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PTSD, guilt, and shame among reckless drivers


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This study examines posttraumatic stress disorder (PTSD), guilt, and shame among men convicted of having caused death through reckless driving. It also examines the contribution of sociodemographic variables, accident-related variables, and punishment-related variables to these outcomes. Seventy-five men participated in the study, 38 who accidentally caused the death of another in a road accident and 37 matched controls. Findings show that drivers who accidentally caused the death of another are a high-risk group for PTSD and accident-related guilt. The findings also reveal that PTSD and guilt are associated with severity of the punishment, degree of responsibility the driver assumes for the accident, and the driver's sense that he could have prevented the accident. Clinical implications are discussed.
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School of Social Work,Tel Aviv University,Tel Aviv, Israel
This study examines posttraumatic stress disorder (PTSD), guilt, and shame among men
convicted of having caused death through reckless driving. It also examines the contribution of
sociodemographic variables, accident-related variables, an d punishment-related variables to
theseoutcomes. Seventy-¢ve men participated in the study, 38 who acc ide ntallycausedthe death of
another in a road accident and 37 matched controls. Findings show that drive rs who accidentally
caused the death ofanother are a high-risk groupfor PTSD and accident-related guilt.The ¢nd-
ings also reveal that PTSD and guilt are associated with sever ity of the punishment, d egree of
responsibility the drive r assumes for the accident, and the drivers sense that he could have
prevented the acci dent. Clinical implications are discussed.
Road accidents are recognized as traumatic events (Kinzie, 1989) and
have been implicated in driving phobia, agoraphobia (Parker, 1977), anxi-
ety (e.g., Mayou, 1992; Mayou et al., 1993), depression (e.g., Blanchard
et al., 1991; Foeckler et al., 1978; Goldberg & Breznitz, 1982; Malt, 1988),
and posttraumatic stress disorder (PTSD) (Bryant & Harvey, 1996;
Feinstein & Dolan, 1991; Kessler et al., 1995). Yet, almost all of the literature
on the pathogenic e¡ects of such accidents deals with persons who were
injured in the accident and tends to ignore the drivers who caused the
death of others. The few studies of drivers involved in fatal accidents con-
sist mainly of clinical reports (e.g., Kogan, 1990). The present study thus
focuses on drivers who caused the death of another person in an auto
accident that they themselves survived.
The research that bears most closely on the issue at hand consists of two
studies of policemen who were involved in shooting incidents in the line of
Received 1March 2004; accepted 2 May 2004.
Address correspondence to Zahava Solomon, Adler Research Center, School of Social Work,Tel Av iv
University, Ramat Aviv,Tel Aviv, Israel 69978. E-mail:
Journal of Loss andTrauma, 9: 327^344, 2004
Copyright # Taylor & Francis Inc.
ISSN: 1532-5024 print=1532-5032 online
DOI: 10.10 8 0/15325020490 477704
duty in which citizens were killed or seriously injured. One study (Stratton
et al., 1986) found that a third of the policemen su¡ered from severe post-
traumatic residuals and that another third su¡ered from subclinical PTSD.
The second study (Gersons, 1989) found that about 78% su¡ered from
PTSD, although none of the policemen who were involved in a fatal shooting
incident sought professional help on their own initiative.
However, policeo⁄cers who kill in the line of duty di¡er markedly from
drivers who unintentionally kill in a road accident. Policeo⁄cers carry
weapons, are trained for violent encounters, and shoot to hit. Drivers who
cause death have no conscious intention of k illing or injuring their victim;
they often know the victim and, in some cases, were close to the victim; and
they are viewed by the law as reckless.
Manmade catastrophes have been found to be grounds for severe guilt
feelings. Guilt is dned as an emotional state stemming from an individuals
awareness that he or she violated moral, social, or ethical principles. In this
state, individuals who su¡er from guilt view their speci¢c past behaviors
negatively, regret those behaviors, and feel the need for punishment to pay for
the injury they caused ( Kugler & Jones, 1992; T angney, 199 0, 1991, 1992;
Tangney et al., 1 989; Wolman, 1 973) .
Guilt feelings are an inherent part of trauma. Persons who ser from
posttraumatic residue describe guilt feelings both regarding their own survi-
val when others died in the catastrophe (survivor guilt) and regarding their
conduct at the time of the traumatic event, in that they did not do enough to
prevent it and its results (Glover, 1984; Jano¡ -Bulman & Wortman,1977).
In every traumatic event in which individuals feel extreme threat, fear, and
helplessness, there is an inherent tendency to feel that, in a way, they are being
deservedly punished. The tendency to feel guilt in the wake of a traumatic
event sometimes constitutes an externalization of feelings of fear and is
anchored in feelings of powerlessness and loss of control at the time of the
catastrophe (e.g., Hendin & Haas,1984).When one was not only exposed to a
traumatic event but was also involved in causing it, the sense of guilt can be
expected to be even more intense.
The association between guilt anchored in a traumatic event and depres-
sion has been found among male soldiers and civilian women who underwent
physical torture (Kubany et al.,1995). In both groups, the more responsibility
the victims assumed for having caused the traumatic event, the more they
viewed their behavior as wrong and unjusti¢ed, the more they believed that
their conduct violated their personal values, and the more they believed that
they could have and should have prevented the traumatic event, the higher
328 T. Lowinger and Z. Solomon
the level of PTSD symptoms and depression from which they su¡ered
(Kubany et al.,1995).
The study of guilt and posttraumatic residuals among persons who cause
death or injury has focused primarily on soldiers and policemen, where there
is an intention of and sometimes also legitimization for injuring another.The
issue has not been examined among other populations of perpetrators or in
other traumatic situations, among them motor vehicle accidents (MVAs).The
present study aims to increase our understanding and knowledge of the
su b ject.
Furthermore, after an accident, along with deep feelings of anger and sad-
ness and often the reproach of the relatives of the dead, the legal system is also
involved. Another feeling that has been found to be related to PTSD is the
feeling of shame. Gilbert (1998) views shame as associated with beliefs that
others look down on oneself and see one as inferior, inadequate, disgusting, or
weak in some way. Jackley (2001) examined the relationship between self-
reported symptom distress and shame in regard to the postwar adjustment of
combat veterans. The study showed a signi¢cant and positive relationship
between shame and PTSD, depression, trait anxiety, and vulnerability.
