Psychological consequences of maxillofacial trauma: a preliminary study

British Journal of Oral and Maxillofacial Surgery (2003) 41, 317–322 © 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/S0266-4356(03)00131-1, available online at www.sciencedirect.com

Psychological consequences of maxillofacial trauma: a preliminary study A. M. Hull, ∗ T. Lowe, † M. Devlin, † P. Finlay, † D. Koppel, † A. M. Stewart ‡ ∗ Aberdeen

Centre for Trauma Research, Bennachie Building, Royal Cornhill Hospital, Aberdeen, Scotland, UK; †Regional Maxillofacial Unit, Glasgow, UK; ‡Liaison Psychiatry Service, Carseview Centre, Dundee, UK SUMMARY. Aims: To identify the prevalence of post-traumatic psychological symptoms after maxillofacial trauma and prognostic factors related to poor outcome. Methods: Thirty-nine patients were assessed within 10 days of injury and 24 again 4–6 weeks later using five standardised self-report measures on each occasion and a short structured interview at the time of initial contact. Results: Specific post-traumatic psychological symptoms were present at initial assessment in 21 patients (54%), with 9 (41%) meeting diagnostic criteria for post-traumatic stress disorder at review 4–6 weeks later. Other psychiatric problems, such as anxiety and depression, were identified by the General Health Questionnaire and the Hospital Anxiety and Depression Scale. Characteristics associated with poorer outcome included: a previous history of psychological distress; fear of the unknown, and female sex. Conclusion: These findings highlight the adverse psychological effect of maxillofacial trauma both immediately after the event and 4–6 weeks after injury. Proper assessment of injured patients must include psychological aspects and further research is needed to identify the most appropriate response. © 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Dundee Liaison Psychiatry Service, and the Aberdeen Centre for Trauma Research. The aim of the study was to identify: the prevalence of post-traumatic morbidity (not just PTSD), and also the prognostic factors relating to the injury, the person and the circumstances.

INTRODUCTION Until recently our understanding of the impact of trauma has derived mainly from the study of survivors of major disasters and wars1 with post-traumatic stress disorder (PTSD) first introduced into classification in the third edition of the Diagnostic and Statistical Manual of Mental Disorders in 1980.2 During the subsequent two decades interest has grown in the traumatic events of everyday life – for example, assaults, industrial accidents and road crashes.3 Maxillofacial trauma was identified by Shepherd4 as an important target for research because of its potential for both physical and psychological disability. Studies have reported high rates of general psychological morbidity, such as anxiety, depression and ‘psychiatric disorder’, after maxillofacial trauma at various times after various injuries, including assault and accidents.5,6 In particular, few studies have examined specific post-traumatic psychological effects of facial injury. Unless recognised and treated, post-traumatic psychological problems can become chronic. Clinicians should be aware of their presenting features, and treatment options that may include referral to mental health services, though it has been noted that psychological aspects of maxillofacial trauma are poorly documented in routine clinical practice.7 This preliminary study is a collaborative project between the Glasgow Regional Maxillofacial Unit, the

PATIENTS AND METHODS Subjects were recruited over a 6-month period between September 2000 and March 2001 after approval had been obtained from the local ethics committee. Participants were those who had been injured and who fulfilled the following inclusion and exclusion criteria. Subjects were included if they were: over 16 years of age, able to give written informed consent, and had had a traumatic facial injury (as opposed to disfigurement as a result of malignancy). We excluded people with obvious cerebral impairment, a peri-traumatic period of unconsciousness exceeding 15 minutes, and those with injuries from deliberate self-harm. Procedure Assessments were carried out at two time intervals. Subjects were interviewed by experienced clinicians, using the specially designed structured interview at initial assessment (within 10 days of the injury) and 317

318

British Journal of Oral and Maxillofacial Surgery

self-report questionnaires were completed at both initial and follow-up assessment. The follow-up assessment occurred between 4 and 6 weeks after the injury.

distressing; and 4: extremely distressing) in relation to the past week. The total possible score is 136. A score of 24 and above has a specificity of 80%: only one in every five people with this score will not meet DSM-IV diagnostic criteria for PTSD.

