The relationship between chronic whiplash-associated disorder and post-traumatic stress: attachment-anxiety may be a vulnerability factor.

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by  Andersen, Tonny Elmose

(cid:1)CLINICAL RESEARCH ARTICLE
The relationship between chronic
whiplash-associated disorder and post-
traumatic stress: attachment-anxiety
may be a vulnerability factor
Tonny Elmose Andersen1*, Ask Elklit1 and Lene Vase2
1Department ofPsychology, University ofSouthern Denmark, OdenseM, Denmark;2Department of
Psychology, Aarhus University, Aarhus C, Denmark
Background:Inmorethan90%ofwhiplashaccidentsagoodexplanationregardingtheassociationbetween
trauma mechanism,organicpathology,andpersistent symptomshasfailed to beprovided.
Objective: We predicted that the severity of chronic whiplash-associated disorder (WAD), measured as
numberof whiplash symptoms, pain duration, pain-related disability, and degree of somatisation would be
associated with the number of post-traumatic stress disorder symptoms (PTSD). Secondly, we expected
attachment-anxietyto beavulnerabilityfactor inrelation to bothPTSDand WAD.
Design:Datawerecollectedfrom1,349womenand360mensufferingfromWADfromtheDanishSocietyfor
Polio, Traffic, and Accident Victims. The PTSD symptoms were measured by the Harvard Trauma
Questionnaire. All three core PTSD clusters were included: re-experiencing, avoidance, and hyperarousal.
Attachmentsecuritywasmeasuredalongthetwodimensions,attachment-anxietyandattachment-avoidance,
by the Revised Adult Attachment Scale.
Results:PTSDsymptomsweresignificantlyrelatedtotheseverityofWAD.Inparticular,thePTSDclusters
of avoidance and hyperarousal were associated with the number of whiplash symptoms, disability, and
somatisation.Attachment-anxietywassignificantlyrelatedtoPTSDsymptomsandsomatisationbutnotto
painanddisability.Aco-morbidityof38.8%wasfoundbetweenthePTSDdiagnosisandWAD,andabout
20%ofthe sample couldbecharacterised as securelyattached.
Conclusions:ThePTSDclustersofavoidanceandhyperarousalweresignificantlyassociatedwithseverityof
WAD. The study emphasises the importance of assessing PTSD symptomatology after whiplash injury.
Furthermore,ithighlights thatattachment theorymay facilitatethe understandingof why somepeople are
moreproneto developPTSD andWADthanothers.
Keywords: Whiplash;post-traumaticstress;attachment;pain;chronic
For abstract or full text in other languages, please see Supplementary files under Reading Tools
online
Received:14 September 2010; Revised:21 December 2010; Accepted:5 January 2011;Published:28January2011
Whiplash is an acceleration and deceleration can be found (Atherton et al., 2006). In addition,
mechanism of energy transfer to the neck approximately 50% with WAD still report neck pain
during a collision (Hendriks et al., 2005). and disability 1 year after the injury (Caroll et al., 2009;
Commonsymptomsafterawhiplashinjuryareheadache, Kamper, Rebbeck, Maher, McAuley, & Sterling, 2008;
neck pain, shoulder pain, fatigue, sleep disturbance, and Williamson, Williams, Gates, & Lamb, 2008). The
memoryproblems(Jansenetal.,2008).Whensymptoms recovery process appears to follow a pattern of rapid
persist for more than 3 months the condition is usually improvementwithin the first 3 months, with only minor,
characterised as chronic whiplash associated disorder if any, improvement thereafter (Kamper et al., 2008).
(WAD).Inmorethan90%ofcasesnoorganicpathology Thereisanongoingdebateregardingprognosticfactors;
EuropeanJournalofPsychotraumatology2011. #2011TonnyElmoseAndersenetal.ThisisanOpenAccessarticledistributedunderthetermsofthe 1
CreativeCommonsAttribution-Noncommercial3.0UnportedLicense(http://creativecommons.org/licenses/by-nc/3.0/),permittingallnon-commercialuse,
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however, high initial pain and disability in addition to addition, high levels of arousal can have a negative
psychological factors such as post-traumatic stress and impact on pain through muscle tension. In agreement
low self-efficacy have been confirmed as indicators of a with the mutual maintenance model, Sterling and
poor prognosis. Socio-demographic and crash-related Chadwick (2010) found that PTSD hyperarousal symp-
factors have been reported as having poor prognostic toms were causally related to pain, and that PTSD
value (Caroll et al., 2009; Kamperet al., 2008). avoidance symptoms were related to disability. Also in
support of the mutual maintenance model, Liedl et al.