Similar ¢ndings have been reported among battered women (Street & Arias,
The literature points to considerable variance in survivors’ psychological
responses to traumatic events. At least part of this variance may be explained
by situational, social, cultural, and personality variables. Many studies have
found that the features of the traumatic event make a special contribution to
its psychological impact (e.g., Green et al., 1985). For instance, Lifton (1967)
found that survivor’s guilt was related to the extent of the physical and emo-
tional closeness to the victim. The more the survivor felt close to the person
who was killed, the higher the intensity of guilt. Jano¡-Bulman andWortman
(1977) found tha t the more people believed tha t they could ha ve prevented the
accident, the more they blamed themselves, and the more time that had
passed since the traumatic event, the more they tended to cast the blame on
environmental factors. They also found that those who blame themselves are
divided into two groups. One group consists of people with trait self-blaming,
who tend to feel global guilt out of their belief of being incapable persons, and
the other group consists of people with behavioral self-blaming, who feel
guilty as a result of a specc experience.
The reaction of society has also been found to contribute to adaptation in
the aftermath of trauma. A study of rape victims (Frieze et al.,1987) pointed
to the problematic situation such victims were caught in.Their self-esteemwas
PTSDAmong Reckless Drivers 329
negatively ected, and they had to deal with feelings of guilt and shame
resulting from social judgment. Similarly, reckless drivers are criticized and
highly judged by their society for what they have done.
We hypothesize that reckless drivers experience intense negative feelings as
a result of the accident. Thus, our aims in the present study were to (a)
examine PTSD, global guilt, event-speci¢c guilt, and shame among drivers
who accidentally caused the death of others; (b) assess changes in the intensity
of the drivers PTSD and sense of guilt after the accident and in the course of
the legal process; (c) examine the association between PTSD, speci¢c guilt;
and global guilt; and (d) assess the contribution of variables associated with
the accident (acquaintance with the victim, seeing the corpse, emotional
relation with the victim) and variables associated with the legal process (type
of punishment, assessment of the severity of the punishment, admission of
guilt) to PTSD, guilt, and shame.
Procedure and Subjects
After receiving permission from the Adult Probation Services (APS) to carry
out the study, we identi¢ed 65 persons who hadcaused the death of people as a
report could be obtained about them. In the second stage, we held conversa-
tions with their individual therapists, following which nine persons who were
regarded as unsuitable for the study, mainly because of psychiatric problems,
were removed. After obtaining informed consent from the drivers to partici-
pate in the study, we mailed two sets of questionnaires to all of the subjects, one
set for them and one set for the prospective controls. Each subject was asked to
complete the set meant for the drivers andto give the other set to a friend of his
own age, gender, education, and marital status who had not been in a road
accident. These friends served as control subjects. Seventy-eight sets of ques-
tionnaires were sent to the persons identi¢ed for the study group. Seventy-six
questionnaires were returned by mail, constituting a 97.4% response rate.
Seventy-¢ve men in two groups participated in the study. The study group
(N ¼ 38) consisted of drivers involved in fatal MVAs who were found guilty of
causing death through reckless driving.These subjects hadbeen referredto the
APS by the court. Members of the control group (N ¼ 37) were matched with
the study group on age and education but had not been involved in an MVA.
330 T. Lowinger and Z. Solomon
About a third of the subjects (37.3%) had graduated high school; another
third (32.1%) had a post^high school education, and the remaining third
(30.7%) had an elementary school or partial high school education. Most of
the subjects (76%) were in the 19-to 30-year age range; about half (57.3%)
were single.
The background questionnaire tapped age, gender, education, military service,
professional occupation, family status, and religious attitudes. The PT SD
Inventory (Solomon, 1993) is based on DSM-IV (American Psychiatric Asso-
ciation, 1994) criteria for the diagnosis of PTSD. It consists of 17 statements,
each describing a PTSD symptom. Subjects were asked to indicate whether
they had experienced each symptom at ¢ve points of time: (a) in the previous
month, (b) before the accident, (c) from the day of the accident to the start of
the trial, (d) from the start of the trial to the day of the verdict, and (e) from
the day of the verdict to the day of ¢lling out the questionnaire.
The control group was also asked to indicate whether they had experienced
a traumatic event in the past. Those who replied that they had were asked to
indicate what it was and when they experienced it. This questionnaire has
been widely used in trauma studies and has proven psychometric qualities.
The internal consistency (Cronbach alpha) among the 17 items was .89, and
the scale was found to have high convergent validity when compared with
diagnoses based on the Structured Clinical Interview for DSM-III-R
(Solomon et al., 1993).
In addition to these 17 statements, two symptoms relating to guilt were
queried. A distinction was made between survivor guilt, dned as a deep
sense of guilt that the person had survived while others were killed in the
accident, andevent-speci¢c guilt,de¢ned as guilt feelings about the persons
behavior at the time of the accident.
Guilt and shame were assessed via Tangney et al.s (19 89) Te s t o f S e l f C o n -
scious A ¡ ect (TOSCA).This test consists of 15 short vignettes (10 negative and 5
positive) accompanied by 5 possible responses that point to a tendency toward
shame, guilt, externalization, dissociation, and pride. With regard to each
vignette, the respondents were asked to indicate the degree to which they
would respond on a 5-point scale ranging fromnot at all likely (1) tomost
likely’ (5). Previous studies (Tangney,1990,1992; Barash-Kishon,1996) found
the shame and guilt factors to have good internal consistency. In the present
study, Cronbachs alpha were .70 for shame and .73 for guilt.
PTSDAmong Reckless Drivers 33 1
The Features of the Event Questionnaire was constructed for the present study
based on clinical knowledge gathered by therapists treating persons who have
caused the death of others in MVAs through negligence. The questionnaire
contains 32 items on the circumstances of the accident, the trial, and the
punishment. The ¢rst part gathered information about the driversfor
exam pl e , their age and occupation at the time of the accident, wh ether or no t
they sought professional help, and whether they discussed their feelings with a
close person. The second part contained questions and items about the trial
and sentence, including whether the driver admitted his guilt immediately
after the accident, whether he had a trial where evidence was brought, how
much time elapsed between the accident and the verdict and between the
verdict and the date of answering the questionnaire, whether the driver had
his driving license revoked, whether he was sentenced to prison, and his feel-
ings about the sentence.The third part of the questionnaire contained details
about the victims (age, identity) and the subjects relationship with them
(degree of prior acquaintance and feelings toward them).
Attributions of responsibility for the accident were examined via four
questions derived from the Questionnaire on Speci¢c Guilt (Jano¡-Bulman,1989).
The questions were adapted to the study population and focused on the dri-
vers perceptions of the causes of the accident. The drivers were asked how
much they blamed themselves, others, the surroundings, and bad luck for the
accident and death and the degree to which they believed they could have
prevented the accident and the d ea th.
Group Di¡erences
First, we examined di¡erences between the study group, consisting of the
reckless drivers, and the matched control group with regard to PTSD, guilt,
and shame .
In the study group, 76.3% of the subjects were classi¢ed as su¡ering from
PTSD after the accident; 44.7% of them still su¡ered from PTSD up to the
time of the study. In contrast, among the control subjects,13% were classi¢ed
as sering from PTSD following an event that they termed traumatic,
and only 5.5% were classi¢ed as su¡ering from the disorder in the present.
