1. Automobile Accidents
2. PTSD and Anxiety
3. Digital Mind Change - S. Greenfield
4. Cranio Sacral System - J. Rollinson
5. MVA's and PTSD


Recovery from Automobile and other Accidents

       If you have ever been in a car accident, you know that the sense of relief that no one was seriously hurt feels about as good as it gets.  Many people are surprised, however, when one day, two days, even up to a week later, they are all of a sudden sore, stiff, aching and out of sorts!  This is due to the body’s self-protective mechanisms, which keep you functional, and sometimes pumped with adrenaline, in case you still need to get yourself or your family out of danger.
       Motor vehicle accidents cause all kinds of injuries, the most troubling of which is concussion.  Post concussive syndrome is the disorientation, lack of focus, headaches, fatigue and lessened mental faculties resulting from a bruise of the brain.  That is what all concussions are, a bruising of neural tissue.  There is a wide range, but it is almost always recommended to get some kind of support or treatment for even a mild concussion.  (The most serious type involves actual bleeding within the cranium, called a subdural bleed or hematoma, and if you have blurred vision, oversensitivity to light, can’t stand or remember basic facts or really any concerning symptoms, you need to go directly to the hospital as this is life-threatening.) 
       Other common MVA injuries are:  whiplash, which is usually several mild to moderate ligament or muscle pulls in the neck.  Low back or lumbar strain, which involves pain and stiffness in the lower back, even if you don’t remember hurting it.  Joint injuries, such as sore shoulders or hips. 
       Cranio Sacral Therapy is highly recommended for automobile accident recovery.  Often even a few treatments will shorten the recovery and rehabilitation time significantly.  The first thing Craniosacral work does is to take the edge off the body’s internal trauma response.  Whenever we experience a trauma, many things happen with the nervous and endocrine systems.  The survival centers in the brain-stem assume there is a danger to your life, and they activate the “fight or flight” response.  Adrenaline and other hormones flood the system, the nerves go on high alert, and our energy and focus shift instantly out into the periphery.  (The body perceives all threats as part of the environment, and directs our resources to unite with our peripheral environment, in an attempt to control it, and so keep us safe.)  This is why we feel numb after a car accident, sometimes even for days! 
       Our first order of business is to assist the body to complete the process of re-setting your fight or flight response.  Now that the accident or trauma is over, a “sympathetic” state of the nervous system is counterproductive.  It just causes more stress and slows healing.  If you feel nervous, numb, edgy, have trouble concentrating, you are irritable or just plain out of sorts, your nervous system has not yet returned to a “parasympathetic” state.  In a perfect world, this reset happens within a few hours, but few people are so lucky.

Some things you can do right away:

1.            Take an Epsom salts bath.Dissolve 2 cups Epsom salts in a hot bath and soak for half an hour.  This will often help alleviate or prevent some of the soreness, until you can get in for a therapeutic treatment.

2.            Take it easy.  Do not resume your regular exercise routine for at least 3 days, or you could make it worse, and slow the healing process.  Your body needs all its resources.

3.            Take a day off from work if you can.  The time allows your body to begin regrouping its forces and sets the stage for a healing process, rather than a make-due process.

4.            Arnica is an herb which has demonstrated effectiveness supporting the recovery from bruising, strain and shocks of all kinds.  It is non-prescription.  Use whatever you have at hand, creams (“Traumeel” is a brand which has other helpful ingredients as well) or homeopathic drops or pellets.  If you have a choice, take 6X or something close to that.

       Cranio Sacral treatment follows a de-stressing and calming of the patient with attention to concussions and then the musculoskeletal system.  Contusions, pulled muscles and strained joints respond well to the gentle approach, where we release tension and kinetic energy from impact and restore range of motion.  Important: healing is slowed in an environment of stress, tension or emotional distress.
       Concussions require a somewhat longer time for complete recovery; because there is no known conventional treatment which actually speeds the healing of post concussive symptoms, we can only prevent further injury or lessen symptoms.  Many people have shown significant improvement while receiving craniosacral work, and most return to a better level of mental clarity within a week or two.
       Interestingly, a car or motor vehicle accident often brings up older injuries or traumas, as if the body in its wisdom takes the opportunity to complete a healing process for an older event for which we originally did not have the resources.  Countless times, because of this, after going through recovery in this careful and attentive way, you end up better than you were to start with.       – John Rollinson

When seeing patients in my Northampton, Massachusetts office, I make every effort to fit you in right away if you have been in an MVA, (motor vehicle accident), and to expedite approval from your insurance company.  After any car accident, It is important for you to take your recovery process in hand, whatever path you choose.

