Post-traumatic symptoms 1
Running head: REDUCING THE RISK OF PTSD
*****Accepted for publication in the British Journal of Health Psychology******
The role of psychological symptoms and social group memberships in reducing the risk of
post-traumatic stress after traumatic injury
Janelle M. Jones1*, W. Huw Williams2, Jolanda Jetten3, S. Alexander Haslam2,
Adrian Harris4 & Ilka H. Gleibs5
1*Department of Psychology, Simon Fraser University, Canada
2School of Psychology, University of Exeter, United Kingdom
3School of Psychology, The University of Queensland, Australia
4Accidents & Emergency Department, Royal Devon & Exeter NHS Foundation Trust, UK
5School of Psychology, University of Surrey, United Kingdom
*Corresponding author: Janelle M. Jones, Department of Psychology, Simon Fraser
University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada; firstname.lastname@example.org
Acknowledgements: We thank Kathryn Bristow and Tamar Lawrence for their help with data
management. This research was funded by the Economic and Social Research Council (RES-
Post-traumatic symptoms 2
Objectives: The costs associated with traumatic injury are often exacerbated by the
development of post-traumatic stress symptoms. However it is unclear what decreases the
risk of developing post-traumatic symptoms over time. The aim of the present research was
to examine the role of psychological symptoms and social group memberships in reducing
the risk of developing post-traumatic stress symptoms after orthopaedic injuries (OI) and
acquired brain injuries (ABI).
Design/Methods: A longitudinal prospective study assessed self-reported general health
symptoms, social group memberships, and post-traumatic stress symptoms among
participants with mild or moderate ABI (n=62) or upper limb OI (n=31) at two weeks (T1)
and three months (T2) after injury.
Results: Hierarchical regressions revealed that having fewer T1 general health symptoms
predicted lower levels of T2 post-traumatic stress symptoms after OI but forming more new
group memberships at T1 predicted lower levels of T2 post-traumatic stress symptoms after
Conclusions: A focus on group memberships may be particularly important in reducing the
risk of developing post-traumatic stress symptoms after injuries, such as ABI, which result in
long-term life changes.
Word count: 176
Keywords: post-traumatic stress, general health symptoms, social group memberships,
Manuscript word count: 4864 + title page: 132 (max is 5000)
Post-traumatic symptoms 3
Traumatic injuries have considerable economic and physical costs. These injuries account for
one tenth of lost lives and one sixth of the disease burden worldwide (World Health
Organisation, 2008) and an estimated $80 billion in medical treatment and $326 billion in lost
productivity in the US alone (Corso, Finkelstein, Miller, Fiebelkorn, & Zaloshnja, 2006).
Over half of the injuries sustained in developed countries such as the US are attributable to
unintentional accidents (e.g., falls, motor vehicle accidents; Johnson, Thomas, Thomas, &
Sarimento, 2009; Polinder, Meerding, Toet, van Baar, Mulder, & van Beeck, 2004). When
fatality does not occur, these accidents often result in injuries that lead to temporary or life-
long disability. Two major types of injury are orthopedic injury (OI), such as a strain, sprain,
dislocation or fracture of the musculoskeletal system (e.g., arm, leg, tendon), and acquired
brain injury (ABI), where normal brain function is impaired by a blow to, or puncturing of,
Given that OI and ABI are often caused by traumatic incidents, it is not surprising that
post-traumatic stress symptoms and post-traumatic stress disorder (PTSD) are common
outcomes. PTSD occurs for 10-14% of individuals who have experienced any traumatic event
and occurs in approximately 7.5% of individuals who have experienced an accident (e.g.,
Breslau, Davis, Andreski & Peterson, 1991; Kessler, Sonnega, Bromet, Hughes & Nelson,
1995). There is also an increased incidence of these outcomes among people with traumatic
accidental injuries. For instance, Mellman, David, Bustamente, Fins and Esposito (2001)
found that 16% of patients with accidental OI exhibited post-traumatic stress symptoms
roughly two weeks after injury. This number increased to 24% six weeks after injury, with an
additional 22% of patients exhibiting sub-clinical PTSD (i.e., 2 of 3 symptoms). Findings
reported by Starr and colleagues (2004) were even more striking. They found that 43% to
57% of patients with OI (due to falls and motor vehicle accidents) met the criteria for PTSD
one year after injury. Reports indicate that a similar proportion of individuals with accidental
Post-traumatic symptoms 4
ABI also meet the criteria for PTSD 3 to 12 months after injury (see McMillan, Williams, &
In light of these findings, the importance of trying to reduce the likelihood of post-
traumatic stress symptoms after accidental injury becomes obvious. A first step in this
process is to identify and address the risk factors associated with post-traumatic stress
symptom development. The present research examined the roles of two factors in reducing
the development of post-traumatic stress symptoms after accidental injury: (a) general health
symptoms and (b) social group memberships.
General health symptoms as predictors of post-traumatic stress symptoms
Symptoms can tell us a lot about injury. Indeed, the persistence or dissipation of
symptoms is an important indicator of people’s overall health and well-being. One of the
more robust findings in the PTSD literature is that stress symptoms immediately after a
traumatic event are strongly related to the development of PTSD (Yehuda, 2002). For this
reason, many post-trauma interventions have focused on reducing initial post-traumatic stress
symptoms. However this strategy is not always effective — suggesting that other factors
might also play a role in the experience and development of initial post-traumatic stress
symptoms and PTSD over time. We propose that general health symptoms can provide
additional insight into these outcomes.