Chi-square tests indicated that these group di¡erences were signi¢cant both
332 T. Lowinger and Z. Solomon
immediately after the accident, w
(1) ¼ 29.84, p <.001, and at the time of the
study w
(1) ¼ 15.33, p < .001 .
To assess the severity of the disorder, we examined group di¡erences in
number of PTSD symptoms at three points in time: before the accident, after
the accident, and at the time of the study. A one-way multivariate analysis of
variance (MANOVA) showed a signi¢cant group di¡erence over the three
periods, F(3, 67) ¼ 13.23, p < .01. Means and standard deviations for number
of PTSD symptoms in the two groups are presented in Figure 1.
Before the event, no group di¡erences were found. Yet, while the control
group continued to report the same low level of symptoms in the subsequent
two periods, the study group reported a signi¢cant increase in symptoms after
the event, followed by a decline in symptoms at the time of the study. At both
latter points, the study group reported signi¢cantly more symptoms than the
A2 3analysisofvariance(GroupT ime ) with repea ted measures showed
a signi¢cant interaction, F(2, 138) ¼ 18.76, p <. 001. A tes t of simpl e main e¡ ec ts
carried out to determine the source of the interaction showed a signi¢cant
derence in time only in the study group.
Shame and Guilt
A MANOVA carried out to compare event-specc guilt in the two
groups after the event and at the time of the study showed a signi¢cant group
FIGURE 1 The means of the number of PTSD symptoms in the two groups dur ing three
periods of time.
PTSDAmong Reckless Drivers 333
di¡erence over the two times, F(2, 66) ¼ 22.02, p <.001. As expected, the
reckless drivers reported greater event-speci¢c guilt than the controls both
immediately after the event (drivers: M ¼ 2.27, SD ¼ 0. 77; controls: M ¼1.19,
SD ¼ 0.54) and at the time of the study (drivers: M ¼1.73, SD ¼ 0.77 ; con-
trols: (M ¼1.0 9, SD ¼ 0.39).
Moreover, as with PTSD symptoms, the means showed a decline in guilt
feelings between the period immediately following the event and the time of
the study. An analysis of variance with repeated measures showed a sig-
ni¢cant di¡erence in event-speci¢c guilt feelings after the event and at the
time of the study, F(1, 67) ¼ 10.48, p < .01. Moreover, a signi¢cant interaction
was foundbetween group and time, F(1, 67) ¼ 10.48, p <.01.The di¡erence in
the two groupscurrent guilt was smaller than that at the time of the event.
A one-way multivariate analysis of covariance carried out to examine
group di¡erences in shame and global sense of guilt yielded no signi¢cant
di¡erences.That is, the drivers who caused death did not feel greater shame or
a stronger global sense of guilt than the controls.
In summary, examination of the di¡erences between the two groups clearly
showed that reckless drivers are a high risk group for PTSD and that their
symptoms may persist for a long period of time.The ¢ndings also clearly show
that this group is characterized by a relatively large number of PTSD symp-
toms and a high level of event-speci¢c guilt feelings.
Changes in DriversPTSD and Guilt Feelings OverT|me
We also examined changes in PTSD and guilt over time in the drivers’
group. The following points in time were measured: between the accident
and the start of the trial, between the start of the trial and the verdict,
between the verdict and the completion of the questionnaires, and in the
previous mon th.
A total of 76.3% of the drivers were classi¢ed as having PTSD between the
accident and the start of the trial; 71.1% during the trial and before senten-
cing; 55.3%, after sentencing; and 44.7%, in the month prior to their ¢lling
out the questionnaire.
To examine changes in PTSD over time, we also calculated the average
number of PTSD symptoms in each period. Findings showed that, before the
accident, the drivers had very few PTSD symptoms. Following the accident,
the number of symptoms they reported rose sharply and then gradually
334 T. Lowinger and Z. Solomon
declined to a moderate level at the time of the study. An analysis of variance
with repeated measures showed signi¢cant di¡erences between the periods,
F(4, 140) ¼ 59. 51, p <.001 . T tests for dependent samples carried out between
each pair of adjacent periods revealed signi¢cant di¡erences in the intensity of
PTSD in all of the periods within an overall pattern of decline. Sign-test
analyses (Sigel, 1956) performed to examine the di¡erences in the number of
persons classi¢ed with PTSD in the four periods revealed signi¢cant di¡er-
ences between the period co vering the time betw een the acciden t and the start
of the tr ial and that covering the time between the start of the trial and sen-
tencing, as well as between sentencing and the time of the study. However, no
signi¢cant di¡erence was found between the two earlier periods and between
the two later periods.
Similar time comparisons were carried out on the drivers’ guilt feelings.
The changes in guilt corresponded with those found for PTSD symptoms.
That is, the greatest guilt was reported in the period between the accident and
the sentencing. After that, the guilt feelings declined, reaching their lowest
level at the time of the study. Here too an analysis of variance with repeated
measures showed signi¢cant di¡erences in the four time periods, F(3,
102) ¼ 12.6 4, p <.001. Paired-com parison t tests showed a signi¢cant di¡er-
ence between all of the periods except for the ¢rst two (between the accident
and the start of the trial and between the start of the trial and the sentencing).
Features of the Accident, PSTD, and Guilt
The drivers were asked about their acquaintance with the victim, whether
they saw the corpse after the accident, andtheir feelings toward the victim. Of
the drivers, 44.27% knew the victim before his or her death. In16.7% of these
cases, the victim was a family member; in the remaining 83.3%, the victim
was a friend or acquaintance. Fourteen percent of the drivers saw the corpse,
and most of the drivers (72%) reported positive feelings toward the victim.
Chi-square tests showed no signi¢cant association between any of these
variables and either PTSD or guilt feelings.
Sense of Responsibility for the Accident, PTSD, and Guilt
The respondents were asked how much they blamed themselves for having
caused the death, how much they believed that they could have prevented the
PTSDAmong Reckless Drivers 335
accident, and how much responsibility they believed that luck, circumstances,
some other factor, and they themselves bore for the accident.
The majority (54.4%) of the drivers viewed themselves as responsible for
the accident;18.2% attributed the responsibility to the circumstances; 11.7%
attributed it to others; and 15.7% blamed luck. The degree of reported self-
blame was relatively high (M ¼ 3.42, SD ¼1.32) on a 5-point scale. Their
assessment that they could have prevented the accident was moderate
(M ¼ 2. 76, SD ¼1.28).
Pearson correlations were carried out to examine the associations between
the responsibility variables, PTSD, and guilt.The coe⁄cients are presented in
Ta b l e 1 .