Co-occurrence of WAD and PTSD (2010) found that the level of pain at 3 and 12 months
Research shows that pain and post-traumatic stress waspredictedbyPTSDre-experiencingandhyperarousal
disorder (PTSD) or symptoms thereof frequently co- symptoms. Baseline pain predicted 3 months hyperarou-
occur. In particular, when pain is secondary to motor sal and 3 months pain predicted all PTSD symptom
vehicle accidents, up to 50% of individuals meet the clusters. In particular, hyperarousal played a key role in
diagnostic criteria for PTSD (Otis, Terence, & Kerns, the development of chronic pain over time.
2003). Even years after the whiplash trauma, a high
prevalence of PTSD is found. For example, Mayou and
Bryant(2002)foundthat17%ofindividualsstillmetthe Predictors of PTSD and vulnerability
diagnostic criteria for PTSD 3 years after their whiplash Pre-trauma risk factors do generally have a weak effect
injury. In addition, Sta˚lnacke (2009) found that almost onPTSDcomparedtotheeffectsoftraumaintensityand
38% still suffered from mild to severe post-traumatic post-trauma factors (Brewin, Andrews, & Valentine,
stress symptoms 5 years after their whiplash injury. 2000). In particular, peritraumatic dissociation, peritrau-
Furthermore, PTSD symptoms are significantly asso- matic emotions, perceived support, and perceived life
ciated with whiplash-related symptoms, pain intensity, threat are found to be the strongest predictors of PTSD
affective distress, and disability (A˚hman & Sta˚lnacke, (Ozer, Best, Lipsey, & Weiss, 2008). However, identifica-
2008; Buitenhuis, Jong, Jaspers, & Groothoff, 2006; tion of possiblevulnerability factors for PTSD may help
Ehlers, Mayou, & Bryant, 1998; Kongsted et al., 2008; identifyingmorespecificcognitivemechanismsinPTSD.
Sta˚lnacke, 2009). Unfortunately, few studies have in- Threecognitivevulnerabilityfactorshavebeendescribed
cluded all PTSD symptom clusters and most are based as relevant in the development of PTSD: negative
onsmallsamples.However,hyperarousalsymptomshave cognitions about the self, the world, and self-blame
been found important in relation to predicting chronic for the trauma (Foa, Ehlers, Clark, Tolin, & Orsillo,
WAD (Buitenhuis et al., 2006). In alternative trauma 1999).Similarly,attachmentinsecurityischaracterisedby
populations, hyperarousal symptoms have also been negative interpersonal cognitive-emotional schemas
associated with somatisation (Elklit & Christiansen, about self and others. Furthermore, it is possible that
2009). both PTSD and attachment-related cognitions can lead
Exploring the recovery process of PTSD symptoms to threat appraisals of the pain and thereby symptom
after acute whiplash, Sterling, Hendrikz and Kenardy exacerbation(Elwood,Hahn,Olatunji,&Williams,2009;
(2010) found three different recovery processes. One Meredith, Ownsworth, & Strong, 2008).
group of patients appeared to be resistant (40%) and AccordingtoBowlby(1969/1997),attachmentschemas
another group with moderate PTSD symptoms at are shaped from early interactions with caregivers and
1 month (43%), recovered to a mild symptomatic level influence the way we perceive situations, regulate emo-
after 3 months. A third chronic group (17%) presented tions, and relate to others. Attachment insecurity has
withmoderatetoseverePTSDsymptomsat1monththat been associated with PTSD and various other health
remained consistent at 12 months follow-up. conditions (for a review see Mikulincer & Shaver, 2007).