General health symptoms refer to the presence of psychological and somatic
symptoms such as fatigue (e.g., feeling run down), anxiety, insomnia, social dysfunction
(e.g., been able to enjoy normal day-to-day activities), and severe depression (e.g., feeling life
is hopeless) after traumatic incidents, and have been associated with several negative
outcomes. For example, Michaels and colleagues (1999a) found that a decline in general
health six months after injury due to a motor vehicle accident was associated with
significantly higher levels of PTSD. This finding, like much of the research on general health,
Post-traumatic symptoms 5
is based on retrospective self-reports of general health symptoms some time after injury.
Accordingly, it is not clear whether general health symptoms are predictive of the
development of initial post-traumatic stress symptoms, or PTSD, over time.
Given that these somatic and psychological concerns may prove to be an unwelcome
change to an individual's daily functioning, we contend that the extent to which general
health symptoms are perceived to be severe or debilitating might be associated with higher
levels of post-traumatic stress symptoms.
Social group memberships as a predictor of post-traumatic stress symptoms
The social identity approach to health and well-being suggests that social group
memberships, such as friendships, families, clubs, and other community or organisational
affiliations, and the identities that are gained from them, make a significant contribution to
people’s outcomes (Haslam, Jetten, Postmes & Haslam, 2009; Jetten, Haslam, & Haslam,
2011; Tajfel & Turner, 1979). The beneficial health effects of group memberships is often
most apparent when people experience important life changes as a result of illness and injury.
For example, it has been found that maintaining or gaining group memberships is associated
with higher levels of life satisfaction and self-esteem, improved cognitive functioning,
enhanced physical health and lower mortality when faced with stroke, dementia, and acquired
brain injury (Boden-Albala, Litwak, Elkind, Rundek & Sacco, 2005; Ertel, Glymour &
Berkman, 2008; Haslam, et al., 2008; Jetten, Haslam, Pugliese, Tonks, & Haslam, 2010;
Jones et al., 2011).
Why would maintaining or gaining group memberships be such an important
determinant of health and well-being? Equally important, why might group memberships
play a role in whether people develop post-traumatic stress symptoms? First, group
memberships provide a basis for the receipt of social support (Haslam, O’Brien, Jetten,
Penna, & Vormedal, 2005). From theories that address issues of social identity (Tajfel &
Post-traumatic symptoms 6
Turner, 1979) and conservation of resource (Hobfoll, 1989; 2002) we know that belonging to
many groups is one way that people can gain the support needed to understand and cope with
illness, injury, and important life transitions (e.g., Haslam et al., 2009; Iyer, Jetten, Tsivrikos,
Haslam, & Postmes, 2009; Jones et al., 2011; Putnam, 2000). Furthermore, past research has
shown that lack of social support is a strong predictor of traumatic stress and PTSD (see
Brewin, Andrews & Valentine, 2000; Ozer, Best, Lipsey & Weiss, 2003). For instance, lower
levels of social support are associated with higher levels of PTSD 14 years after spinal cord
injury (Nielsen, 2003) and after motor vehicle accidents (Clapp & Beck, 2009). However,
what is not known is whether group memberships predict the initial development of post-
traumatic stress symptoms and the persistence of these symptoms over time. If group
memberships provide a basis for social support, then it follows that having access to more
group memberships (and thus more coping resources) should be associated with reduced
traumatic stress (Hobfoll, 1991).
Second, because group life is central to our sense of who we are, the maintenance of
group memberships provide individuals with an important sense of self-continuity (Haslam et
al., 2008; Sani, Bowe, & Herrera, 2008). When people are able to maintain memberships in
groups that they belonged to before injury, this provides psychological ties to the past that
can help them make sense of the present (Iyer et al., 2009; Iyer & Jetten, 2011). Moreover,
such self-continuity also provides a platform for the acquisition of new group memberships in
the future (Bluck & Alea, 2008).
Third, because group life is also a crucible for the formation of identity (Postmes,
Haslam & Swaab, 2005), gaining new group memberships can help individuals to re-build
their sense of self after illness or injury. In particular, new group memberships provide
opportunities for interaction, influence and sense-making which allow individuals to re-
negotiate, re-define, and re-invent who they are when faced with important life changes such
Post-traumatic symptoms 7
as traumatic injury (e.g., Jones et al., 2011). This in turn is linked to post-traumatic growth
(Muenchberger, Kendall & Neal, 2008). For all of these reasons we contend that changes to
social group memberships might play an important role in determining the development of
post-traumatic symptoms and the persistence of such symptoms over time.
Research overview and hypotheses
The aim of the present research was to examine the contributions of general health
symptoms and social group memberships in reducing the development of post-traumatic
stress symptoms over time. We examined this question within two injury groups —
individuals with orthopaedic injuries (OI) and individuals with acquired brain injuries (ABI)
— at two weeks (T1) and three months (T2) after discharge from the emergency department
of a large hospital in the United Kingdom. At both measurement points, we obtained self-
reports of post-traumatic stress symptoms, general health symptoms, and group memberships.
We hypothesized (a) that fewer initial symptoms post-injury (T1) would be associated with
lower levels of post-traumatic stress symptoms at T2 over and above initial levels of post-
traumatic stress symptoms (H1), and (b) that the more social group memberships individuals
maintained and acquired immediately following injury, the lower their levels of post-
traumatic stress symptoms would be at T2 (over and above initial levels of post-traumatic
stress symptoms) (H2).