As can be seen, signi¢cant positive correlations were found between self-
blame (the driver’s belief that he could have prevented the accident and his
attribution of the cause of the accident to himself ) and (a) PTSD symptoms
after the accident and (b) event-related guilt after the accident and at the time
of the study. Similarly, negative correlations were found between attribution
of the cause of the accident to other people and PTSD symptoms and event-
speci¢c guilt feelings. The more the drivers saw themselves as responsible for
the accident, the more PTSD symptoms they reported, and the more severe
their event-speci¢c guilt. On the other hand, no signi¢cant correlations were
found between these variables and intensity of PTSD at the time of the study.
A positive correlation was found between the driver’s belief that he could have
prevented the accident and his feelings of shame, and a negative correlation
was found between attribution of the accident to luck and feelings of global
guilt. Drivers who attributed the accident to luck felt less guilt.
The drivers were asked to assess the reasons for the accident.Their answers
were grouped into two categories : internal reasons (e.g., my careless driving)
and external reasons (e.g., the car malfunctioned, weather conditions). Chi-
square tests carried out to determine whether there was any association
between causal attribution for the accident and PTSD after the accident and
at the time of the study showed signi¢cant di¡erences between drivers who
attributed the accident to external factors and those who attributed it to
internal ones in regard to PTSD at the time of the study, w
ð1Þ¼3:80, p <.05,
and PTSD after the accident, w
ð1Þ¼4:38, p <.05. Figure 2 presents the
¢ndings with regard t o PTS D after the accident .
As can be seen, the PTSD drivers were more inclined to attribute the acci-
dent to internal causes than to external ones. At the time of the study, although
the number of PTSD drivers declined, those who attributed the accident to
external factors still tended to report fewer PTSD symptoms than those who
336 T. Lowinger and Z. Solomon
TA B LE 1 Pearson Correlations Between Responsibility variables and PTSD and Guilt
Blaming the
self for
causing death
Belief that the
could have
been prevented Luck
people Self
PTSD symptoms at time of study .22 .20 7.28* .03 7.01 . 17
PTSD symptoms after the accident .42** .28* 7.01 7.01 7.47* .32*
Speci fic guilt at time of study .48** .51** 7.24 7.08 7.26 .37*
Speci fic guilt after the accident .47** .42** 7.13 7.11 7.35* .38*
Shame .29* .29* 7.17 .10 7.09 .11
Global guilt .09 .14 7.28* .22 7.02 .07
*p <.05; **p < .01 .
33 7
attributed it to internal factors. In other words, the more the driver saw him-
self as responsible for the accident and the more he believed that he could have
prevented it, the more likely he was to su¡er from PTSD.
LegalVariables, PTSD, and Guilt
The subjects who accidentally killed persons were asked a number of questions
about the legal process, for example, whether they admitted their guilt and
the severity of their punishment (e.g., prison, community service, suspended
sentence). About 60% of the drivers had admitted their guilt to the police.
Most (62.5%) received community service. About a ¢fth (21.9%) received
prison sentences, and only 15.6% received suspended sentences. Close to half
(45.5%) felt that their punishment ¢t their crime. Over a third (36.4%) felt
that it was too severe. Only 18.2% felt that it was too lenient.
Chi-square tests revealed no signi¢cant association between these variables
and PTSD rates, either after the accident or at the time of the study. None-
theless, signi¢cant associations were found between the length of time for
which the persons driving license was revoked and both his level of symptoms
after the accident (r ¼.40, p <.01) and his event-specc guilt after the acci-
dent (r ¼.44, p <.01). Persons whose driving license was revoked for longer
periods reported higher levels of symptoms.
To examine the association between the legal process and feelings of guilt, t
tests were carried out on admission of guilt, and one-way analyses of variance
were carried out on perceived severity of the punishment. These analyses
showed no di¡erences with regard to admission of guilt and the judge’s
FIGURE 2 The distribution of drivers with and without PTSD after the accident according
to attribution of accident.
338 T. Lowinger and Z. Solomon
assessment of the punishment. But several signi¢cant di¡erences were found
in regard to subjects’assessment of the severity of the punishment.
Those who regarded their punishment as too lenient seemed to di¡er from
the two other groups on all of the measures. They reported more guilt and
more PTSD in the present, though the di¡erence did not reach signi¢cance.
The di¡erence was signi¢cant only for shame (punishment too severe:
M ¼ 2.69, SD ¼ 0.48; punishment appropriate, M ¼ 2. 79, SD ¼ 0.64; punish-
ment too easy: M ¼ 3.82, SD ¼ 0.42). A Sche paired-comparison analysis
showed that the di¡erence was between those who believed that their pun-
ishment was too lenient and the other two groups. It thus seems that persons
who believed that their punishment was too lenient tended to feel more guilt
and shame and to report more PTS D symp t oms than those who believed tha t
their punishment was appropriate or too severe.
Consistent with the ¢rst hypothesis, we found that men who caused the death
of others through reckless driving su¡ered from high rates of PTSD and event-
speci¢c guilt. While this study showed that around 45% of reckless drivers
continue to su¡er from PTSD, two recent prospective studies showed that
32% of road accident victims in Israel had PTSD 6 (Sayag, 2000) and 12
months after the accident (Koren et al., 1999). These ¢ndings suggest that
road accidents can cause psychological damage in both the victims and the
reckless drivers and that the latter are at even more risk than the former.
Most of our knowledge of the pathogenic e¡ects in perpetrators comes from
clinical observations of soldiers with PTSD (Haley, 1978; Hendin & Hass,
1984; Lifton, 1973). Both the careless driver and the soldier cause the death of
others, though it is important to remember that the circumstances and
meanings in the two cases are very di¡erent. Wars and road accidents di¡er
from one another both in the legitimacy they provide for killing and in the
emotional readiness of the perpetrators to cause and be exposed to death.
Causing death without malicious intent can explain the high rates of event-
speci¢c guilt found among the study group. Drivers who caused death and
remain alive become a target for feelings of anger, aggression, accusations,
and helplessness from all social circles: the families of the victims, society, and
the legal system.Thus, they feel a lack of legitimacy to externalize and express
their distress openly. Thus, as in other traumatized populations under similar
constraints, these feelings are displaced into strong feelings of guilt. The
PTSDAmong Reckless Drivers 339
drivers reported two sources for their guilt feelings.The ¢rst related to killing,
and thus crossing the boundaries of moral and social laws and values. The
second was that they themselves survived while others, sometimes their
friends and family, died because of their actions.The combination of causing
death and surviving intensi¢ed their speci¢c feelings of guilt.
