Hindawi Publishing Corporation
Depression Research and Treatment
Volume 2012, Article ID 184572, 8 pages
Posttraumatic andDepressive SymptomsinVictimsof
GiuliaBuodo, CaterinaNovara,Marta Ghisi,andDanielaPalomba
Department of General Psychology, University of Padova, Via Venezia 8, 35131 Padova, Italy
Correspondence should be addressed to Giulia Buodo, firstname.lastname@example.org
Received 13 October 2011; Revised 12 January 2012; Accepted 24 March 2012
Academic Editor: Eric Vermetten
Copyright © 2012 Giulia Buodo et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
The present descriptive study was aimed at evaluating posttraumatic and depressive symptoms and their cooccurrence, in a
sample of victims of workplace accidents. Also, posttraumatic negative cognitions were assessed. Eighty-five injured workers were
evaluated, using the PTSD Symptom Scale, the Beck Depression Inventory II, and the posttraumatic Cognitions Inventory. 49.4%
of injured workers reported both depressive and posttraumatic symptoms of clinical relevance. 20% only reported posttraumatic,
but not depressive, symptoms, and 30.6% did not report either type of symptoms. The group with both posttraumatic and
depressive symptoms displayed greater symptom severity and more negative cognitions about the self and about the world than
the other two groups. The obtained findings indicate that workplace accidents can have a major impact upon the mental health of
victims. Early interventions should be focused not only on the prevention or reduction of posttraumatic and depressive symptoms
but also on restructuring specific maladaptive trauma-related cognitions.
It has been consistently demonstrated that in some individu-
als exposure to traumatic events is followed by full or partial
posttraumatic stress disorder (PTSD; see ). However, in
a substantial proportion of cases PTSD is not the only
psychological disorder occurring after a traumatic event.
Indeed, survey studies report that lifetime comorbidity of
PTSD with at least one other psychiatric disorder is found
in about 70–80% of affected individuals [2, 3]. Among axis I
disorders, major depression has the highest comorbidity rate
with PTSD, with 30–50% of individuals affected by PTSD
showing significant depressive symptoms [2, 4].
In order to explain the frequent cooccurrence of PTSD
and depression, different hypotheses have been proposed.
The possibility of a common underlying vulnerability to
both disorders is suggested by the apparent bidirectional
relationship between PTSD and depression, where preexist-
ing depression can increase an individual’s susceptibility to
develop PTSD after a trauma and, on the other hand, PTSD
can increase the onset probability of depression [2, 5–7].
The hypothesis of a shared diathesis is further strengthened
by data showing an increased risk for major depression in
individuals with PTSD, but not in trauma-exposed individu-
als without PTSD . Therefore, these findings suggest that
exposure to traumatic events in itself does not increase the
risk for developing depression independent of PTSD effects.
Although the cooccurrence of PTSD and depression fol-
lowing trauma is the rule rather than the exception, it is
pendently of one another in a small but significant minority
of cases (e.g., [8, 9]). This evidence runs against the idea that
PTSD and depression are parts of a single general traumatic
stress construct and rather suggests that they might be
independent outcomes of traumatic events. Importantly in
this respect, it has been reported that a two-factor model
of PTSD and depression as correlated but independent
conditions following trauma exposure provides the best fit
of quantitative data measuring the two constructs  and
that the combination of variables predicting depression is
different from the group of factors predicting PTSD, at least
in the acute aftermath of trauma . Research on the types
of attributional styles associated with differential psycho-
logical outcomes after traumatic events provides additional
indications of disorder-specificity for PTSD and depression.