Assessments

EQ-5D12

Structured interview A specially designed structured interview collected information about social circumstances, current and previous trauma, subjective experience of the event, injuries sustained, proposed treatments, and an objective assessment of the prevailing mood. General Health Questionnaire (GHQ-28)8 This 28-item version of the GHQ provides a measure of general distress. There are four subscales that measure somatic symptoms, anxiety and insomnia, social dysfunction, and depressive symptoms. Using the conventional bimodal GHQ scoring method there is a range of 0–28 with a score above a threshold of 4 indicative of psychiatric disorder (i.e. if a clinical interview took place a psychiatric diagnosis would be present). Both a score of 4 or above and total score were used for the analyses. Hospital Anxiety and Depression Scale (HADS)9 HADS is a well-validated 14-item questionnaire with anxiety and depression subscales. Each subscale has a range of 0–21 with a score above a threshold of 7 indicative of disorder. The HADS avoids questions about somatic complaints that could introduce bias in physically injured subjects. Impact of Event Scale, revised (IES-R)10 This is a widely used, valid and reliable 22-item scale that measures subjective distress caused by intrusion (such as flashbacks and nightmares), avoidance (of reminders) and autonomic hyperarousal. Each of the 22 items uses a 4-point scale (0: not at all; 1: a little bit; 2: moderately; 3: quite a bit; and 4: extremely) in relation to the past week. Total scores have a possible range of 0–88. A total score is used for analyses. Davidson Trauma Scale (DTS)11 This scale measures all 17 primary symptoms of PTSD with specific criteria for both frequency and intensity with each item rated on a 5-point scale (for frequency, 0: not at all; 1: once only; 2: 2–3 times; 3: 4–6 times; and 4: every day. For severity, 0: not at all distressing; 1: minimally distressing; 2: moderately distressing; 3: markedly

The EQ-5D is a simple, standardised instrument that measures health-related variables of the quality of life, such as: mobility, self care, pain, and discomfort, anxiety and depression levels, and ability to carry out usual activities. Each item comprises three levels (1: no problem; 2: some or moderate problems; and 3: unable to or extreme problems). In addition, respondents are asked to indicate their general health status. Statistical analysis SPSS for Windows (version 9) software was used to store and to analyse the data. Non-parametric methods were used because data were skewed and variance heterogeneous. The Mann–Whitney U test (corrected for ties) was used for comparison between groups. The relationship between variables was assessed by Spearman’s rank correlation coefficient, and the chi-square test for association. (With regard to the latter, Fisher’s exact test was used when expected values were less than 5.) All probability values relating to the hypotheses are one-tailed. RESULTS Participants All 39 patients recruited completed the initial assessment, with 24 (62%) also completing the follow-up questionnaires. The personal and clinical profiles of all patients are summarised in Table 1. The details of those who did and did not complete the follow-up were similar. In terms of clinical characteristics, those who did not were significantly more likely to have a fracture of the mandible (P = 0.04, z = −2.23). There was a trend for those who did not to have higher total GHQ (P = 0.06, z = −1.94) and DTS scores (P = 0.06, z = −1.92), but these were not significant. Of the injuries listed, most were isolated fractures of the zygoma (20; 51%) and mandible (11; 28%). Coexisting non-maxillofacial injuries were present in only 3 (8%) of the subjects. Most injuries were sustained in a public place (30; 77%) with alcohol involved in 23 (59%) and the police in 16 (41%). The commonest cause of injury was assault 29 (74%) and almost half had had a previous facial injury (19; 49%). Treatment was as likely to be operative intervention (19; 49%) as conservative management (20; 51%).

Psychological consequences of maxillofacial trauma

319

Table 1 Personal and clinical details of participants (n = 39)

General psychological disturbance

Variable

The median (range) total score for the GHQ-28 was 8.5 (0–24) initially and 5.5 (0–28) at follow-up. Twenty-three of the 39 patients (59%) scored 4 or above on the GHQ-28 at initial assessment and 13 of the 20 patients who completed the questionnaire (65%) did so at follow-up. One patient scored 4 or above at follow-up but not at initial interview. Table 2 shows the distribution of patients on the anxiety and depression subscales of the HADS. At initial assessment the median (range) HADS anxiety scale score was 6.5 (0–17) and the median (range) depression scale score was 3.5 (0–13). At follow-up assessment the median (range) HADS anxiety scale score was 6.5 (0–18) and the median (range) depression scale score was 2.5 (0–11). Factors associated with meeting threshold levels for psychological disturbance on the GHQ and HADS at initial and follow-up assessment are summarised in Table 3.