Moreover, recently growing evidence has linked attach-
Mutual maintenance and shared vulnerability ment insecurity to maladaptive adjustment to chronic
It is indicated that WAD and PTSD are not necessarily pain conditions, which results in higher levels of pain,
distinct disorders, but may have a shared vulnerability somatisation, and disability (for a review see Meredith
that mutually maintains each other. Shared characteris- et al., 2008). Longitudinal studies support the assump-
tics of the two disorders are hyperarousal symptoms, tion that attachment representations are relatively stable
avoidance behaviour, emotional liability, and attention traits (Hamilton, 2000; Waters, Merrick, Treboux,
biastowardssomaticcues(Asmundson,Coons,Taylor,& Crowell, & Albersheim, 2000). However, severe negative
Katz, 2002; Sharp & Harvey, 2001). Within the mutual life events, for instance physical or sexual abuse, can
maintenance model (Sharp & Harvey, 2001) it is pro- change attachment classification (Weinfield, Sroufe, &
posed that pain may be interpreted as a reminderof the Egeland,2000).Sanberg,Suess,andHeaton(2010)found
whiplash trauma and as such triggers trauma memories that interpersonal traumas, in particular, havean impact
that,inturn,triggerarousalandavoidancebehaviour.In on attachment-anxiety. In contrast, non-interpersonal
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TherelationshipbetweenWADandPTSD
trauma types such as motor vehicle accidents had no Table1. Demographicdetails
impact on attachment security.
Variable N(cid:1)1,618 %
Aims and hypotheses
Gender
Few studies have looked at the co-occurrence of PTSD
Male 341 21.1
and WAD when the disorder persists for more than
Female 1,276 78.9
1 year. In addition, none of the extant literature has
Meanage(SD) 42.9(10.2)
included all three PTSD symptom clusters. To our
Meanyearsofeducation(SD) 13.0(3.3)
knowledge, there are no studies that have examined the
role of attachment dimensions in relation to PTSD after
Maritalstatus
whiplashtrauma.Wewantedtofurthervalidateandtest
Notmarried 157 9.8
the robustness of earlier findings linking PTSD with
Livingtogether 295 18.4
WAD and also include attachment insecurity as a
Married 971 60.7
possible vulnerability factor for developing PTSD and
Widower 22 1.4
persistent WAD.
Divorced 155 9.7
Hypotheses Children
First, we predicted that PTSD symptoms would be No 316 19.5
associated with severity of WAD, measured as number Yes 1,302 80.5
of whiplash symptoms, pain duration, pain-related dis-
Employmentaffected
ability,anddegreeofsomatisation.Secondly,weexpected
No 215 14.3
that attachment-anxiety would be positively associated
Yes 378 25.2
with both WAD and PTSD.
Hadtostopwork 907 60.5
Pension 587 38.4
Methods
Numberofwhiplash
Participants One 1,388 86.1
Data were collected from 1,349 women and 360 men Two 185 11.5
sufferingfromchronicWAD. Participantswererecruited Three 36 2.4
from the Danish Society for Polio, Traffic, and Accident Missing 9 .6
Victims. The society works for interests of the various
Otherinjuries
member groups by addressing the government and by
Yes 795 50.1
offeringservicestoits members suchasself-help groups,
No 792 49.9
counselling, and so on. In most cases, membership of
Missing 31 1.9
the society is obtainedvia a referral process through the
Danish National Health Service and other sources. The Timesincelastwhiplashinjury
present study was part of a larger study investigating Meanmonth(SD) 60.8(65.0)
the characteristics of those suffering from chronic WAD MeetingcriteriaforPTSD 627 38.8
organised in the Danish Society for Polio, Traffic, and
Attachmentsecurity(RAAS)
Accident Victims. All members of the whiplash group
Secure 297 18.4
were contacted (N(cid:1)2,320). The response rate was 74%.
Insecure 1,097 67.9
Demographic information is reported in Table 1. There
Non-categorised 224 13.7
were no differences found between responders and non-
respondersongenderorage.Thefemaletomaleratioof
respondents(approximately4:1)closelymatchedtheratio
1990). The RAAS is an 18-item self-report scale on
of the complete patient group (Fink, Toft, Hansen,
which participants rate statements about how they
Ørnbøl, & Olesen, 2007). In addition, the findings are
in linewith findings from epidemiological studies, which function and feel in a relationship with a partner,
have shown women to be at a higher risk of developing someoneclose,andpeopleingeneralona5-pointLikert
and maintaining whiplash-related symptoms compared scale(1(cid:1)notatallcharacteristic,5(cid:1)verycharacteristic).
to men (Harder, Veilleux, & Suissa, 1998). The scale is two-dimensional: (1) items on closeness
and dependency are merged into one dimension
Measures ‘‘close-dependency’’ (a(cid:1).62) and (2) an anxious attach-
Attachment security was measured with the Revised ment dimension (a(cid:1).84). Secure attachment is charac-
Adult Attachment Scale (RAAS; Collins & Read, terisedbyacombinedscore,abovemidpoint (cid:1)36onthe
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close-dependencydimensionandascorebelowmidpoint 1(cid:1)difficulty in performing some tasks, 2(cid:1)difficulty in
B18 on the anxious dimension (Collins, 1995, unpub- performing many tasks, 3(cid:1)difficulty in performing
lished reasearch note). A high score on the anxious nearly all tasks).
attachmentdimensionischaracterisedbyworryoverthe
availability,responsiveness,andpositiveregardofothers.