We also explored whether there might be differences in the contributions of
symptoms and group memberships to post-traumatic stress symptoms over time as a function
of the type of injury sustained (H3). On the one hand, there are important similarities between
ABI and OI: both result from traumatic incidents, are treated at hospital emergency
departments, and vary in their severity. On the other hand, there are marked differences. The
effects of OI on individuals are often temporary: symptoms heal and relationships with others
tend to be unaffected. However, the effects of ABI on individuals can be permanent:
Post-traumatic symptoms 8
Symptoms can persist or get worse and relationships with others can become strained or
dissolve often because ABI is associated with psychological and physical changes that do not
occur with OI (Wood, Liossi & Wood, 2005; see also C. Haslam et al., 2008). Exploring the
impact of these variables within injuries could highlight important differential indicators of
post-traumatic stress symptoms over time.
Two weeks after being admitted to a large hospital in England 141 patients completed
the first measurement (T1; Overall age: M=45.16, SD=14.31; Male: n= 57, Female: n=84; All
White British). Patients had sustained mild head injury (i.e., no loss of consciousness
reported: n=58), moderate head injury (i.e., loss of consciousness reported: n=40), or upper
limb orthopaedic injury (no loss of consciousness reported: n = 43). Data had been screened
to eliminate individuals who had sustained injury from assault, sexual assault, and individuals
who had sustained orthopaedic injuries that also involved blows to the head. All T1
participants were also contacted three months after discharge (T2). T2 participants were 93
patients (Overall age: M=47.24, SD=14.01; Male: n=36, Female: n=57) who had sustained
mild head injury (MHI: n=35), moderate head injury (MoHI: n=27), or upper limb
orthopaedic injuries (OI: n=31). All analyses reported below were conducted with the 93
participants who had participated at both T1 and T2 and who had completed all relevant
measures. For these participants, injuries had been sustained through falls (n=57), accidents
(n=12), sports injury (n=11), hitting their head (n=4; MHI only), road traffic accidents (n=4),
migraine/virus (n=2; HI conditions only), or alcohol related fall/blackouts (n=3; MoHI only).
Participants responded to a single item to assess injury severity (i.e., How serious was the
event?) on a scale from 1 (Minor) to 4 (Severe). On average, injuries were seen as minor,
although participants who had sustained MoHI rated their injuries more serious (M=1.77,
Post-traumatic symptoms 9
SD=.71) than did participants who had sustained MHI (M=1.27, SD=.67; p = .004). Neither
HI condition differed significantly from the OI condition in perceived injury severity
(M=1.52, SD=.51, ps > .12; F (87)=4.48, p=.014, ηp2 =.09; 3 participants did not rate their
injury’s severity). Analyses indicated that there were no significant differences in the number
of participants who remained versus dropped out in terms of their membership in different
injury groups: 2 (2) = 1.58, p = .46 or by gender: 2 (1) = .33, p = .56. The only observed
difference was in terms of age. Participants who remained in the study were significantly
older (M = 47.24, SD = 14.01) than those who dropped out (M = 40.87, SD = 14.11; t (136) =
2.50, p = .014.
Measures and Procedure
Participants who had given their consent to be contacted at discharge were contacted
by mail to take part in a longitudinal study on well-being after injury. During the first mail-
out they were sent a package that included an information sheet, informed consent, and the
questionnaire. The questionnaire assessed general health symptoms, group memberships, and
post-traumatic stress and asked for demographic information (e.g., injury severity, age,
gender). Participants were told that they would be approached again at three months post-
injury to complete the same questionnaire and told that they could opt out at any point. A
total of 890 questionnaires were mailed out as part of our initial data collection. In total we
had a response rate of 16% at T1, and retained 66% of these respondents at T2. Respondents
were entered into monthly draws for £50 worth of department store vouchers.
Participants completed the short form of the General Health Questionnaire (GHQ-12;
Goldberg, 1992) to assess their symptoms after injury. Here they made subjective judgements
about changes in the presence of somatic symptoms (e.g., feeling run down), anxiety,
insomnia, social dysfunction, and depression over the past week on a 3-point scale (worse=-
1, same=0, better=1). Participants’ scores were summed across the 12 questions to compute a
Post-traumatic symptoms 10
total GHQ score, where negative scores indicated worsening symptoms and positive scores
indicated improving symptoms (T1: α=.88, M=-1.96, SD=3.86; Range: -12 to 6).
Participants also completed three measures assessing the sense of belonging,
connection, and support associated with their group memberships before and after injury
(EXeter Identity Transitions Scales — EXITS; Haslam et al., 2008). Four items measured
their maintained group memberships since injury (e.g., I still belong to the same group(s) that
I was in before; I still receive support from the same groups I was in before; T1: α=.87,
M=3.80, SD=.81), and four items measured their new group memberships since injury (e.g., I
am active in one or more new groups; I get practical help from people in one or more new
groups; T1: α=.95, M=2.24, SD=.96). To control for pre-existing differences in number of
group memberships participants belonged to before the injury, four items measured their pre-
injury group memberships (e.g., I was a member of lots of different groups, I had friends in
many different groups; T1: α=.91, M=3.27, SD=.99).
