself. The VA says a person may keep very busy or avoid getting help so they do not have to think or talk about the event. On the arousal side, the VA lists driving aggressively among the unhealthy ways a person might act.

Treatment works on avoidance directly. In Prolonged Exposure therapy, a person learns to gradually approach trauma-related memories, feelings, and situations that have been avoided since the trauma, the VA explains. NIMH says exposure therapy may include thinking or writing about the trauma or visiting the place where it happened.

Risk and Resilience Factors

Several known risk factors overlap with what happens in a serious crash. Getting hurt or seeing people hurt or killed, feeling horror, helplessness, or extreme fear, and dealing with pain and injury after the event all appear on the NIMH list of factors that may increase the likelihood of PTSD. Being injured during the trauma can increase the risk, the VA National Center for PTSD says.

Other factors predate the crash. NIMH names exposure to previous traumatic experiences, particularly during childhood, and a personal or family history of mental illness or substance use. StatPearls adds physical injury, including traumatic brain injury, and the initial severity of the reaction to the trauma.

The kind of trauma matters in the research. StatPearls reports that intentional trauma has a greater association with PTSD than accidental trauma or nonviolent trauma, and that repeated trauma and longer exposure are associated with a higher risk.

Support after the event pulls the other way. Stress can make PTSD more likely while social support can make it less likely, according to the VA, and NIMH lists seeking out and receiving support from friends, family, or support groups among resilience factors. Having one or more risk factors does not mean a person will develop PTSD, Cleveland Clinic notes.

Conditions With Overlapping Symptoms

Timing separates PTSD from acute stress disorder. The symptoms of the two significantly overlap, StatPearls says, and acute stress disorder is diagnosed if the symptoms are present for less than 1 month. The National Center for PTSD adds that ASD leaves out some PTSD mood and thought symptoms, such as negative beliefs about the self, self-blame, and detachment.

Adjustment disorder describes emotional or behavioral symptoms that develop in response to an identifiable stressor, not necessarily trauma, within 3 months of the stressor’s onset, StatPearls explains.

The table below compares the three using the timing and symptom rules from StatPearls, the StatPearls review of acute stress disorder, the National Center for PTSD, and NIMH.

Depression overlaps heavily. With both depression and PTSD, a person may have trouble sleeping or keeping the mind focused and may lose interest in things once enjoyed, according to the VA National Center for PTSD, which reports that a large national survey found depression nearly 3 to 5 times more likely in people with PTSD. A diagnosis of major depressive disorder requires at least one major depressive episode, which StatPearls describes as persistent decreased mood for at least 2 weeks.

Depersonalization/derealization disorder shares dissociation with PTSD but lacks its other symptoms, according to StatPearls. Medical causes get checked too: MedlinePlus says a provider may do a mental health exam, physical exam, and blood tests to look for other illnesses that are similar to PTSD.

Concussion and PTSD Together

Severe vehicle accidents are among the VA National Center for PTSD examples of events that can cause a traumatic brain injury and may also lead to PTSD. The VA draws the line this way: a TBI creates a physical injury in the brain, while PTSD develops from the psychological trauma of the event.

A head strike is not required. A TBI can occur even when there is no direct contact to the head, the VA explains, since the brain may be shaken within the skull when a person suffers whiplash, and a mild TBI may also be called a concussion. Traumatic brain injury may co-occur with acute stress disorder after motor vehicle crashes, StatPearls notes.

The symptoms blur together. Both conditions may include sleep problems, negative thoughts and feelings, irritability and anxiety, or memory problems, according to the VA, which adds that TBI-related symptoms and PTSD symptoms may together decrease a person’s ability to recover on their own. In the PTSD criteria summarized by StatPearls, an inability to recall parts of the event counts when it comes from dissociative amnesia, not from head injury, drugs, or alcohol.

Treatment does not have to wait for the brain injury to clear. Research suggests that Cognitive Processing Therapy and Prolonged Exposure work as well for people with a history of TBI as for those without, the VA says, and having TBI-related symptoms does not mean waiting to start PTSD treatment.

Screening Tools and Clinical Interviews

No scan or blood test confirms PTSD. There is no single test to diagnose it and no lab test that can diagnose it directly, Cleveland Clinic says; a mental health specialist makes the diagnosis by talking through symptoms, medical and mental health history, and trauma. Only a mental health provider can diagnose PTSD, according to the VA National Center for PTSD.