Age

Mean 31, range 17–56

Sex Male

33 (85)

Employment Employed Student At home Unemployed

26 (67) 4 (10) 1 (2) 8 (21)

Previous facial injury

19 (49)

Cause of injury Assault Sport Other

29 (74) 5 (13) 5 (13)

Site of fracture Zygoma Mandible Maxilla Nasal Multiple

20 (51) 11 (28) 3 (8) 2 (5) 2 (5)

Soft tissue only

1 (3)

Other injuries

3 (8)

Location Public place Home Work Other

30 (77) 7 (18) 1 (3) 1 (2)

Treatment Operative Conservative

19 (49) 20 (51)

Psychiatric history†

12 (31)

Alcohol involved

23 (59)

Police involved

16 (43)

Post-traumatic psychological disturbance The median (range) total score for subjective distress after the traumatic event as measured by the IES-R was 22.0 (0–79) initially and 15.0 (0–72) at follow-up. The median (range) total score for the DTS was 25.0 (0–126) initially and 16.5 (0–112) at follow-up. Initially 19/35 patients (54%) had a total DTS score of more than 23, and of the 22 patients who completed the follow-up DTS in sufficient detail 9/22 (41%) scored more than 23. (Two patients failed to complete all questions.) According to their response on the DTS, nine patients met DSM-IV criteria for the diagnosis of PTSD (41%). Table 4 shows the distribution of subscales of intrusion, avoidance and hyperarousal on the DTS. Factors associated with high DTS

Data are number (%) of patients. † Psychiatric history: having seen either a general practitioner or a mental health professional for psychological problems. Table 2 Hospital Anxiety and Depression Scale Severity

Anxiety

Normal (0–7) Mild (8–10) Moderate (11–14) Severe (15–21) Incomplete

Depression

Initial (n = 39)

Follow-up (n = 24)

Initial (n = 39)

Follow-up (n = 24)

19 (49) 4 (10) 7 (18) 6 (15) 3 (8)

13 (54) 5 (21) 3 (13) 3 (12) 0

31 (79) 4 (10) 1 (3) 0 3 (8)

22 (92) 1 (4) 1 (4) 0 0

Data are number (%) of patients. Table 3 Measures of general psychopathology Initial assessment (n = 39)

Caseness

Sex Worry about facial injury Inability to carry out usual activities

Chi square P Chi square P Chi square P

Follow-up assessment (n = 24)

GHQ-28

HADS-anxiety

HADS-depression

GHQ-28

HADS-anxiety

HADS-depression

5.9 0.05 5.0 0.04 0.8 0.37

9.2 0.01 5.4 0.02 8.1 0.01

6.3 0.04 3.2 0.08 0.0 1.00

1.4 0.24 0.3 0.59 1.3 0.26

2.3 0.13 2.1 0.15 9.5 0.002

5.9 0.01 1.1 0.30 0.7 0.39

320

British Journal of Oral and Maxillofacial Surgery

Table 4 Mean (SD) Davidson Trauma Scale (DTS) subscale scores Subscale (range)

Table 6 Percentage distributions of EQ-5D descriptive questionnaire

Initial assessment (n = 39)

Follow-up (n = 24)

Intrusion (0–40) Avoidance (0–56) Hyperarousal (0–40)

9.1 (11.0) 13.6 (15.3) 14.5 (13.5)

8.7 (11.3) 11.2 (12.4) 11.6 (12.8)

Total DTS (0–136)

38.9 (38.9)

31.5 (35.5)

General population

and IES-R scores at initial and follow-up assessment are summarised in Table 5. Quality of life The frequency distributions of each quality of life variable from the EQ-5D descriptive questionnaire are summarised in Table 6.