Statisticalanalyses
A low score on the close-dependency dimension is
The analyses were conducted in SPSS 17.0. For missing
characterised by discomfort with closeness and interde-
data replacement, multiple imputation was used as
pendence (Fraley & Waller, 1998).
described by Rubin (1987). Missing data resulted in the
The Trauma Symptom Checklist (cid:2) Revised (TSC-R;
exclusion of the case if more than 15% of the total
Briere & Runtz, 1989; Krog & Duel, 2003) was used to
answers were missing. Ninety-one cases were excluded
measuresomatisation.Thescaleconsistsof23itemsand
from the sample. The excluded cases did not differ from
measures a number of general distress symptoms on a
thetotalsampleonanyofthedemographicvariables.The
4-point Likert scale (1(cid:1)never, 4(cid:1)always). The internal
distribution of the data is presented as percentages,
consistencies as measured by Cronbach’s alpha were
means,andstandarddeviations.Toexaminetherelations
excellent (somatisation a(cid:1).89).
between the continuous scales, a series of correlations
To measurethe severityof PTSD symptomotology we
werecalculated.Thehypotheseswerefurthertestedusing
usedTheHarvardTraumaQuestionnairepartIV(HTQ;
a series of hierarchical multiple regressions. The regres-
Mollicaetal.,1992).TheHTQconsistsof30itemsona
sions involved two steps for each dependent variable. In
4-pointLikertscale(1(cid:1)notatall,4(cid:1)veryoften).Sixteen step 1, the demographic variables, (sex, age, years of
items relate to the three core clusters in PTSD in DSM- education) andvariables related to the injury (time since
IV: avoidance (7 items, a(cid:1).77), re-experiencing (4 items, injury, numbers of whiplash, and whether other injuries
a(cid:1).77), and hypervigilance (5 items, a(cid:1).72). Following were sustained or not) were entered. In step 2, the
the DSM-IV, a PTSD diagnosiswas proposed if partici- independent variableswere entered.
pants reported at least one re-experiencing symptom,
three avoidance symptoms, and two hyperarousal symp-
toms. An item was deemed to be positively endorsed if Results
scoreswere ]3. The HTQ self-report measure of PTSD A high co-morbidity between chronic WAD and PTSD
had 88% concordance with interview-based estimates was found. According to the DSM-IV criteria, 38.8% of
ofPTSD(Mollicaetal.,1992).Theinternalconsistency, theparticipantsfulfilledthecriteriaforaPTSDdiagnosis
measured by Cronbach’s alpha was excellent (total (measured with HTQ). Only 18.8% of the participants
a(cid:1).92). were characterised as securely attached (measured with
The degree of pain symptoms, sensory symptoms, RAAS).
and cognitive symptoms after whiplash trauma were
assessed using The Whiplash Symptom Checklist (WSC; Correlationanalysis
Elklit & Jones, 2007). Participants were asked to As shown in Table 2, all the correlations between the
indicate on the WSC whether within the month prior three PTSD symptom clusters (avoidance, hyperarousal,
to the study they had experienced any of the following re-experiencing) and the outcome variables (whiplash
symptoms: headache, neck pain, shoulder pain, weak- symptoms, pain duration, disability, and somatisation)
ness in arms, paraesthesia, vertigo, fatigue, nausea, met criteria for statistical significance at pB.01. The
tinnitus, auditory disturbances, reduced bite-function, weakest correlations were between re-experiencing and
visual disturbances, memory problems, problems read- the outcome variables (whiplash symptoms, pain dura-
ing and writing, or sleep disturbance. Cronbach’s alpha tion, disability, and somatisation). The correlations
was (total a(cid:1).77). between the attachment dimensions and the PTSD
Theprevalenceofpainfulepisodeswasmeasuredonan symptoms also reached statistical significance at pB.01.