Post-traumatic stress symptoms were measured using the Trauma Screening
Questionnaire (Brewin et al., 2002). Participants agreed or disagreed to 10 yes/no statements
concerning emotional and physical disturbances related to their injury (e.g., Bodily reactions
when reminded of the event; Upsetting thoughts or memories about the event come into your
mind against your will). The number of statements with which they agreed was summed and
divided by the total number of items to produce an index of the proportion of post-traumatic
stress symptoms experienced (T1: Myes=.24, SD=.24, T2: Myes=.16, SD=.18). Using Brewin et
al.’s criteria of experiencing 6 or more disturbances, we found that 17% of participants with
acquired brain injury and 11% of participants with orthopaedic injury experienced post-
traumatic stress symptoms at T1. These figures dropped to 9% and 3% respectively at T2. It
should be noted that hat there were no significant differences between participants who
remained in the study and those who left in terms of their GHQ scores, the number of
Post-traumatic symptoms 11
maintained groups or new groups that they had formed, or their reported PTSD at T1, all ts <
-.93, all ps > .34.
Pearson’s correlations were computed to examine the bivariate relationships between
general health symptoms, groups memberships, and post-traumatic stress symptoms after
injury (see Table 1). Findings revealed that higher levels of post-traumatic stress symptoms at
T2 were associated with higher levels of T1 post-traumatic stress symptoms, general health
symptoms at T1, and fewer new group memberships at T1. There were no relationships
between age, injury severity, the number of old group memberships, or the number of
maintained group memberships, on T2 post-traumatic stress symptoms. However, old and
new group memberships were positively related to new group memberships at T1. General
health symptoms were also marginally correlated with new group memberships at T1.
Next, hierarchical multiple regressions were used to examine the contributions of
symptoms and group memberships, over and above initial levels of post-traumatic stress
symptoms, on post-traumatic stress symptoms over time. On the basis of the correlations and
our hypotheses, we targeted our analyses on the two T1 predictor variables that were
significantly related to post-traumatic stress symptoms at T2. Post-traumatic stress symptoms
at T1 were entered into the first step as a control variable. General health symptoms at T1
were entered into the second step and new group memberships at T1 were entered into the
third step. Post-traumatic stress symptoms at T2 served as the dependent variable. The
control variable and predictors were all mean centred.
Post-traumatic stress symptoms at three months
Over and above the contribution of post-traumatic stress symptoms at T1, we found
that general health symptoms at T1 accounted for an additional 3% of the variance in post-
traumatic stress symptoms at T2 (see Table 2). Not surprisingly, fewer general health
Post-traumatic symptoms 12
symptoms at T1 were associated with lower levels of post-traumatic stress symptoms at T2,
β=-.20, t=-2.02, p = .047. This provided support for H1: the fewer general health symptoms
individuals had at T1, the less likely it was that they would develop post-traumatic stress
symptoms over time. In support of H2 we found that new group memberships at T1
accounted for an additional 7% of the variance in post-traumatic stress symptoms at T2 when
controlling for post-traumatic stress symptoms and general health symptoms at T1.
Participants who indicated they had joined new groups after injury at T1 reported lower
levels of PTSD symptoms at T2 (β=-.19, t=-2.19, p=.031). Having fewer general health
symptoms and joining new groups two weeks after injury, explained some of the variance in
post-traumatic stress symptoms over time, with new group memberships having an impact on
post-traumatic stress symptoms over and above that of general health symptoms. Yet while
these patterns are broadly consistent with H1 and H2, we argue that it is also important to
examine support for these hypotheses as a function of the nature of the injury sustained (i.e.,
Orthopaedic Injury. Separate analyses of individuals with OI (see Table 3) indicated
that over and above the effects of initial levels of post-traumatic stress symptoms, general
health symptoms at T1 accounted for an additional 10% of the variance in post-traumatic
stress symptoms at T2. In particular, there was a significant effect such that fewer general
health symptoms at T1 were associated with lower levels of post-traumatic stress symptoms
at T2, β = -.36, t(26)=-2.23, p=.035. Acquisition of new group memberships at T1 did not add
any additional explanatory power to understanding subsequent levels of post-traumatic stress
Head injury. Analyses of individuals with acquired brain injuries (see Table 4)
indicated that general health symptoms at T1 did not contribute any additional explanatory
power to our understanding of post-traumatic stress symptoms at T2. However, group
Post-traumatic symptoms 13
memberships at T1 explained an additional 4% of the variance in post-traumatic stress
symptoms at T2. Participants who were able to form new group memberships at T1 reported
experiencing lower levels of post-traumatic stress symptoms at T2, β=-.21, t=-2.09, p=.042.
In support of H3, then, there appear to be clear differences in the additional factors that
predict post-traumatic stress symptoms as a function of the type of injury that individuals
The present study sought to identify the factors that might reduce the risk of
developing post-traumatic stress symptoms after unintentional accidents resulting in
orthopaedic and acquired brain injury. Extending previous research, we found that when
controlling for initial levels of post-traumatic stress symptoms, having more new group
memberships predicted lower levels of post-traumatic stress symptoms after injury over and
above the contribution of general health symptoms.