DISCUSSION

Follow-up (n = 24)

Mobility No problems Some problems Confined to bed

95.1 4.7 0.2

89.5 10.5 0

86.4 13.6 0

Self-care No problems Problems Not possible

96.7 2.9 0.3

94.7 5.3 0

95.5 4.5 0

Usual activities No problems Some problems Not possible

85.8 11.7 2.4

63.2 34.2 2.6

72.7 27.3 0

Pain or discomfort None Moderate Extreme

68.0 30.5 1.5

7.9 89.5 2.6

45.5 50.0 4.5

Anxiety-depression None Moderate Extreme

83.6 15.7 0.7

57.9 31.6 10.5

68.2 27.3 4.5

73.2 (14.9)

78.3 (18.2)

Valuation of own health (0–100) Mean (SD) 85.3 (8.3)

This study confirms that psychological morbidity commonly follows maxillofacial injury. We found 41% of patients had appreciable specific post-traumatic symptoms as measured by the DTS; they also met DSM-IV criteria13 for the diagnosis of PTSD. The high rates of distress reported on the IES-R confirm that these injuries can cause considerable psychological morbidity. Further, this distress is not limited to specific post-traumatic symptoms with GHQ scores of 4 or above three times the rate found in general population studies.14 High numbers of patients with scores above 7 on the HADS anxiety subscale also emphasise the importance of screening for more than just PTSD. Bisson et al.7 have previously reported a prevalence of PTSD of 27%, and high numbers of patients with scores above 7 on the HADS, 7 weeks after injury.

Initial assessment (n = 39)

The early response of people after traumatic events may have a bearing on later psychological adjustment. Whilst PTSD cannot be diagnosed within 4 weeks of the incident or until symptoms have been present for 4 weeks, we chose to try and identify people with psychological problems within the first week and study them prospectively 4–6 weeks later. In this study, psychological disturbances that were initially present persisted at a high level throughout the follow-up period. As more than a third of patients did not attend for later review, debilitating psychological disturbance may remain undetected. Strenuous attempts should therefore be made to identify

Table 5 Measures of specific post-traumatic psychological condition Initial assessment (n = 39)

Visited GP for stress before trauma Visited mental health professional for stress before trauma Worry about facial injury No previous facial injury Police involvement Operative treatment Inability to carry out usual activities

z P z P z P z P z P z P z P

DTS: Davidson Trauma Scale; IES-R: Impact of Event Scale.

Follow-up assessment (n = 24)

DTS

IES-R

DTS

IES-R

−3.26 0.01 −3.15 0.000 −3.53 0.000 −2.22 0.03 −1.90 0.06 −1.21 0.23 −2.26 0.02

−2.75 0.01 −2.38 0.01 −3.47 0.000 −1.28 0.20 −2.09 0.04 −1.54 0.12 −2.59 0.01

−1.68 0.09 −1.35 0.18 −1.20 0.23 −0.10 0.92 −2.78 0.01 −1.99 0.05 −1.29 0.20

−0.96 0.34 −1.01 0.31 −1.78 0.08 −0.41 0.68 −2.96 0.002 −2.20 0.03 −1.37 0.18

Psychological consequences of maxillofacial trauma

at an early stage people who may be at risk of developing enduring psychological problems. This would allow communication with the patient’s general practitioner and an offer of follow-up where applicable. It is vital that nursing and surgical staff have an understanding of psychological reactions to trauma, risk factors and treatment options. However, at least one study has shown that this knowledge is limited among staff in trauma units.15 Trauma research is increasingly clarifying factors predictive of post-traumatic psychological disturbance. This study identifies some factors that should be incorporated within a comprehensive initial assessment, such as: pre-trauma psychological problems (initially), loss of normal function (initially and at follow-up) and type of treatment (at follow-up). This reflects the complex interaction of factors relating to the injury, the patient, and the circumstances in the aetiology of psychological reactions.3 Post-traumatic psychological disturbance may have an impact on compliance with treatment and recovery from physical injury. Indications from early research are that PTSD is associated with chronic disturbance in homeostasis.16 This may mean patients with PTSD will fail to recover as expected because of a prolonged inflammatory response, and may require more protracted treatment, for in addition to their psychological difficulties their physical injuries may also heal less well. The development of post-traumatic psychological problems is not confined to people with severe physical injuries; those with minor injuries may also develop PTSD.17–19 In addition, a clinical assessment of the severity of injury is not predictive of future PTSD.20 In our study patients did not perceive their injuries to be life-threatening and yet psychological distress was high. Our findings also confirm previous reports that it is the subjective perception of the injury that is more closely related to the development of PTSD.21,22 The consulting surgeon, as part of the structured interview, assessed each patient’s psychological status with eight options as prompts. This did not identify those with high levels of psychological morbidity on self-report either initially or at follow-up, suggesting that in this setting either a standardised structured interview or a validated self-report questionnaires may be needed to identify patients with psychological problems. The limitations of this study are that: it is a moderately sized sample with an attrition rate of 38%; limited pre-trauma data were available to exclude pre-existing post-traumatic psychological disturbance; acute stress reactions may not have been identified as the assessment was delayed for up to 10 days after injury; predominantly self-reporting measures were used; the patients were not consecutive because of the limitation of availability of clinical researchers over the 6-month recruitment period, and people with very minor or very severe injuries were