8-point verbal rating scale (0(cid:1)no painful episodes, 1(cid:1) Attachment-anxiety in particular correlated modera-
very seldom, 2(cid:1)periodically, 3(cid:1)approximately 2 days tely with PTSD symptoms. Only small correla-
per week, 4(cid:1)approximately 3.5 days per week, 5(cid:1) tions were found between the attachment dimension
approximately 5 days per week, 6(cid:1)most of the time, ‘‘close-dependency’’ and PTSD symptoms. There were
7(cid:1)all of the time). no statistically significant correlations between the at-
Disability was measured as the level of interference tachment dimensions and pain duration and disability.
caused from painful episodes on daily chores. The However, a moderate correlation was found between
participants rated the disability level on a 4-point verbal attachment-anxietyandsomatisation.Forthatreasonthe
rating scale (0(cid:1)no difficulty in performing daily tasks, attachmentdimensionswereexcludedfromthefollowing
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TherelationshipbetweenWADandPTSD
Table2. Means,standarddeviations, andcorrelations forprimary study measures(n(cid:1)1,618)
M SD 1 2 3 4 5 6 7 8 9
1.PTSDsymptoms 37.83 9.39
2.Avoidance 15.17 4.99 .92**
3.Hyperarousal 14.85 3.32 .84** .65**
4.Re-experiencing 7.81 2.71 .75** .55** .49**
5.Attachment-anxiety 13.74 5.73 .36** .36** .31** .22**
6.Close-dependency 34.61 3.77 .11** .10** .11** .07** .21**
7.Whiplashsymptoms 10.23 3.01 .45** .38** .49** .24** .11** .05*
8.Painduration 5.70 1.70 .29** .26** .32** .15** .00 .02 .48**
9.Disability 2.05 .73 .39** .38** .36** .21** .04 (cid:3).00 .46** .52**
10.Somatisation 26.32 5.89 .63** .55** .69** .34** .26** .10** .63** .45** .45**
Note:*pB.05.**pB.01.
PTSDsymptoms(cid:1)totalscoreofsymptoms.
Disability(cid:1)pain-relateddisability.
regressions on severity of WAD measured as whiplash meet criteria for significance pB.006 in any of the
symptoms, pain duration, disability, and somatisation. regressions.
RegressionanalyseswiththePTSDsymptom Regressionanalyseswiththeattachmentdimensions
clustersasindependentvariablesandseverity asindependentvariablesandPTSDsymptoms
ofWADasdependentvariables asdependentvariables
Four separate regressions were calculated, testing the To test the role of attachment security on PTSD
association between the three PTSD clusters (avoidance, symptoms, a final regression was calculated entering the
hyperarousal, re-experiencing) and the dependent vari- total score of the three PTSD clusters as the dependent
ables (whiplash symptoms, pain duration, disability, and variable and the attachment dimensions as independent
somatisation). The regression results are presented in variables.TheregressionresultsarepresentedinTable4.
Table 3. The contribution of the background variables in the
The six background variables, as a block, contributed first block was statistically significant explaining about
statistically significantly to the regression models, but 5%ofthevariance.Lookingatthesinglepredictorsusing
explainedonlyabout4(cid:2)5%ofthevariance.Usingamore amoreconservativeBonferroni-typecorrectionforalpha
conservative Bonferroni-type correction for alphavalues values (.05/9(cid:1).006), gender, time since injury, and
(.05/9(cid:1).006), only injuries, education, and age met number of whiplash traumas did not met criteria for
criteria for significance at pB.006. Injuries had signifi- significance. Education correlated negatively with PTSD
cantcontributioninallequationsexceptfrominrelation symptoms. In step 2 of the regression, the attachment
to somatisation. Education contributed negatively in dimensions explained 12.8% of the unique variance in
relation to pain duration. Finally age had a positive relation to PTSD symptoms. Only attachment-anxiety
relationship with somatisation. Surprisingly, using the met criteria for significance pB.006.