The development of feelings of hopelessness and depression
2Depression Research and Treatment
has been related to a helpless attributional style, in which
negative events are attributed to global, stable, and internal
causes (e.g., ). On the other hand, higher levels of
PTSD symptoms after trauma exposure seem to be predicted
by the tendency to attribute negative events to external,
rather than internal, causes [12–15]. Besides attributional
styles, maladaptive beliefs have also been suggested to play
a symptom-specific role in the context of posttraumatic
adjustment. Negative thoughts about the self (the beliefs
about being weak and incompetent) have been found to
uniquely correlate with PTSD severity even after controlling
for the severity of concurrent depressive symptoms, whereas
negative thoughts about the world (the belief that the world
blame (the perception of being responsible for the traumatic
event) seem to share notable variance with depression in
their association to the severity of posttraumatic symptoms
. These findings suggest that, beyond a number of
non-specific cognitive factors, PTSD and depression might
involve disorder-specific sets of cognitive distortions .
Lastly, subgroups of traumatized individuals who are
diagnosed with PTSD only and comorbid PTSD and depres-
sion seem to differ with regard to subjective distress and
social impairment. Individuals who meet diagnostic criteria
for both PTSD and major depression have been found to
report more severe posttraumatic, depressive, and anxiety
symptoms, increased impulsivity, hostility and suicidality,
and worse social functioning than those with PTSD alone
(see [8, 10, 18]).
In view of the methodological heterogeneity and design
limitations that inevitably exist in studies on PTSD depres-
prognosis, commonality, or independence of the two disor-
ders following trauma exposure remain a matter of debate.
Much of the existing research on PTSD, depression, and
their comorbidity has considered such traumatized pop-
ulations as combat veterans, victims of childhood sexual
abuse,and survivalsof natural disasters (e.g.,[19–21]).More
recently, the victims of occupational accidents are receiv-
ing increasing attention as a trauma group. Occupational
accidents include a broad range of unforeseeable, sudden
events occurring in the workplace, that cause the worker
functional or physical disability of varying severity, whether
temporary or permanent. Although accidents can occur in
virtually every workplace, some occupations have a high and
predictable risk of being exposed to threat, serious injuries
or disasters, for instance, policemen, rescue personnel,
firefighters, bank officers, or medical emergency personnel
(e.g., [22, 23]). Therefore, most of the investigations on
the psychological consequences of work-related injuries have
considered such occupational categories. Other occupational
settings, such as the industrial and the constructions sectors,
where traumatic accidents occur frequently but that are not
typically considered as high-risk settings, have received less
systematic attention in this context. However, the relevant
increased levels of emotional distress, anxiety and depres-
sion, subjective personal vulnerability, anger, irritability,
somatic focus, preoccupations about the future, inactivity,
and dependence [24–27]. Indeed, workplace accidents are
increasingly reported as potentially traumatic events that
may result in the development of acute stress disorder,
adjustment disorder, or eventually PTSD [24, 25, 28–31]. A
percentage of injured workers as high as 30–40% has been
reported to show symptoms consistent with full or partial
PTSD after the accident (see [29, 31]).
Research in this area is still rather limited. In particular,
the comorbidity of posttraumatic and depressive symptoms
in injured workers, although expected, remains underex-
plored. Although previous research indicates that comorbid-
ity rates for PTSD and other disorders are similar across
different trauma populations, the type of trauma appears
to be an important variable affecting the type, extent, and
course of PTSD comorbidity [32, 33]. In particular, the find-
ings of studies on PTSD and depression comorbidity, mostly
obtained in victims of intentional and/or repeated traumatic
events such as domestic violence, sexual abuse and combat,
may not warrant generalization to victims of single, non-
intentional traumas such as workplace accidents. Indeed,
intentional events are generally reported to be associated
with worse posttrauma adjustment than non-intentional
events , as events that are purposely inflicted are thought
to be more difficult to cope with than are unintentional
Therefore, the aims of the present descriptive study were
(a) to examine the proportion of victims of workplace acci-
and (b) to assess whether subgroups of injured workers with
posttraumatic and/or depressive symptoms would differ in
symptom severity and in posttraumatic negative cognitions.
Based on the available literature on PTSD-depression
comorbidity, and on the psychological sequelae of work-
related accidents in particular, we hypothesized to show
evidence of (a) clinically relevant symptoms of PTSD in
a large proportion of injured workers, (b) the presence of
comorbid depressive symptoms in a subgroup of injured
workers with PTSD (c) greater symptom severity and
more negative posttraumatic cognitions in individuals with
comorbid PTSD and depressive symptoms than in individu-
als with PTSD or depression alone.