321

excluded. Those with minor facial injuries not requiring treatment would not have been seen at the unit. In addition, the brief nature of our study excluded patients with severe and coexisting injuries that required admission elsewhere (the intensive care unit) as they were unable to complete the assessments within our study timeframe. The 24 subjects (62%) who completed the follow-up assessments is an acceptable rate when compared with other prospective trauma studies.23,24 The response rate of 62% at follow-up reflects difficulties in recruitment and retention that bedevils trauma research. A number of people with high initial scores did not attend follow-up despite further contact by letter. Weisæth25 stated that the true prevalence of post-traumatic reactions is underestimated when response rates drop as reluctance to participate may reflect avoidance of reminders, a core symptom of post-traumatic reactions. Coupled with the trend for higher scores at initial assessment for both GHQ and DTS, it may be that our result is an underestimate of the problem. The limitations are compensated for by: the prospective nature of the study; the early identification of cases; the incorporation of an assessment of function; and the comprehensive assessment of a range of post-traumatic psychological distress, as PTSD is not the only manifestation of psychological disturbance after injury. Our findings are consistent with those of Bisson et al.7 despite the differences in protocols and samples. For example, our group was predominantly male (85%) and the commonest cause of injury was assault (74%); Bisson et al.’s sample was 43% male and assault accounted for only 35% of the injuries. Our finding that there was no association with assault as the cause of the facial injury may have arisen by chance because of the size of the study, as an association was found with police involvement that would often be related. Fear of the unknown was an important contributor with both worry about the injury (and its consequences) and no previous history of facial trauma being associated with post-traumatic psychological disturbance at initial assessment. These findings suggest that it would be helpful to ensure that patients are provided with adequate information about their injuries, treatment and prognosis. There is now compelling evidence that a combination of factors provoke post-traumatic reactions in a large proportion of survivors of trauma, and it is important to identify early those affected. A screening instrument has been developed to be used in surgical units to identify trauma survivors at high risk of developing specific and general psychological disturbance,23 though it has not yet been validated for maxillofacial trauma. However, self-reporting questionnaires, such as the DTS and GHQ-28, have proved to be effective in the detection of patients with established symptoms.8,11 Management may include medication or additional treatment (including

322

British Journal of Oral and Maxillofacial Surgery

psychotherapy) from mental health specialists. Some patients may decline the latter and it is therefore helpful to know that there are empirically confirmed treatments for PTSD available to non-specialists. There is increasing evidence in favour of serotonergic antidepressants, such as paroxetine, sertraline or fluoxetine.26 Early treatment may also limit the development of chronic PTSD or maladaptive coping, such as misuse of alcohol or drugs. ACKNOWLEDGEMENT We thank Professor David A. Alexander and Dr Susan Klein, Aberdeen Centre for Trauma Research, for their advice on the study protocol and analyses.