Bonferroni-corrected alpha value, gender did not reach
statisticalsignificanceinrelationtoanyofthedependent Discussion
variables. In accordancewith previous studieswefound a high co-
In step 2 of the regressions, the PTSD clusters morbiditybetweenchronicWADandPTSD.About38%
predicted 22.3% of the unique variance in relation to of the participants met the DSM-IV criteria for PTSD.
whiplash symptoms, 9% in relation to pain duration, Thisresultisinagreementwithstudiesthathavereported
14.4% in relation to disability, and 45.7% in relation to between 30(cid:2)50% of individuals meeting criteria for
somatisation.Inparticular,theclustersofavoidanceand PTSD after motor vehicle accidents (Otis et al., 2003).
hyperarousal contributed a significant increment in all However, when looking at whiplash injuries alone, as in
the equations except from in relation to pain duration. the present study, other studies only found a PTSD rate
Here only hyperarousal met criteria for significance of about 17% (Ehlers et al., 1998; Mayou & Bryant,
at pB.006. The PTSD cluster re-experiencing did not 2002). Another recent study also found a high incidence
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Table3. Hierarchical multiple regressionswiththe PTSD Table4. Hierarchical multiple regressionswiththe attach-
symptomclusters ment dimensions
Predictors Beta(final) DR2 Adj.R2 Predictors Beta(final) DR2 Adj.R2
Whiplashsymptoms PTSDsymptoms
1.Gender .408* 1.Gender .640
Age .013 .041*** Age .090*** .052***
Education (cid:3).016 Educationyears (cid:3).328***
Time .001 Time (cid:3).006
Whiplash .321* Whiplash 1.332**
Injuries .634*** Otherinjuries 2.124***
2.Avoidance .077***
2.Attachment-anxiety .588***
Hyperarousal .377*** .223*** .263***
Close-dependency .054 .128*** .175***
Re-experiencing (cid:3).065*
Painduration Note:**pB.01.***pB.001.
1.Gender (cid:3).248* PTSDsymptoms(cid:1)totalscoreofsymptoms.
Age .007 .043*** Time(cid:1)timesincelastwhiplashinjury.
Whiplash(cid:1)numberofwhiplashinjuries.
Educationyears (cid:3).055***
Time .000
Whiplash .159 ourstudytheydidnotincludethehyperarousalsymptom
Otherinjuries .301*** scaleandwerethereforenotabletodeterminehowmany
oftheparticipantsactuallymeettheDSM-IVcriteriafor
2.Avoidance .031**
PTSD.ThehighincidenceofPTSDinourstudymaybe
Hyperarousal .138*** .090*** .127***
explained by the grouping characteristics. The partici-
Re-experiencing (cid:3).036
pantsrepresent aseverelychronicgroupandmaynotbe
Pain-relateddisability representative of the general WAD population. On the
1.Gender (cid:3).105* other hand, a high rate of PTSD in a severely chronic
Age .006** .046*** sample underlines the importance of the association
Educationyears (cid:3).003 between PTSD and chronic WAD.
Time .000 The first hypothesis regarding the association
Whiplash .056 between PTSD symptoms and severity of WAD, mea-
Otherinjuries .150*** suredaswhiplashsymptoms, painduration, pain-related
disability,andsomatisationwasconfirmed.Thestrongest
2.Avoidance .036***
associations were in relation to the hyperarousal symp-
Hyperarousal .046*** .144*** .185***
tomclusteralsoinalignmentwithBuitenhuisetal.(2006)
Re-experiencing (cid:3).011
andLiedletal.(2010),whofoundhyperarousaltobethe
Somatisation most important predictor of chronic pain and WAD
1.Gender (cid:3).256 symptoms. In agreement with Elklit and Christiansen
Age .047*** .045*** (2009), we also found the strongest association between
Educationyears (cid:3).075* hyperarousal symptoms and somatisation. The results
Time (cid:3).002 further validate that hyperarousal symptoms are impor-
Whiplash .300 tant in relation to chronic WAD. Studies that use PTSD
Otherinjuries .376 symptom scales not including hyperarousal symptoms
possibly underestimate important characteristics of the
2.Avoidance .233***
disorder. The association between hyperarousal and
Hyperarousal 1.024*** .457*** .500***
chronic WAD may be due to anxiety sensitivity. It is
Re-experiencing (cid:3).137**
hypothesised that anxiety sensitivity amplifies the inten-
sityofemotionalreactionsandtherebyincreasestherisk
Note:*pB.05.**pB.01.***pB.001.
of developing and maintaining both PTSD and chronic
Time(cid:1)timesincelastwhiplashinjury.
Whiplash(cid:1)numberofwhiplashinjuries. pain (Asmundson & Stapleton, 2008).