2.1. Participants. Eighty-five injured workers were recruited
in several towns in Northern, Central, and Southern Italy
among associates of the Associazione Nazionale Mutilati e
Invalidi del Lavoro (ANMIL, a nonlucrative organization
with several seats in Italy, that provides social, material,
and moral support to individuals who sustained work
accidents). ANMIL administrative staff members identified
eligible participants by searching through the organization’s
database those who met the criteria established by the
authors (see the following). The full database was used to
avoid sampling bias. ANMIL staff members then contacted
potential participants by telephone to preliminary assess
their willingness to take part in the study and scheduled an
Depression Research and Treatment3
appointment for those who agreed. ANMIL had no further
involvement in data collection, analysis, and interpretation.
by the authors and their collaborators.
Injured workers were eligible for participation if they
met the following criteria: age between 18 and 60 years,
time elapsed from the accident between 6 months and 10
years before the study, and degree of physical impairment
between 25% and 75% (corresponding to a medium level of
physical impairment), as evaluated by the Istituto Nazionale
per l’Assicurazione contro gli Infortuni sul Lavoro (INAIL,
Italian Workers’ Compensation Authority).
Exclusion criteria were the following: use of drugs or
medications that could influence the individual’s ability to
undergo the assessment procedure, presence of physical ill-
matic brain injury, and incapacity to give informed consent.
The sample included 78 males (91.8%) and 7 females
(8.2%). Mean age was 38.3 years (S.D. = 7.7; range = 22–
58) and mean years of education were 10.7 (SD = 2.7; range
= 5–18). Marital status was as follows: 23 participants were
single (27.1%), 43 were married (50.6%), 9 were cohabitant
(10.6%), and 9 were divorced (10.6%).
Mean degree of impairment was 47.3% (S.D. = 15.5;
was 5.3 years (S.D. = 2.3; range = 1–10). With regard to
the occupational status after the accident, 55 participants
(64.7%) were employed and 30 (35.3%) were unemployed.
(1) A semistructured interview covering socio-demo-
graphic data (age, marital status, education, use of
medication, presence of physical illnesses, etc.) and
accident-related data (a description of the work ac-
cident, the degree of physical impairment, and the
length of time since the accident). Also, the interview
was aimed at ascertain the absence of other traumatic
events beyond the workplace accident.
(2) Beck Depression Inventory: second edition (BDI-II;
; Italian version by ) is a widely used self-
administered questionnaire evaluating the severity
of depressive symptoms during the last two weeks
preceding the assessment. It consists of 21 items
answered on a 0–3 scale. The Italian BDI-II cutoff
score is 12 .
(3) PTSD Symptom Scale (PSS; ) contains 17 items
designed to measure the frequency of PTSD symp-
toms (according to DSM III-R). The respondents
are asked to evaluate on a Likert scale (0: never;
3: five or more times per week) how often they
have experienced each symptom in the past week.
The items are grouped into three subscales: reex-
periencing (detecting symptoms such as nightmares
as detachment and loss of interests), and arousal
(detecting symptoms such as irritability, difficulty
concentrating, and hypervigilance). A total score is
also derived, which reflects the severity of PTSD
symptomatology (up to 10: mild; 11–20: moderate;
21–35: moderate to severe; above 36: severe; ).
(4) Posttraumatic Cognitions Inventor (PTCI; ) is
a 33-item self-report measure that assesses trauma-
related thoughts and beliefs on a Likert scale (1:
totally disagree; 7: totally agree). The PTCI is com-
posed of three subscales: Negative Cognitions About
Self, Negative Cognitions About the World, and Self-
The Italian translations of the PSS and the PTCI had
been obtained from back translation by two expert English
2.3. Procedure. All individuals participated on a voluntary
basis. Before entering the study, they were informed of the
study aims and gave their written consent. Each participant
underwent the semistructured interview and was then
requested to fill in the questionnaires. The order of admin-
istration of questionnaires was rotated across participants to
control for order effects.