Onthe other hand, global guilt and shame were not characteristic feelings of
reckless drivers. Subjects in the two groups did not di¡er from one another on
these measures. These ¢ndings are similar to a study of concentration camp
survivors, who did not di¡er in the level of guilt they experienced in their daily
lives from controls who had not been exposed to the Holocaust (Lobel &
Yahia, 1985). That is, our ¢ndings do not support generalizing from event-
speci¢c guilt feelings to general guilt feelings. This points to the need to distin-
guish between guilt that is specc to and focused on a particular event and
guilt that is global and represents a personality tendency (Tangney,1990,1991).
With regard to changes over time, the highest rates of both PTSD and
speci¢c guilt feelings were reported in the period between the accident and
the sentencing, and gradually declined with time. The period between the
accident and the end of the trial was characterized by intense psychological
distress as the drivers were exposed to stimuli resembling or symbolizing the
traumatic accident. Furthermore, during the legal process the drivers had to
deal with both the court’s accusations and their own personal guilt. Kubany
et al. (1995) found that the intensity of guilt that individuals feel after a trau-
ma tic event depends on the d egree to which they view the resul ts of the even t
as negative, see themselves as responsible for the negative results of the event,
see their act as unjusti¢ed, and believe that they could have prevented the
event had they acted di¡eren tl y. In a way, the legal syst em acts as the other
voice’ that continues to remind the driver that he could or should have acted
di¡erentl y.
Our ¢ndings are similar to those of Kubany et al. (1995), who found asso -
ciations between the intensity of event-speci¢c guilt feelings and the rate of
PTSD symptoms among both American soldiers who had fought inVietnam
and physically abused women.The subjects in the present study di¡ered from
these groups in terms of age, ethnic origin, culture, gender, and, of course,
type of traumatic event. Nonetheless, our ¢ndings reinforce Kubany et al.s
(1995) contention that it is important to deepen and broaden the systematic
study of di¡erent types of guilt and of their implications for PTSD.
Contrary to expectation, our ¢ndings showed no signi¢cant correlation
between the features of the accident and the legal process (e.g., acquaintance
with the victim, seeing the corpse after the accident, feelings toward the
340 T. Lowinger and Z. Solomon
victim, type and severity of punishment) and PTSD or guilt feelings. Our
¢ndings are inconsistent with a previous study of soldiers who were involved in
atrocities committed against civilians and prisoners.They were found to be at
higher risk for PTSD and had stronger guilt feelings than soldiers who fought
an enemyarmy from a distance andwithoutclose personal contact (Hendin &
Haas, 1984). The ceiling e¡ect’ phenomenon could serve as an explanation
for our ¢ndings.The ceiling ect occurs when a variable is rated very highly
across all study groups, and this lack of variability prevents one from obtain-
ing signi¢cant results. As we have seen, causing death give rise to very high
negative feelings among the reckless drivers, and so other associated variables
such as acquaintance with the victim did not enhance PTSD rates and guilt as
we had expected (e.g., Fatzinger, 1997; Parente, 2001).
Drivers who perceived their punishment as too easy reported more feelings
of guilt, shame, and PTSD symptoms at the time of the study than drivers
who regarded their punishment as appropriate or too severe. It seems that
severe punishments made the reckless drivers feel as though they were paying
for what they had done or getting what they deserved thus promoting a sense
of relief. However, more than half of the drivers in this study assumed
responsibility for causing the accident, while the other half divided the
responsibility in roughly equal proportions between the surrounding circum-
stances, luck, and other people.
In the last two decades, substantial e¡orts have been made to study the
psychological ects of traumatic events. In light of the proliferation of stu-
dies, the limited attention paid to perpetrators is salient. The high rates of
psychological distress found among the perpetrators in this study and in other
studies (e.g., Haley, 1978) raise the question of why these individuals receive
limited professional attention.
Haley (1978) pointed out the di⁄culties that therapists experience in
treating Vietnam veterans who had been involved in atrocities, suggesting
that these encounters challenge their values and give rise to feelings of vul-
nerability. Similar observations were documented in a study of o¡spring of
Nazi perpetrators conducted by Bar-On (1989; Bar-On & Charny, 1988).
Bar-On claims that both perpetrators and professionals use denial when they
are engaged in a dialogue. He suggested that there is a double arrow’
between perpetrators of death and clinicians and researchers: It is not only
that perpetrators ¢nd it di⁄cult to share their moral hesitations; professionals
also prefer not to ask and not to listen. The double arrow’ allows both the
perpetrator and the mental health professional to maintain their silence
(Bar-On, 1989; Bar-On & Charny, 1988).
PTSDAmong Reckless Drivers 341
Drivers who injure others evoke complex reactions. On the one hand, it is
impossible to ignore the terrible consequences of their carelessness; on the
other hand, the act occurred accidentally. It would seem that all drivers could
¢nd themselves in a similar situation, and no one is immune to being involved
in a fatal accident. In meeting a perpetrator of the Holocaust, for example,
people may think that they are di¡erent’ and would not have behaved like
the Nazis. But there is no such‘immunity’ for reckless drivers.
Some claim that relating to perpetrators as victims is immoral. For exam-
ple, Alan Young (1995) objects to viewing a¥icted Vietnam veterans as vic-
tims. In his opinion, the victim label legitimizes the war and promotes
mobilization to help. He sees these soldiers as war criminals who committed
terrible acts. A possible result of such a claim is the delegitimization of
various traumatized populations (Witzum et al.,1996;Young,1995) including
perpetrators such as reckless drivers.
Although the ¢ndings of this study are limited because it involved a small
sample and a retrospective design, our results point to the need to draw clin-
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Zahava Solomon, PhD, is the director of the Adler Research Center and professor of
Psychiatric epidemiology and social work at Tel Aviv University, Israel. She has pub-
lished over 200 scienti ¢c articles and 6 books on man-made psychological trauma. Her
work focuses on war, captivity, the Holocaust, and terror. She is the recipient of
numerous grants and awards, including the ISTSS Laufer award for outstanding sci-
enti¢c achievement in the ¢eld of PTSD.
Tamar Lowinger works as a social worker in a psychiatric hospital and has worked
withreckless drivers inthe past.ShereceivedbothherB.A. andher M.A.fromtheSchool
of SocialWorkatTel Aviv University, Israel.This article is base d on her master’s thesis.
344 T. Lowinger and Z. Solomon
... The paradox of guilt is that someone can cause an accident but not feel guilty, while someone else can be the victim but feel guilty even if the accident was not his/her fault. Subjective, irrational guilt in the victims of traumatic events is much more often investigated than in the perpetrators of such events [18,19]. It has been proven that excessive, irrational guilt exacerbates stress and makes the process of regaining mental balance even more difficult [19,20]. ...