Importantly, we provide novel evidence that the contribution of general health
symptoms and group memberships to post-traumatic stress symptoms after injury differs as a
function of the type of injury sustained. For individuals with orthopedic injuries fewer
general health symptoms were associated with lower levels of post-traumatic stress
symptoms three months later. For individuals with acquired brain injuries, gaining new group
memberships post-injury predicted lower levels of post-traumatic stress symptoms at three
months. Although post-traumatic stress symptoms are a common experience for individuals
with both types of injuries, these findings suggest that addressing general health symptoms
may be critical in reducing the development of post-traumatic stress symptoms after
orthopedic injury whereas facilitating group memberships may provide an important
additional buffer against the development of post-traumatic stress symptoms after acquired
Post-traumatic symptoms 14
Evidence that general health symptoms and group memberships appear to have
different implications for the development of post-traumatic stress symptoms as a function of
the type of injury sustained might reflect fundamental differences in the consequences of
orthopedic and acquired brain injuries. As noted earlier, despite the fact that these injuries are
similar in some ways, they differ in the extent to which they involve long-term life changes.
Orthopaedic injuries often result in temporary impairment of physical functioning. Broken
bones, fractures, strains and sprains eventually heal, enabling individuals to regain most, if
not all, of their physical functioning. Individuals with orthopaedic injuries and fewer initial
symptoms may therefore experience lower levels of post-traumatic stress symptoms over
time because their injury is minimally disruptive of their way of life — it does not result in
major changes or challenges to which they must adjust.
In contrast, acquired brain injuries often result in more lasting impairment of physical
and psychological functioning. The physical, cognitive, emotional, and behavioural changes
that accompany acquired brain injuries do not always heal, and are often absent from
orthopaedic injuries. In fact people who sustain brain injuries can be left with permanent
changes to both their abilities and their sense of self. These changes often strain social
relationships (e.g., Wood et al. 2005), which may jeopardise a person’s ability to deal
effectively with the consequences of the permanent changes associated with injury. In these
terms, individuals with acquired brain injuries who are able to join new groups may
experience lower levels of post-traumatic stress symptoms because these relationships
provide the psychological resources (e.g., opportunities for self-continuity and identity
formation) and social resources (e.g., social support) needed to manage the changes
associated with brain injury that can help them makes sense of, and reframe, their post-injury
experiences (Hobfoll, 1991; Iyer & Jetten, 2011; Jones et al., 2011). In these ways, group
Post-traumatic symptoms 15
memberships might help to smooth the disruption to one’s life caused by more permanent
Implications and Recommendations
In light of these findings we can make two simple recommendations for dealing with
individuals who have sustained accidental injury. First, upon discharge, patients’ group
memberships should be assessed at various points in time (see Haslam, Jetten, & Haslam,
2011). Monitoring the quantity and quality of lost, maintained, or gained group memberships
may be an important line of defence against post-traumatic stress symptoms after injury.
Indeed, research suggests that the more groups individuals belong to, the more resources they
can draw upon and the better they cope when faced with the changes and challenges of life
transitions and physical stressors (Iyer et al., 2009; Jones & Jetten, 2011). Furthermore,
having good, supportive groups that provide useful and needed resources plays a substantial
role in the reduction of negative outcomes when contending with the changes and challenges
associated with different health conditions (Cohen, 2004; Haslam et al., 2011; Stinson et al.,
2008). In addition to more traditional assessments of symptoms, monitoring changes in the
quantity and the quality of pre-injury and post-injury group memberships might be a useful
indicator of who is at risk of developing negative outcomes such as post-traumatic stress
symptoms, or PTSD over time.
The present findings are notable because they reflect one of the first prospective and
longitudinal assessments of the contribution of both psychological symptoms and group
memberships in the development of post-traumatic stress symptoms. They suggest that
group-building activities might be a fruitful avenue for the design and implementation of
interventions to reduce post-traumatic stress symptoms. Recent work by Gleibs and her
colleagues has demonstrated that group-based based interventions, such as water clubs to
promote behaviour change among older adults, and gender-based clubs to promote social
Post-traumatic symptoms 16
connection and community within residential care, are associated with positive outcomes
including increases in water consumption and lower levels of psychological distress (e.g.,
depression, anxiety; Gleibs, Haslam, Haslam & Jones, 2011; Gleibs, Haslam, Jones et al.,
2011). On the basis of such findings a second recommendation would be to have health care
professionals and clinicians refer individuals who have sustained traumatic injuries to
relevant support groups. The mutual support gained from these groups may be especially
useful for conditions that carry a large social burden (i.e., conditions that are embarrassing,
disfiguring, or stigmatizing; Davison, Pennebaker & Dickerson, 2000). Support groups can
be a therapeutic, and cost-effective, addition to primary care services, or a much-needed
supplement for patients who have lost other social resources (e.g., Hobfoll, 2002). Informing
patients that support groups exist can increase the uptake of these types of services, and has
the potential to increase the breadth of the care received by patients, which may improve their
Limitations and future directions
Despite the important contribution to our understanding of the development of post-
traumatic stress symptoms over time, there are some limitations associated with the present
research. First, the sample size was relatively small. Our initially low response rate and
subsequent dropout may reflect the fact that participants were entered into a random prize
draw rather than receiving compensation individually. Questionnaire length and the multiple
time points for data collection might have also contributed to participant drop-out (see
Edwards et al., 2002, for relevant discussion). While this does not invalidate our findings, it
does make it necessary to determine whether similar patterns are observed among larger
samples of injured individuals.