The study was conducted in compliance with the Decla-
ration of Helsinki and approved by the institutional board of
the participating institution.
2.4. Statistical Analyses. As a first step, injured workers were
divided into groups, based on the scores obtained on the PSS
and the BDI-II. Those who scored equal or above 11 on the
PSS were classified as High PSS, and those who scored below
11 were classified as Low PSS. Individuals who scored equal
or above 12 on the BDI-II were classified as High BDI, and
those who scored below 12 as Low BDI.
Then, a multivariate analysis of variance (MANOVA)
was performed to compare the groups on the following
sociodemographic data: education, degree of impairment
and time since the accident. Chi-squared analyses were
Lastly, a multivariate analysis of covariance (MANCOVA)
was performed to compare scores on self-report question-
naires between the three groups, using the time since the
accident as a covariate.
When results were significant (P
identify specific differences between groups.
< .05), Student-
Overall, sixty-four percent (N = 59) of injured workers
scored ≥11 on the PSS, corresponding to a moderate or
more severe posttraumatic symptomatology, and 49.4%
(N = 42) scored ≥12 on the BDI-II, corresponding to
depressive symptoms of clinical relevance. Interestingly, all
the individuals who scored above the cut-off on the BDI-II
also had moderate or more severe posttraumatic symptoms
(High PSS/High BDI, N = 42).
4 Depression Research and Treatment
Table 1: Percentages of participants scoring high or low on the PSS
(High = ≥ 11, Low = < 11) and on the BDI-II (High = ≥ 12, Low =
Another group of individuals scored ≥11 on the PSS and
below the cut-off on the BDI-II (High PSS/Low BDI, N =
A third group of individuals reported low scores on both
questionnaires (Low PSS/Low BDI, N = 26).
There were no subjects scoring above the cut-off on the
BDI-II and below 11 on the PSS.
These data are shown on Table 1.
the three groups with regard to age, education, gender,
marital status, and degree of physical impairment. The
unemployment rate was lower in Low PSS/Low BDI partic-
ipants as compared with the other two groups. The number
of years since the accident was lower in the High PSS/High
BDI group as compared with the High PSS/Low BDI and the
Low PSS/Low BDI groups.
the High PSS/High BDI group obtained higher scores on all
groups, while the High PSS/Low BDI group scored higher
than the Low PSS/Low BDI group only on the avoidance
The High PSS/High BDI group scored higher than the
other two groups on the PTCI and on its subscales of
Negative cognitions about self and Negative Cognitions
About the World. The three groups did not differ on the Self-
Blame subscale score.
Results did not change when entering the years since
the accident as a covariate in the multivariate analysis (F =
0.78; P = ns). Therefore, Table 3 reports the results of the
In the present descriptive study, we observed that a propor-
tion as high as 64% of injured workers had moderate-to-
severe posttraumatic symptoms. More in particular, three
subgroups of victims of workplace accidents were identified
on the basis of self-reported posttraumatic and depressive
symptomatology: individuals with both posttraumatic and
depressive symptoms (49.4%), individuals with PTSD symp-
toms only (20%), and trauma-exposed workers without
either type of symptoms (30.6%). These three subgroups
differed with respect to symptom severity and trauma-
related cognitions, with the High PSS/High BDI group
reporting greater severity of posttraumatic and depressive
symptomatology, and more negative cognitions about the
self and about the world than the High PSS/Low BDI and
the Low PSS/Low BDI groups.