... Research into the relationship between a conviction for causing an accident, feelings of guilt related to trauma and the development of PTSD is rare. Although Lowinger and Salomon [18] have undertaken such a task, they have found no differences in the intensity of PTSD symptoms depending on the severity of the sentence (prison, community service, probation), but have observed a correlation between the length of the decision to detain a driving license and the intensity of PTSD symptoms. The longer the license withdrawal penalty, the more serious the symptoms of PTSD were reported by the punished drivers. ...
... With regard to the psychological consequences of car accidents, the focus of researchers and practitioners is mainly on victims and their relatives. Only in a few studies has the topic of the psychological consequences of causing death or injury to another person been addressed [4,5,18,26,33,34]. All of these studies have shown that causing an accident, whether fatal or resulting in an injury, in many cases leads to serious life crises, to the induction and persistence of PTSD symptoms, to depression and to a change in self-perception. ...
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Objectives: The study aimed at exploration of a relationship between PTSD symptoms, traumarelated guilt (TRG), time perspective (TP), and guilt/shame proneness among perpetrators of motor vehicle accidents (MVA). We also analyzed relationships between length of imprisonment, PTSD and trauma-related guilt. Methods: The sample consisted of 37 incarcerated perpetrators of MVA. They were asked to fill in the set of questionnaires: Zimbardo Time Perspective Inventory, Guilt and Shame Proneness Inventory, Trauma-Related Guilt Inventory). Results: The results showed that 50% of the perpetrators met the DSM-5 PTSD criteria. The proneness to guilt and shame positively correlated with the trauma-related guilt. Shame susceptibility as a consequence of negative self-esteem was associated with a greater traumarelated shame. There was no correlation between guilt/shame or trauma-related guilt and PTSD. The time perspective was associated with PTSD - the stronger the tendency of the respondents to focus on the present/past, the greater the symptoms of PTSD. Focusing on the hedonistic present positively correlated with guilt related to trauma. Conclusions: In the studied population, every second perpetrator of the accident was affected by PTSD, which was associated with the past and present time perspective. Negative assessment of self and behavior intensified the guilt associated with trauma and reduced the search for justification for one's own actions in external circumstances. Time spent in prison had no effect on moral attitudes or on the moral evaluation of one's own behavior that caused harm to others. However, it was associated with experiencing stress and focusing on one's own suffering.
... The challenge associated with disentangling the relative magnitude of shame and guilt in relation to PTSD is likely a reflection of study methodology such as measurement artifacts, and heterogeneity in clinical presentations. Majority of reviewed studies did not control for the effects of shame despite significant correlations between shame and guilt and shame and PTSD (Beck et al., 2011;Kubany et al., 1996;Leskela et al., 2002;Lowinger & Solomon, 2004;Robinaugh & McNally, 2010;Street & Arias, 2001). It is possible that the relationship between both shame and guilt in relation to PTSD may have been confounded by their construct overlap. ...
Although shame is a common emotional response to trauma exposure, it may be precipitated by distinct trauma types. To our knowledge, our study is the first to investigate the relationship between shame and PTSD symptom severity and whether exposure to at least one interpersonal trauma influences the relationship between shame and PTSD symptoms. One-hundred and fifty-seven participants from Australia, Canada, United States, United Kingdom, and New Zealand completed a series of self-report measures. Although shame was significantly associated with PTSD symptom severity, it was not an independent predictor of PTSD when considering anxiety, depression, trauma history and guilt. Participants exposed to at least one interpersonal traumatic event endorsed higher levels of shame and PTSD compared to those who did not. Interpersonal trauma exposure also moderated the relationship between shame and PTSD. Clinical implications and directions for future research are also discussed.
... The levels of guilt feelings have differed depending on type of trauma, and an association between the levels of guilt and PTSD has been identified (Pugh et al., 2015). Several studies that revealed the association between guilt feelings and PTSD symptoms in adults have been reported; among combat veterans (Henning & Frueh, 1997), after someone's death due to reckless driving (Lowinger & Solomon, 2004), and among women who experienced intimate partner violence (Bean & Möller, 2002). Reports of survivor guilt in children are common (Yule, 2001); however, reports of survivor guilt in children as a group phenomenon are rare. ...
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The Great East Japan Earthquake and Tsunami struck Japan on March 11, 2011, leaving more than 400,000 people, including 100,000 children, homeless. These displaced children lived in temporary housing and “temporarily” attended schools, which provided them with professional mental health support after the disaster. The aim of this article is to highlight the role of disaster mental health support teams from Miyagi Prefecture through a problem reported by one of the schools—the excessive feeding of fish by children who narrowly escaped the tsunami. The support team helped schoolteachers understand the perspective of survivor guilt by facilitating a group discussion among the children and exploring their feelings about the disaster, with a focus on the guilt of leaving their pets behind. We demonstrate the role of mental health professionals working with schools to help children resolve negative thoughts and feelings during disaster recovery, including the often-overlooked survivor guilt caused by life-threatening events. Keywords: school mental health, survivor guilt, children, trauma, Great East Japan Earthquake (GEJE)
... Yapılan çalışmalarda savaş gazilerinde, partner şiddeti gören kadınlarda, kaza sonucu başkasının ölümüne yol açan kişilerde suçluluk ve utanç duyguları en belirgin duygular olarak bulunmuştur. 31,32 Buna ek olarak, travmatik olaya maruz kalan kişilerin olay esnasındaki davranışları hakkındaki olumsuz düşünceleri de suçluluk ve utanç duygusu yaratabilmektedir. Örneğin,'olay anında neyi farklı yapsam sonucu değiştirebilirdim', 'ben başa çıkamadığım için bunlar oldu', 'karşı koymalıydım', 'ben işe yaramaz ve kusurlu biri olduğum için bu olayın kurbanı oldum' gibi bilişlerin utanç ve suçluluk duygularını düzenlemeyi zorlaştırdığı gösterilmiştir. ...