Second, the incidence of post-traumatic stress in the present sample was low over
time in comparison to some of the numbers reported in the literature (e.g., Starr et al., 2004;
Post-traumatic symptoms 17
McMillan et al., 2003). This may reflect national differences in the perception of traumatic
events and/or the support available to manage injuries. Indeed, differences in the British
versus American medical systems might have an impact on the personal economic burden of
treatment and/or the type of care and support obtained. Furthermore, national differences also
exist in the outcomes associated with accidental injuries. Developing countries (e.g., Eastern
Europe) report higher levels of mortality from accidental injuries relative to developed
countries (e.g., Western Europe, North America; Peden, McGee, & Sharma, 2002). More
detailed cross-national comparisons (e.g., taking into account injuries sustained, available
support, the presence of differential risk factors) could provide useful information about the
generalizability of the present findings across different cultural contexts.
Third, while three months after injury is a considerable length of time, it could take
longer to recognize and diagnose PTSD after accidental injury. Extended follow-ups of
individuals at 6 and 12 months after injury might yield additional insight into the roles that
symptoms and groups memberships play in the development of PTSD.
Finally, although the measures used in the present research are adequate, future
research could use measures that conceptualize general health, social group memberships,
and post-traumatic stress symptoms in slightly different ways. For instance, with respect to
social group memberships, we do not know the specific groups that individuals were thinking
about when responding to the EXITS items. Future research should ask individuals to list
these groups and examine whether there are specific types of groups that are more (or less)
beneficial to individuals who are recovering from different injuries. Alternative measures of
general health symptoms (e.g., the Short-form 36 Health Survey; Ware, Kosinski, & Keller,
1996; Ware & Sherbourne, 1992) and post-traumatic stress symptoms (e.g., the PTSD
Symptom Scale Self-Report; Foa, Riggs, Dancu, & Rothbaum, 1993) might also improve the
specificity of the variables of interest in the present research and, if patterns are similar, can
Post-traumatic symptoms 18
provide converging evidence of the roles of symptoms and groups memberships in the
development of initial post-traumatic stress symptoms and PTSD over time.
Accidental injury has substantial costs that are often compounded by the development
of post-traumatic stress symptoms after injury. The present research suggests that whether
symptoms or group memberships contribute to the development of post-traumatic stress
symptoms after injury depends on the nature of the injury and its implications for long-term
physical and psychological functioning. Strategies for reducing the development of post-
traumatic stress symptoms may therefore need to be more sensitive to the nature of the injury
itself. In particular, while a traditional strategy of symptom alleviation seems to be the best
way of managing those recovering from orthopaedic injury, the maintenance and
development of group memberships seems to the best way of improving outcomes for those
who are recovering from acquired brain injury. This conclusion is consistent with growing
recognition that the road to cure is not only physical but also social (Jetten, Haslam &
Haslam, 2011), and that effective patient management requires sensitivity to both of these
Post-traumatic symptoms 19
Bisson, J. I. (2007). Post-traumatic stress disorder. British Medical Journal, 334, 789-793.
Bluck, S. & Alea, N. (2008). Remembering being me: The self continuity function of
autobiographical memory in younger and older adults. In F. Sani (Ed.) Self
continuity: Individual and collective perspectives (pp. 55-70). New York, NY, US:
Boden-Albala, B. Litwak, E., Elkind, M.S.V., Rundek, T. & Sacco, R. L. (2005). Social
isolation and outcomes post stroke. Neurology, 64, 1888-1892.
Breslau, N., Davis, G. C., Andreski, P., Peterson, E. (1991). Traumatic events and
posttraumatic stress disorder in an urban population of young adults. Archives of
General Psychiatry, 48, 216 - 222.
Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for
posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and
Clinical Psychology, 68, 748 –766.
Brewin, C. R., Rose, S., Andrews, B., Green, J., Tata, P., McEvedy, C., Turner, S. & Foa, E.
B. (2002). Brief screening instrument for post-traumatic stress disorder. British
Journal of Psychiatry, 181, 158-162.
Cohen, S. (2004). Social relationships and health. American Psychologist, 59, 676-684.
Clapp, J. D. & Beck, J. G. (2009). Understanding the relationship between PTSD and social
support: The role of negative network orientation. Behaviour Research and Therapy,
Davison, K. P., Pennebaker, J. W. & Dickerson, S. S. (2000). Who talks? The social
psychology of illness support groups. American Psychologist, 55, 205-217.
Edwards, P., Roberts, I., Clarke, M., DiGiuseppi, C., Pratap, S., Wentz, R. & Kwan, I.
(2002). Increasing response rates to postal questionnaires: Systematic review. BMJ,
Post-traumatic symptoms 20
Ertel, K. A., Glymour, M. M., & Berkman, L. F. (2008). Effects of social integration on
preserving memory function in a nationally representative US elderly population.
American Journal of Public Health, 98, 1215-1220.
Foa, E. B., Riggs, D. S., Dancu, C. V., & Rothbaum, B. O. (1993). Reliability and validity of a
brief instrument for assessing posttraumatic stress disorder. Journal of Traumatic Stress,
Gleibs, I. H., Haslam, C., Haslam, S. A., & Jones, J. M. (2011). Water clubs in residential
care: Is it the water or the club that enhances health and well-being? Psychology &
Health, 26, 1361-1377.