Several things emerge from our findings. Firstly, our data
on the occurrence and severity of PTSD symptoms (with
or without comorbid depression) converge with those of
previous research on victims of occupational accidents (see
), and confirm that a sizeable proportion of injured
workers experience significant posttraumatic stress symp-
toms. Secondly, our finding that depressive symptomatology
cooccurred with posttraumatic symptoms in about half of
participants indicates that comorbidity is as high among
injured workers as it is in other trauma groups (see [8,
33]). The greater severity of posttraumatic symptoms in
the High PSS/High BDI group than in the High PSS/Low
BDI group is again in agreement with other studies in
the trauma literature, reporting an association of PTSD-
depression comorbidity with greater severity of posttrau-
matic symptoms [8, 10, 33]. Lastly, the finding that the
group of injured workers with both PTSD and depressive
and about the world than the High PSS/Low BDI group fits
with previous research reporting relatively more distorted
trauma-related beliefs in individuals with both PTSD and
depression as compared with individuals with PTSD only
. The absence of group differences with regard to the
scorings on the Self-Blame subscale of the PTCI might have
multiple reasons, that is, the poorer discriminant validity of
this scale as compared with the other two scales (see ),
or the possibility that in our sample of injured workers the
development of psychopathology had no relationship with
self-attribution of responsibility for the accident.
Overall, our findings largely converge with the existing
literature on PTSD and depression following traumatic
events, by showing that comorbidity is common also among
victims of occupational accidents and that in these indi-
viduals comorbidity is accompanied by more severe PTSD
symptoms and more maladaptive trauma-related cognitions.
Although these results were somehow expected and may not
be surprising, similarities across different trauma popula-
trauma types have been found to be associated with different
posttraumatic symptom presentations .
Although the present study indicates that workplace
accidents are often followed by cooccurring PTSD and
depression, it is worth pointing out that a subgroup of
injured workers in our sample had PTSD symptoms without
depression. This evidence supports the view that PTSD and
depression might be separate outcomes of traumatic events,
occurring independently of one another in a significant
minority of cases (e.g., [8, 9]). In this regard, it has to be
noted that the mean time elapsed from the accident was
significantly longer in the High PSS/Low BDI group (6.31
years) than in the High PSS/High BDI group (4.63 years).
symptom remission, but a firm conclusion about this issue
could only be drawn from longitudinal data. Importantly,
however, the results of the present study did not change
when the number of years since the accident was entered
in the analyses as covariate, indicating that the observed
group differences existed independent from the length of
time elapsed from the accident. The High PSS/Low BDI
Depression Research and Treatment5
Table 2: Demographic characteristics of the three groups (High PSS/High BDI, High PSS/Low BDI, Low PSS/Low BDI).
BDI (N = 42)
BDI (N = 17)
BDI (N = 26)
F or Chi (df)P
Age; years (standard deviation)
Female gender; percent
Education; years (standard
Marital status; percent married
Degree of physical impairment;
percent (standard deviation)
Time since the accident; years
∗Note: 1 = High PSS/High BDI; 2 = High PSS/Low BDI; 3 = Low PSS/Low BDI.
10.64 (2.85)10.00 (2.44) 11.39 (2.74)1.23 (2,79) ns
28.2%5.9% 16.5%15.24 (6)
46.35% (15.99)49.06% (17.52) 46.61% (12.70)0.18 (2,79) ns
4.63 (2.28) 6.31 (1.99) 5.91 (2.08)4.57 (2,79) 0.011 < 2,3∗
Table 3: Clinical characteristics of the High PSS/High BDI, High PSS/Low BDI, and Low PSS/Low BDI groups. Mean scores (standard
deviations) are reported for each questionnaire.
BDI (N = 42)
BDI (N = 17)
BDI (N = 26)
F or Chi (df)P Post-hoc SNK
About the Self
About the World
∗Note: 1 = High PSS/High BDI; 2 = High PSS/Low BDI; 3 = Low PSS/Low BDI.