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55 55 T ravma Sonrası Stres Bozukluğu (TSSB)'nda duygu düzenlemede yaşanan güç-lüğün önemli sürdürücü faktörlerden biri olduğu bilinmektedir. 1 Ayrıca, duygu düzenleme güçlüğünün TSSB tedavisinin etkililiği konusunda da önemli bir dü-zenleyici değişken olabileceği belirtilmiştir. 2 Bu derlemede, TSSB tanısı almış kişiler-deki duygular, duygu düzenleme stratejileri ve duygu düzenleme güçlüğünü açıklayan teorik modeller ve araştırma bulguları gözden geçirilmiştir. TRAVmATİK YAŞAm OLAYI VE TSSB Travmatik yaşam olayı beklenmedik bir anda ortaya çıkan, başa çıkma becerilerini aşıp kişiyi çaresiz hissettiren, yoğun bir şekilde korku ve dehşete sebep olan sarsıcı yaşam olaylarıdır. 3 Genel olarak, travmatik durumlar tehlikeli, baş edilemez ve beklenmedik bir zamanda ortaya çıkan yaşantılardır. 4 Amerikan Psikiyatri Birliği'ne (APA) göre trav-matik yaşam olayı gerçek bir ölüm tehdidi, ağır bir yaralanma veya cinsel saldırı gibi fi-ziksel ve zihinsel bütünlüğe karşı bir tehdidin yaşanmasına karşılık gelir. 5 Amerikan Psikiyatri Birliği (APA) tarafından düzenlenip yayınlanan Ruhsal Bozuklukların Tanı-sal ve İstatistiksel Elkitabı-5'e (DSM-5) göre, bu olayların başkasının başına gelmesine Travma Sonrası Stres Bozukluğunda Duygular ve Duygu Düzenleme Emotions and Emotion Regulation Strategies in Post-Traumatic Stress Disorder ÖZET Travmatik yaşam olayı beklenmedik bir anda ortaya çıkan, kişiyi çaresiz bırakan, yoğun bir şe-kilde korku ve dehşete sebep olan sarsıcı yaşam olaylarıdır. Travmatik yaşam olayına maruz kalan bi-reylerin önemli bir kısmı zamanla gündelik yaşamlarına uyum sağlayabilmektedir. Bir grup insan ise travmatik olayın olumsuz etkisinden kurtulamamakta, yıllarca sürebilecek ruhsal zorluk yaşayabilmek-tedir. Bu durum tanı ve sınıflama sisteminde Travma Sonrası Stres Bozukluğu (TSSB) olarak adlandı-rılmaktadır. Bugüne kadar yapılan araştırmalar TSSB'nin başlangıcı, sürdürülmesi ve tedavisinde bazı duyguların ve duygu düzenleme stratejilerinin belirleyici rolünün olduğunu göstermiştir. Bu derlemede duygular ve duygu düzenlemenin TSSB ile ilişkisi değerlendirilmiştir. Söz konusu ilişkiler güncel alan yazın ışığında tartışılmıştır. Anah tar Ke li me ler: Travma; duygular; duygu düzenleme; TSSB ABS TRACT Traumatic life events are unexpected, sudden, and shocking life events which can cause intense helplessness, fear, or horror. While the majority of the trauma survivors are able to adjust to their daily lives over time, a minor group of them are not able to get over the effect of the traumatic event. This phenomenon is named as Post Traumatic Stress Disorder (PTSD). To date, researches have shown that some emotions and emotion regulation strategies may have a determining role on the onset, maintenance , and treatment of PTSD. In this review, the relationships between PTSD, emotions, and emotion regulation were evaluated. These relations were discussed in light of current literature.
... Guilt is conceptualized as a negative emotional experience accompanying a belief that one should have thought, felt, or acted differently in the past (e.g., "I should have known better"; Kubany et al., 1996). Guilt is common among trauma survivors and has been associated with a higher level of posttraumatic stress disorder (PTSD) symptom severity in military personnel and veterans (Bryan et al., 2015;Henning & Frueh, 1997) and civilians (Beck et al., 2011;Lowinger & Solomon, 2004). Individuals with PTSD may experience guilt about various aspects of the trauma, including the actions, feelings, and thoughts that were or were not experienced during the event (Kubany & Manke, 1995). ...
The current study examined the role of trauma‐related guilt on posttraumatic stress disorder (PTSD) symptom change during prolonged exposure therapy (PE) as well as the efficacy of PE in reducing three dimensions of guilt (responsibility, wrongdoing, and lack of justification) during treatment. Participants were 331 active duty U.S. military personnel seeking treatment for PTSD who were randomized to one of four groups: massed PE (10 sessions delivered over 2 weeks), spaced PE (10 sessions delivered over 8 weeks), present‐centered therapy (PCT; 10 sessions delivered over 8 weeks), or minimal contact control (MCC; weekly therapist phone check‐in for 4 weeks). The results showed that baseline guilt did not predict reductions in PTSD symptoms for spaced PE or for PCT, ps = .178–.387, ds = −0.02–0.07. Treatment condition (massed PE vs. MCC; spaced PE vs. PCT) did not moderate reductions in guilt for spaced PE versus PCT. Guilt decreased significantly over treatment in all groups, p < .001 to p = .038, ds = −0.19 to –0.42, except concerning justification in the spaced PE and PCT groups, p = .140, d = −0.10. The findings suggest that guilt may be reduced significantly following active PTSD treatment and attention control and that PTSD recovery is not impacted by baseline levels of trauma‐related guilt in military personnel with PTSD, although reported levels of guilt were low to moderate in this sample.
... A study that utilized the National Comorbidity Survey showed that individuals responsible for the death or severe injury of another person were at increased risk for developing PTSD, depression, anxiety, and substance use disorders (Connorton et al., 2011). Similarly, a study that examined blame attributions, PTSD, and event-related guilt in a sample of reckless drivers convicted of killing another person further demonstrated instances of distress that resulted from perpetration among the general population (Lowinger & Solomon, 2004). The limited research conducted on distress associated with criminal offense shows that convicted criminals who have few antisocial personality traits often experience grief, remorse, shame, guilt, and high rates of PTSD symptoms from their offending behaviors (Evans et al., 2007). ...
Although the topic of moral injury (MI) has been garnering increasing attention in recent years within military populations, research has rarely applied the concept to civilian contexts. Extant literature on distinct acts of perpetration or transgressions suggests similar emotional, cognitive, and behavioral patterns of distress associated with appraisals of wrongdoing. However, the absence of a psychometrically sound measure to detect and quantify pathological levels of distress associated with perpetrating harm against others has hindered additional research from being conducted on the topic. The current research presents the Perpetration‐Induced Distress Scale (PIDS) as a valid and reliable measurement of distress associated with MI within civilian contexts. Factor analytic techniques revealed a two‐factor solution characterized by perpetration‐induced distress related to maladaptive reactions to shame (seven items) and guilt/self‐blame (seven items). The PIDS demonstrated favorable temporal stability over a 1‐week period as well as excellent internal reliability. Further, the PIDS evidenced convergent validity with functional impairment, posttraumatic stress disorder, and existing scales of shame and guilt; associations were large (rs = 0.62–0.87). The development of the PIDS represents one of the first studies to measure MI within a civilian population and indicates evidence that additional research on the topic is warranted.
... Guilt is commonly found in war veterans, victims of violent crime and the perpetrators of traffic accidents (Lowinger and Solomon, 2004;Marx et al., 2010;Semb et al., 2011;Solomon et al., 2015). Niederland (1968) referred to the guilt caused by trauma as survivor guilt, and Lifton (1980) described an individual suffering from survivor guilt as one who has encountered, been exposed to, or witnessed death and has remained alive. ...