Gleibs, I. H., Haslam, C., Jones, J. M., Haslam, S. A., McNeill, J. & Connolly, H. (2011). No
country for old men? The role of a ‘Gentlemens’ Club’ in promoting social
engagement and psychological well-being in residential care. Aging and Mental
Health, 15, 456-467.
Goldberg, D. (1992). General Health Questionnaire (GHQ-12). Windsor, UK: NFER-
Haslam, C. Jetten, J., & Haslam, S. A. (2011). Advancing the social cure: Implications
for theory, practice, and policy. In J. Jetten, C. Haslam & S. A. Haslam (Eds.) The
Social Cure: Identity, health, and well-being. London: Psychology Press.
Haslam, C., Holme, A., Haslam, S.A., Iyer, A., Jetten, J., & Williams, W.H. (2008).
Maintaining group membership: Identity continuity and well-being after stroke.
Neuropsychological Rehabilitation, 18, 671-691.
Haslam, S. A., O’Brien, A., Jetten, J., Vormedal, K., & Penna, S. (2005). Taking the strain:
Social identity, social support and the experience of stress. British Journal of Social
Psychology, 44, 355–370.
Post-traumatic symptoms 21
Haslam, S. A., Jetten, J., Postmes, T. & Haslam, C. (2009). Social identity, health and well-
being: An emerging agenda for applied psychology. Applied Psychology: An
International Review, 58, 1-23.
Hobfoll, S. E. (1989). Conservation of resources: A new attempt at conceptualizing stress.
American Psychologist, 44, 513-524.
Hobfoll, S. E. (1991). Traumatic stress: A theory based on rapid loss of resources. Anxiety
Research, 4, 187-197.
Hobfoll, S. E. (2002). Social and psychological resources and adaptation. Review of General
Psychology, 6, 307-324.
Hu, Y., Stewart-Brown, S., Twigg, L. & Weich, S. (2007). Can the 12-item General Health
Questionnaire be used to measure positive mental health? Psychological Medicine,
Iyer, A., & Jetten, J. (2011). What's left behind: Identity continuity moderates the effect of
nostalgia on well-being and life choices. Journal of Personality and Social
Psychology, 101, 94-108.
Iyer, A., Jetten, J., Tsivrikos, D., Haslam, S. A., & Postmes, T. (2009). The more (and the
more compatible) the merrier: Multiple group memberships and identity compatibility
as predictors of adjustment after life transitions. British Journal of Social Psychology,
Jetten, J., Haslam, C., Pugliese, C., Tonks, J., & Haslam, S.A. (2010). Declining
autobiographical memory and the loss of identity: Effects on well-being. Journal of
Clinical and Experimental Neuropsychology, 32, 408-416.
Jetten, J., Haslam, C. & Haslam, S. A. (Eds) (2011). The Social Cure: Identity, health, and
well-being. New York: Psychology Press.
Jetten, J., Haslam, C., Haslam, S.A., & Branscombe, N. (2009, September/October). The
Post-traumatic symptoms 22
social cure: How and why groups make us healthier. Scientific American Mind, 26-33.
Johnson, R. L., Thomas, R.G., Thomas, K.E. & Sarmiento, K. (2009). State Injury Indicators
Report: Fourth Edition— 2005 Data. Atlanta (GA): Centers for Disease Control and
Prevention, National Center for Injury Prevention and Control.
Jones, J. M., Haslam, S. A., Jetten, J., Williams, W. H., Morris, R., & Saroyan, S. (2011).
That which doesn’t kill us can make us stronger (and more satisfied with life): The
contribution of personal and social changes to well-being after acquired brain injury.
Psychology & Health, 26, 353-369.
Jones, J. M. & Jetten, J. (2011). Recovering from strain and enduring pain: Multiple group
memberships promote resilience in the face of novel physical challenges. Social
Psychological and Personality Science, 3, 239-243.
Jones, J. M., Jetten, J., Haslam, S. A. & Williams, W. H. (2011). Deciding to disclose: The
importance of social relationships for well-being after acquired brain injury. In J.
Jetten, C. Haslam & S. A. Haslam (Eds). The Social Cure: Identity, health, and well-
being (pp. 255-271). London: Psychology Press.
Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic
stress disorder in the National Comorbidity Survey. Archives of General Psychiatry,
52, 1048 - 1060.
King, N. S. (1996). Emotional, neuropsychological, and organic factors: their use in the
prediction of persisting postconcussion symptoms after moderate and mild head
injuries. Journal of Neurology, Neurosurgery & Psychiatry, 61, 75-81.
King, N. S., Crawford, S., Wenden, F.J., Moss, N.E.G. & Wade, D.T. (1995). The Rivermead
Post Concussion Symptoms Questionnaire: A measure of symptoms commonly
experienced after head injury and its reliability. Journal of Neurology, 242, 587-592.
McCauley, S. R., Boake, C., Levin, H. S., Contant, C. F., & Song, J. X. (2001).
Post-traumatic symptoms 23
Postconcussional disorder following mild to moderate traumatic brain injury: Anxiety,
depression, and social support as risk factors and comorbidities. Journal of Clinical
and Experimental Neuropsychology, 23, 792 - 808.
McMillan, T. M., Williams, W. H., & Bryant, R. (2003). Post-traumatic stress disorder and
traumatic brain injury: A review of causal mechanisms, assessment, and treatment.
Neuropsychological Rehabilitation, 13, 149–164.