1 > 2,3∗
1 > 2 > 3
1 > 2,3
1 > 2> 3
1 > 2,3
1 > 2,3
72.93 (23.77)48.94 (19.23)38.43 (14.41)22.47 (2,79)0.0011 > 2,3
31.83 (9.13)24.56 (11.41)24.57 (8.51)5.81 (2,79)0.0011 > 2,3
13.55 (7.38)11.12 (5.31) 9.74 (6.24)3.04 (2,79)ns
group of injured workers endorsed more avoidance, but not
reexperiencing and hyperarousal, symptoms as compared
with the Low PSS/Low BDI group. Theoretical models of
PTSD substantially agree in recognizing that avoidance of
thoughts and feelings and/or external stimuli related to
the trauma play a key role in the long-term maintenance
of PTSD symptoms, since avoidance is thought to prevent
adequate emotional processing of the traumatic event and to
interfere with integration and restructuring of dysfunctional
cognitions concerning the trauma (e.g., ). Our finding
might indicate that in injured workers that have developed
long-term PTSD symptoms without concurrent depressive
symptoms, poor adjustment is specifically associated with
persistent avoidance symptoms.
A substantial proportion of injured workers in our
sample were relatively well adjusted following the workplace
accident, as they did not show either posttraumatic or
depressive symptoms of clinical relevance. Importantly, in
the Low PSS/Low BDI group the mean degree of physical
disability was comparable with that of the other two groups,
whereas the rate of unemployment was significantly lower
than that in the other two groups. These findings fit with
recent observations that the objective severity of physical
injury following a traumatic accident is not related to the
occurrence or severity of the psychological consequences
(e.g., ) and that the absence of psychopathological
symptoms after a severe accidental injury is a positive
prognostic factor for early return to work (e.g., [44, 45]).
However, the design of this study does not provide a direct
way of knowing the direction of causality, if any, between
the absence of posttraumatic and depressive psychopathol-
ogy and return to work. Further studies in the field of
occupational health research should clarify which individual
psychological factors best predict return to work following
an injury, and develop tailored interventions for facilitating
a timely return in the work force [46–49].
In contrast with other studies on PTSD, depression,
and their comorbidity in different trauma populations,
6 Depression Research and Treatment
where subgroups of individuals with depression only were
identified (e.g., [8, 11]), we did not observe a depression-
only subgroup in our sample of injured workers. The reason
for this may be in the length of time elapsed between the
accident and the assessment. In the studies where depression
was found as a separate disorder following the trauma,
independent of PTSD, traumatized individuals were assessed
between 1 and 3-4 months post-trauma. Differently, the
participants in our sample had been injured one to ten
years before the assessment. Indeed, the mean time from the
accident was 4.63 years in the High PSS/High BDI group.
Together, these findings suggest that, in the acute aftermath
of trauma, depressive symptoms may develop independent
of PTSD, whereas in the longer run a more general traumatic
matic symptoms, seems to be more prevalent among trauma
survivors. Of course, the intrinsic limitations of a descriptive
study do not allow us to address crucial issues regarding the
order of onset of cooccurring posttraumatic and depressive
symptoms, or cause-effect relationships.
We recognize that some limitations need to be taken into
account when interpreting the findings of the present study.
Firstly, as a descriptive study it can only quantify, but it
cannot explain, the causal relationships among the variables
underconsideration.Secondly,themajority of injured work-
ers in our study were males, thus limiting the generalizability
of findings to female victims of occupational accidents.
Because gender differences in relation to PTSD have been
reported (see ), further studies should consider this
variable carefully. Lastly, we did not explicitly assess the
workers’ attributional styles and their assumptions regarding
responsibility for their accidents. These important issues
should be addressed in future research studies.
The results of the present descriptive study have the potential
to improve our understanding of the cooccurrence of post-
traumatic and depressive symptoms following workplace
accidents. Overall, the obtained rates indicate that workplace
accidents occurring in the industrial/constructions settings
can have a major impact upon the mental health of victims.
Early treatment interventions should be designed, focusing
not only on the prevention or reduction of posttraumatic
and depressive symptoms but also on restructuring specific
maladaptive trauma-related cognitions.
The authors thank Drs. Elisa Andrighi, Arianna Di Natale,
Marianna Munaf` o, and Simona Scozzari for their support
during data collection and analysis. The study was supported
by the Associazione Nazionale Mutilati e Invalidi del Lavoro
(ANMIL) in Padova, Italy.
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