The psychiatric evaluation is the most important component of diagnosing PTSD, StatPearls says. MRI studies of people with PTSD have revealed nonspecific findings, including reduced total brain volume, though StatPearls notes that the results are not consistent, and physical exam findings are typically nonspecific as well.

The PCL-5 is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD and takes about 5 to 10 minutes, according to the National Center for PTSD. Initial research suggests a PCL-5 cutoff score between 31 and 33 indicates probable PTSD, the VA says, and a clinician should interpret the results.

The National Center for PTSD calls a structured clinical interview the gold standard for diagnosing PTSD. The Clinician-Administered PTSD Scale (CAPS-5) is a 30-item interview that also asks about onset and duration, distress, and the impact of symptoms on social and occupational functioning, the VA explains, and the full interview takes 45 to 60 minutes. PTSD is diagnosed when symptoms have lasted at least 30 days, MedlinePlus says.

Psychotherapy and Medication

Trauma-focused psychotherapy is the preferred treatment for PTSD, StatPearls says. The VA National Center for PTSD names Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), and Eye Movement Desensitization and Reprocessing (EMDR) as the 3 most effective types, and explains that trauma-focused therapy concentrates on the memory of the traumatic event or its meaning.

Each takes a different route. CPT teaches skills for understanding how trauma changed thoughts and feelings, PE works through gradual approach to avoided memories and situations, and EMDR processes the memory while the person pays attention to a back-and-forth movement or sound, the VA explains. Most of these therapies last about 3 months, according to the VA, and NIMH says psychotherapy usually lasts 6 to 12 weeks but can last longer.

Medication is the other main option. The FDA has approved two selective serotonin reuptake inhibitors (SSRIs) for PTSD, NIMH says, and StatPearls names them as sertraline and paroxetine. The VA lists sertraline, paroxetine, and venlafaxine as recommended medications, and its medication page says people may start to feel better in about 4 to 6 weeks.

Therapy and medication can be combined. When trauma-focused psychotherapy is compared against medication, there may be slightly improved outcomes with therapy, StatPearls reports, and patients with severe symptoms may start on medication with the intent to add therapy once they are more clinically stable. For PTSD nightmares, StatPearls says prazosin is commonly used off-label, with mixed and inconsistent results.

Recovery Time Ranges

The course of PTSD varies. Although some people recover within 6 months, others have symptoms that last for 1 year or longer, according to NIMH.

Chronic PTSD is common, StatPearls reports, with estimates that one-third of patients still have symptoms 1 year after diagnosis and another third still have symptoms 10 years after diagnosis. Those who engage in PTSD treatment tend to have improved outcomes compared with those who do not, StatPearls adds.

For many people, treatment can get rid of symptoms altogether, the VA National Center for PTSD says, while others find they have fewer symptoms or that their symptoms are less intense. Cleveland Clinic describes progress that often is not a straight line, with ups and downs, and improvement that often happens gradually.

Depression, Substance Use, and Other Complications

People with PTSD often have co-occurring conditions, such as depression, substance use, or anxiety disorders, according to NIMH. Symptoms that are not treated may lead to other problems, and the complications Cleveland Clinic lists include anxiety disorders, depression and other mood disorders, problems at work or school, risky or self-destructive behaviors, sleep problems, substance use disorder, suicidal thoughts, and trouble with relationships.

Patients with PTSD are at increased risk for suicide and should have regular screenings for suicidal ideation by clinicians, StatPearls says. StatPearls adds that people with PTSD are more likely to have occupational problems than those without it and have higher rates of disability.

Impairment ranges widely. Among U.S. adults with PTSD in the past year, an estimated 36.6% had serious impairment, 33.1% moderate impairment, and 30.2% mild impairment, according to NIMH survey data from 2001 to 2003.

Avoiding alcohol and recreational drugs appears among the steps MedlinePlus lists for increasing the chance of a good outcome, because they can make PTSD worse.

Records That Track Symptoms Over Time

Function sits at the center of the diagnosis. To meet the criteria, the symptoms must be severe enough to interfere with aspects of daily life, such as relationships or work, NIMH says, and the CAPS-5 interview asks directly about the impact of symptoms on social and occupational functioning.

Good clinical care requires that clinicians monitor patient progress, according to the National Center for PTSD, which suggests a 10-point change on the PCL-5 as an indicator of response.

The diagnosis can change with time. Patients may no longer meet PTSD criteria as their symptoms improve, StatPearls says, and clinicians should assess whether PTSD is current, improved, resolved, or comorbid with other psychiatric disorders.

Missed or delayed visits leave their own trace in a chart; the page on treatment gaps after car accidents covers how they arise.