Mellman, T.A., David, D., Bustamante, V., Fins, A. I. & Esposito, K. (2001). Predictors of
post-traumatic stress disorder following severe injury. Depression and Anxiety, 14,
Michaels, A, J., Michaels, C. E., Moon, C. H., Smith, J, S., Zimmerman, M. A., Taheri, P.
A., & Peterson, C. (1999). Posttraumatic stress disorder after injury: Impact on
general health outcome and early risk assessment. The Journal of Trauma: Injury,
Infection, and Critical Care, 47, 460-467.
Muenchberger, H., Kendall, E., & Neal, R. (2008). Identity transition following traumatic
brain injury: A dynamic process of contraction, expansion and tentative balance.
Brain Injury, 22, 979-992.
Nielsen, M. S. (2003). Prevalence of posttraumatic stress disorder in persons with spinal cord
injuries: The mediating effect of social support. Rehabilitation Psychology, 48, 289-
Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S. (2003). Predictors of posttraumatic
stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129,
Peden, M., McGee, K., & Sharma, G. (2002). The Injury Chart Book: A graphical overview
of the global burden of injuries. Geneva: World Health Organization. Retrieved
online: January 25, 2012; URL:http://whqlibdoc.who.int/publications/924156220x.pdf
Post-traumatic symptoms 24
Perkonigg, A., Pfister, H., Stein, M. B., Hofler, M., Lieb, R., Maercker, A., & Wittchen, H-
U., (2005). Longitudinal course of posttraumatic stress disorder and posttraumatic
stress disorder symptoms in a community sample of adolescents and young adults.
American Journal of Psychiatry, 162, 1320-1327.
Perry, S., Difede, J., Musngi, G., Frances, A. J., & Jacobsberg, L. (1992). Predictors of
posttraumatic stress disorder after burn injury. American Journal of Psychiatry, 149,
Polinder, S., Meerding, W.J., Toet, H., van Baar, M.E., Mulder, S. & van Beeck, E. (2004).
A surveillance based assessment of medical costs of injury in Europe: phase 2.
Erasmus Medical Centre: Rotterdam and Consumer Safety Institute: Amsterdam.
Retrieved online from: http:/www.euroipn.org/grd/attachments/80/final%20report.pdf
Postmes, T. & Haslam, S. A, & Swaab, R. (2005). Social influence in small groups: An
interactive model of identity formation. European Review of Social Psychology, 16, 1-
Putnam, R. D. (2000). Bowling alone: The collapse and revival of American community.
New York: Simon & Schuster.
Ryan, L. M. & Warden, D. L. (2003). Post concussion syndrome. International Review of
Psychiatry, 15, 310-316.
Sani, F., Bowe, M., & Herrera, M. (2008). Perceived collective continuity and social well-
being: Exploring the connections. European Journal of Social Psychology, 38, 365–
Sareen, J., Cox, B. J., Stein, M. B., Afifi, T. O., Fleet, C., Asmundson, G. J. G. (2007).
Physical and mental comorbidity, disability, and suicidal behavior associated with
posttraumatic stress disorder in a large community sample. Psychosomatic Medicine,
Post-traumatic symptoms 25
Shalev, A.Y., Peri, T., Canetti, L., & Schreiber, S. (1996). Predictors of PTSD in injured
trauma survivors: A prospective study. American Journal of Psychiatry, 153, 219-
Smith-Seemiller, L., Fow, N. R., Kant, R., & Franzen, M. D., (2003). Presence of post
concussion syndrome in patients with chronic pain versus mild traumatic brain injury.
Brain Injury, 17, 199–206.
Starr, A. J., Smith, W. R. , Frawley, W. H., Borer, D. S., Morgan, S. J., Reinert, C. M. &
Mendoza-Welch, M. (2004) Symptoms of posttraumatic stress disorder after
orthopaedic trauma. Journal of Bone & Joint Surgery, 86, 1115 - 1121.
Stinson, D. A., Logel, C., Zanna, M. P., Holmes, J. G., Cameron, J. J., Wood, J. V., &
Spencer, S. J. (2008). The cost of lower self-esteem: Testing a self- and social-bonds
model of health. Journal of Personality and Social Psychology, 94, 412-428.
Tate, R.L., & Broe, G.A. (1999). Psychosocial adjustment after traumatic brain injury: What
are the important variables? Psychological Medicine, 29, 713–725.
Ware, J., Jr., Kosinski, M., & Keller, S. D. (1996). A 12-Item Short-Form Health Survey:
construction of scales and preliminary tests of reliability and validity. Medical Care,
Ware, J. E., & Sherbourne, C. D. (1992). The MOS 36 Item Short Form Health Survey (SF-
36). Medical Care, 30, 473-481.
Wilcox, S. (2010). Social relationships and PTSD symptomatology in combat veterans.
Psychological Trauma: Theory, Research, Practice and Policy, 2, 175-182.
Williams, W. H., Potter, S. & Ryland, H. (2010). Mild traumatic brain injury and
postconcussion syndrome: A neuropsychological perspective. Journal of Neurology,
Neurosurgery & Psychiatry. DOI: 10.1136/jnnp.2008.171298
World Health Organisation (2008). The global burden of disease: 2004 update. Retrieved
Post-traumatic symptoms 26 Download full-text
online: September 20, 2010; URL: http://www.who.int/entity/healthinfo/global_
Yehuda, R. (2002). Post-traumatic stress disorder. The New England Journal of Medicine,