REFERENCES 1. Alexander DA. Trauma research: a new era (editorial). J Psychosom Res 1996; 41 (1): 1–5. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: American Psychiatric Association, 1980. 3. Alexander DA. Psychological aspects of trauma. In: Greaves I, Porter K, Burke D, ed. Key Topics in Trauma. Oxford: Bios Scientific Publishers Ltd, 1997: 249–257. 4. Shepherd JP. Strategies for the study of long-term sequelae of oral and facial injuries. J Oral Maxillofac Surg 1992; 50: 390–399. 5. Shepherd JP, Qureshi R, Preston MS, Levers BGH. Psychological distress after assaults and accidents. BMJ 1990; 301: 849–850. 6. Sen P, Ross N, Rogers S. Recovering maxillofacial trauma patients: the hidden problems. Wound Care 2001; 10: 53–57. 7. Bisson JI, Shepherd JP, Dhutia M. Psychological sequelae of facial trauma. J Trauma 1997; 43: 496–500. 8. Goldberg DP, Hillier VF. A scaled version of the General Health Questionnaire. Psychol Med 1979; 9: 139–145. 9. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983; 67: 361–370. 10. Marmer CR, Weiss DS. The Impact of Event Scale – revised. In: Wilson JP, Keane TM, eds. Assessing Psychological Trauma and PTSD. New York: The Guilford Press, 1997: 399–411. 11. Davidson JRT, Book SW, Colket JT et al. Assessment of a new self-rating scale for post-traumatic stress disorder. Psychol Med 1997; 27: 153–160. 12. Brazier J, Jones N, Kind P. Testing the validity of the EuroQol and comparing it with the SF-36 Health Survey Questionnaire. Qual Life Res 1993; 2: 169–180. 13. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994. 14. Hardy GE, Shapiro DA, Borill CS. Fatigue in the workforce of the national health service trusts: levels of symptomatology and links with minor psychiatric disorder, demographic, occupational and work role factors. J Psychosom Res 1997; 43: 83–92. 15. Alexander DA, Atcheson SF. Psychiatric aspects of trauma care: a survey of nurses and doctors. Psychol Bull 1998; 22: 132–136.

16. Miller RJ, Sutherland AG, Hutchison JD, Alexander DA. C-reactive protein and interleukin-6 receptor in posttraumatic stress disorder: a pilot study. Cytokine 2001; 13: 253–255. 17. Helzer JE, Robins LN, McEvoy L. Post-traumatic stress disorder in the general population. Findings of the epidemiological catchment area survey. New Engl J Med 1987; 317: 1630–1634. 18. Pilowski I. Minor accidents and major psychological trauma: a clinical perspective. Stress Med 1992; 8: 77–78. 19. Blanchard EB, Hickling EJ, Mitnick N, Taylor AE, Loos WR, Buckley TC. The impact of severity of physical injury and perception of life threat in the development of post-traumatic stress disorder in motor vehicle accident victims. Behav Res Ther 1995; 33: 529–534. 20. Green BL. Psychosocial research in traumatic stress. J Trauma Stress 1994; 7: 341–362. 21. Jeavons S. Predicting who suffers psychological trauma in the first year after a road accident. Behav Res Ther 2000; 38: 499–508. 22. Schnyder U, Morgeli H, Nigg C et al. Early psychological reactions to life-threatening injuries. Crit Care Med 2000; 28: 86–92. 23. Klein S, Alexander DA, Hutchinson JD, Simpson JA, Simpson JM, Bell JS. The Aberdeen Trauma Screening Index: an instrument to predict post-accident psychopathology. Psychol Med 2002; 32: 863–871. 24. Shalev AY, Freedman S, Peri T, Brandes D, Sahar T. Predicting PTSD in trauma survivors: prospective evaluation of self-report and clinician-administered instruments. Br J Psychiatry 1997; 170: 558–564. 25. Weisæth L. Importance of high response rates in traumatic stress research. Acta Psychiatr Scand 1989; 80: 131–137. 26. Hidalgo RB, Davidson JRT. Selective serotonin reuptake inhibitors in post-traumatic stress disorder. J Psychopharmacol 2000; 14: 70–76.

The Authors A. M. Hull MRCPsych Aberdeen Centre for Trauma Research Bennachie Building, Royal Cornhill Hospital Aberdeen, Scotland, UK T. Lowe FRCS M. Devlin FRCS P. Finlay FDSRCPS D. Koppel FRCS Regional Maxillofacial Unit Glasgow, UK A. M. Stewart MRCPsych, FDSRCPS Liaison Psychiatry Service Carseview Centre, Dundee, UK Correspondence and requests for offprints to: Alastair M. Hull MRCPsych, Aberdeen Centre for Trauma Research, Bennachie Building, Royal Cornhill Hospital, Aberdeen, Scotland AB25 2ZH, UK. Tel: +44 (0) 1224 557898; Fax: +44 (0) 1224 557894; E-mail: [email protected] Accepted 20 June 2003