The association between the avoidance symptom
of PTSD symptoms; Sta˚lnacke (2009) reported that cluster and severity of WAD was also significant,
almost 38% of individuals suffered from mild to severe although not as strong as was the case for the hyperar-
stress symptoms 5 years after their injury. In contrast to ousal symptom cluster. Avoidance of activities that
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TherelationshipbetweenWADandPTSD
remind you of the accident possibly maintains chronic statistically (time since last injury, number of whiplash
WAD similarly to the mechanisms proposed by the fear- injuries, andwhetherother injurieswere sustained).
avoidance model of chronic pain (Asmundson et al., Despitetheselimitations,amajorstrengthofthestudy
2002).Accordingtothemodel,catastrophicthinkingand isthesamplesize andits uniquefocusonchronicWAD,
fear of movement lead to maintenance of fear and to PTSD, and attachment. The study describes important
hypervigilanceinrelationtobodilysensationsasinsome characteristicsofthosewithseverechronicWAD.Finally,
phobias. the inclusion of all three PTSD symptom clusters is a
The second hypothesis, regarding the association be- major strength, which makes it possible to estimate the
tweenattachment-anxiety,PTSD,andchronicWADwas prevalenceofPTSDaccordingtotheDSM-IVdiagnostic
partly confirmed. The association between attachment- criteria.
anxiety and PTSD symptoms is in agreement with
previous studies done in other trauma populations Conclusion
(Declercq & Palmans, 2006; Diepernik, Leskela, Thuras, Establishing a strong association between attachment
&Engdahl,2002;Elwood&Williams,2007;O’Conner& insecurity,PTSD,andchronicWADmaybeimportantin
Elklit, 2008). The association might be explained preventing the development of chronic WAD. Previous
by similar cognitive appraisals for both PTSD and studies have identified early PTSD symptoms after
attachment-anxiety. In agreement with Meredith et al. whiplashtraumaasoneofthebestpredictorsofchronic
(2008), we found a moderate correlation between WAD (Williamson et al., 2008). Moreover, both PTSD
attachment-anxiety and somatisation. However, we did symptoms and an insecure attachment have been found
notfindanyevidenceofadirectrelationshipbetweenthe to complicate pain management (Meredith et al., 2008;
attachment dimensions and pain duration. Furthermore, Otisetal.,2003).Toachievesuccessfuloutcomesinpain
wefoundahighprevalenceofinsecureattachment.Only management it is also important to address PTSD
about 20% of the participantswere classified as securely symptoms (Otis et al., 2003), as the two conditions are
attached, a result far from the 60% normally found in reported as mutually maintaining each other (Sharp &
the general population (Mickelson, Kessler, & Shaver, Harvey, 2001).
1997). This might indicate that attachment insecurity Attachment-anxiety may serve as maintenance of
is a vulnerability factor in the development of chronic chronic WAD through biased information processing,
WAD. hypervigilance regarding threat, and the use of poor
emotion regulation strategies leading to maladaptive
coping (Meredith et al., 2008; Mikulincer & Shaver,
Limitations
2007).However,itistooearlytodrawconclusionsabout
This study has several limitations. One limitation relates
treatment based on individual attachment orientations
to the population of the study, which is only repre-
giventhepreliminarynatureoftheseresults.Ontheother
sentativeof asegment of individualswith chronicWAD.
hand, psychological interventions in pain management
Therefore, others should be cautious about the general-
programs could profit by specifically targeting indivi-
isationofthefindings.Thesampleisasubsetofseverely
duals with PTSD symptoms (particularly hyperarousal
chronic WAD patients who, on average, have had chro-
symptoms) in pain management programs.
nic WAD for about 5 years. Some sustained multiple
Obviously,morelongitudinalstudiesareneededtotest
whiplash injuries and the majority of the participants
the relationship between attachment-anxiety, PTSD,
were classified as insecurely attached. Answers about
and the development of chronic WAD. Future studies
causality call for longitudinal studies and further infor-
should take special interest in possible moderators and
mation about those who recover from the trauma.
mediators of the association between attachment inse-
Although attachment orientations are considered rela-
curity, PTSD, and chronic WAD.
tivelystable throughoutthe lifecourse, itispossible that
the whiplash trauma and the stress related to the
Conflict of interest and funding
persistent pain condition may have altered the partici-
Thereisnoconflictofinterestinthepresentstudyforany
pants’attachmentorientations.Anotherlimitationisthat
of the authors.
the study was part of a larger study with outcome
measures not specifically chosen for the present study.
A future study should consider using more standardised References
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22(cid:2)28. Campusvej55,DK-5230OdenseM,Denmark
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