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Objective: This study aims to examine the mediating roles of gratitude and social support in the relationship between survivor guilt and posttraumatic stress disorder (PTSD) as well as the relationship between survivor guilt and posttraumatic growth (PTG). Methods: The current study used self-report questionnaires to investigate 706 adolescent survivors of Lushan county three and a half years after the Ya’an earthquake. The structural equation model was used to evaluate the relations between survivor guilt, gratitude and social support in PTSD and PTG. Results: The results indicated that survivor guilt had a positive effect on both PTSD and PTG. Gratitude partly mediated the relation between survivor guilt and both PTSD and PTG; social support partly mediated the relation between survivor guilt and PTG but not PTSD as well as the relation between gratitude and PTG. Conclusion: Survivor guilt has a double-edged sword effect. Survivor guilt affects PTSD and PTG through gratitude, and it could affect PTG but not PTSD through social support. Gratitude decreases PTSD and increases PTG, whereas social support only increases PTG.
... Henning e Frunch (1997) reported a significant positive association between guilt feelings and PTSD symptoms severity in combat veterans with PTSD. The same emerged in civilian samples among men convicted of having caused someone's death through reckless driving (Lowinger and Solomon, 2004), and women who had experienced intimate partner violence (Bean and Moller, 2002), suggesting guilt as a possible important concomitant of PTSD in a variety of trauma samples. Further, differences in the levels of guilt feelings reported have been highlighted in patients survived to different types of trauma. ...
Important changes were introduced concerning posttraumatic-stress disorder (PTSD) by the DSM-5 recognizing the role of negative emotions such as guilt and shame, but little evidence is yet available on their prevalence in population assessed by means of DSM-5 criteria. In this study we explored the rates of guilt and shame DSM-5 PTSD diagnostic symptoms among Italian survivors to a massive earthquake and their possible correlation with PTSD and maladaptive behaviors. 869 residents of the town of L’Aquila exposed to the earthquake of April 6th 2009 were investigated by the Trauma and Loss Spectrum-Self Report (TALS-SR) with particular attention to guilt and shame feelings. DSM-5 symptomatological PTSD was reported by 41,7% of survivors, further 11,6% endorsed at least one guilt/shame symptoms, with significantly higher rates of endorsement were in PTSD respect to No-PTSD subjects, and in the subgroup with at least one maladaptive behavior respect to those with none. There was a significant main effects of PTSD and at least one guilt/shame symptom on TALS-SR symptomatological domains. Mean TALS-SR Maladaptive coping domain score appeared significantly higher in the subgroup with at least one guilt/shame symptom. Further study are needed to investigate guilt and shame feelings in survivors to a natural disaster.
Backgroud: Network models suggest that co-occurring symptoms are conceptualized as a syndrome due to interactions, rather than a categorical entity with an underlying common cause. Aim: Our study aimed to examine the network structure and centrality of Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV posttraumatic stress disorder (PTSD) symptoms, including essential and associated features. Methods: We constructed a network structure of 21 intertwined symptoms, evaluated with the Clinician-Administered PTSD Scale (CAPS), in 249 PTSD patients who have been exposed to various types of traumatic events (73% being traffic or other accidents) and were beginning psychiatric treatment. In addition, we estimated the centrality of the 21 symptoms through network analysis. Each of the symptoms was defined as ordered-categorical variables. Results: The network, with 21 symptoms, demonstrated a strong correlation among difficulty concentrating, reduced awareness of surroundings, and derealization. In addition, reduced awareness of surroundings was estimated as the most central symptom, whereas inability to recall important aspects of trauma was estimated as the least central symptom in the subjects. A community-detection analysis estimated that the 21 PTSD symptoms were organized into three clinically meaning clusters. Conclusion: Although dissociative features have been defined as associative symptoms rather than essential symptoms for the DSM diagnostic criteria, reduced awareness of surroundings may be regarded as the most central symptom in patients in the early phase of PTSD. Thus, evaluation and intervention for dissociative features may be needed in clinical practice and studies on PTSD.
Posttraumatic stress disorder (PTSD) has been associated with negative emotions such as shame, guilt, anger, and disgust, as well as impairments in the ability to effectively regulate these emotional states. There is evidence showing that each of these negative emotions and emotion regulation difficulties are related to the severity of PTSD stemming from various trauma types. In contrast, much less is known about the temporal relationship between these features and PTSD. Studies have found that treatments for PTSD often lead to improvements in these negative emotions and in emotion regulation difficulties, but how these features impact the efficacy of various PTSD treatments is less clear.
In this highly readable text, the author details the findings of an exhaustive series of studies of Isreali combat veterans, documenting the effects of combat stress reaction on mental and physical health, social interaction, and military effectiveness. In addition to providing mental health professionals, trauma victims, and military personnel with an unparalleled source of information, the work's exploration of the cultural, social, and political processes affecting recovery from combat stress reaction offers a unique perspective of contemporary Isreali culture.
Background: Data were obtained on the general population epidemiology of DSM-III-R posttraumatic stress disorder (PTSD), including information on estimated lifetime prevalence, the kinds of traumas most often associated with PTSD, sociodemographic correlates, the comorbidity of PTSD with other lifetime psychiatric disorders, and the duration of an index episode.Methods: Modified versions of the DSM-III-R PTSD module from the Diagnostic Interview Schedule and of the Composite International Diagnostic Interview were administered to a representative national sample of 5877 persons aged 15 to 54 years in the part II subsample of the National Comorbidity Survey.Results: The estimated lifetime prevalence of PTSD is 7.8%. Prevalence is elevated among women and the previously married. The traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women. Posttraumatic stress disorder is strongly comorbid with other lifetime DSM-III-R disorders. Survival analysis shows that more than one third of people with an index episode of PTSD fail to recover even after many years.Conclusions: Posttraumatic stress disorder is more prevalent than previously believed, and is often persistent. Progress in estimating age-at-onset distributions, cohort effects, and the conditional probabilities of PTSD from different types of trauma will require future epidemiologic studies to assess PTSD for all lifetime traumas rather than for only a small number of retrospectively reported "most serious" traumas.
The psychiatry of road traffic accidents has been neglected. Psychiatric factors especially alcohol and drug abuse are important causes. Psychiatric consequences are common and include post-traumatic stress disorder and phobic travel anxiety. Legal and compensation issues and whiplash neck injury are discussed. Clinical implications are outlined.
PTSD's most distinctive feature is its etiological event. With out this event, PTSD symptoms are indistinguishable from symptoms associated with combinations of other psychiatric diagnoses. The DSM definition of PTSD assumes that the relation between the etiological event and its symptoms is equivalent to a cause and effect. In reality, these events are often reasons rather than causes of the syndrome. Where this is true, the syndrome loses its specificity. This paper explains why it is often impossible to distinguish between the reasons and causes of PTSD, and why this difficulty is generally ignored.