Hampshire County, Western Mass.

Cranio Sacral Therapy and PTSD  

Stress, Emotional Trauma, Anxiety, Depression
CranioSacral Therapy is well known as an effective and safe therapeutic support for individuals who have passed through traumatic experiences, and has been helpful to combat veterans, survivors of abuse or in working through the “invisible trauma” of childhood.  CST works to heal us in our PTSD or ongoing stress by allowing the body and central nervous system to change their ingrained emotional patterns.
If you have symptoms you feel are related to ongoing emotional stress or previous emotional trauma, CST and SER may help you to significantly lighten the load you are carrying.  Anxiety and Depression-like symptoms are often the result of emotional “energy” trapped in the human nervous system.  Normally, the body dissipates emotional trauma soon after the event.  If we do not have the resources to initiate our dissipating mechanisms, it is still possible at a later date to facilitate this process and help our central nervous system to release, integrate and heal.
Following a study of 38 Tibetan refugees suffering from PTSD, Naturopath Dr. Lisa Chavez explains:  “I think this therapy works so well for body mind conditions because it induces the parasympathetic branch of the nervous system, or as it is commonly called the 'rest and digest' state.  This allows the entire body to enter a state of restoration, unlike psychoactive drugs that just dampen the sympathetic response."1
She found that ‘survey scores for anxiety and somatic complaints of the participants who received the Craniosacral Therapy decreased, while the somatic complaint scores of the participants who did not receive therapy actually increased.  "The decrease in somatic, anxiety and total scores of the treatment group was statistically significant…”’2
Key in Chavez’ assessment is the idea that for deep and lasting healing from post traumatic stress or stress disorder, it is not enough to “dampen the sympathetic response” (the body’s anxiety/survival response).  What we really want is to strengthen the body and indeed the whole person, reconnecting them to their core and facilitating a processing and release of trauma and trauma patterns within the emotional consciousness and the nervous system.  This ultimately brings us into a “parasympathetic” state, where we are no longer looking around every corner for the next stressor, but calmly centered at home, in ourselves.
These processes: of realigning with our selves, and shedding stress, must generally go hand in hand.  As we feel less urgency, we can come back to our center.  As we feel our selves strong, stress falls away.       -John Rollinson

1 http://www.news-medical.net/news/20090821/PSTD-could-be-treated-with-Craniosacral-therapy-according-to-a-research-study.aspx#
2 http://www.news-medical.net/news/20090821/PSTD-could-be-treated-with-Craniosacral-therapy-according-to-a-research-study.aspx#

I work with all levels of PTSD in my office in Northampton, MA including both acute and chronic types.  And, one should not imagine that one has to pass through war and famine to struggle with stress levels which are beyond an appropriate response from the body.  Our modern human condition makes our emotional and mental digesting of stressful events (and thoughts) a complex inner process which is usually confusing and frustrating.  Take heart, there are a lot of us out here who are able to offer support.


Susan Greenfield: “Mind Change: How Digital Technologies Are Leaving Their Mark on Our Brains”

Susan Greenfield, neuroscientist, senior research fellow at Oxford University and a member of the House of Lords.
Excerpted from Mind Change by Susan Greenfield.  Copyright © 2015 by Susan Greenfield.  Reprinted here by permission of the author.

Let’s enter a world unimaginable even a few decades ago, one like no other in human history. It’s a two-dimensional world of only sight and sound, offering instant information, connected identity, and the opportunity for here-and-now experiences so vivid and mesmerizing that they can outcompete the dreary reality around us. It’s a world teeming with so many facts and opinions that there will never be enough time to evaluate and understand even the smallest fraction of them. For an increasing number of its inhabitants, this virtual world can seem more immediate and significant than the smelly, tasty, touchy 3-D counterpart: it’s a place of nagging anxiety or triumphant exhilaration as you are swept along in a social networking swirl of collective consciousness. It’s a parallel world where you can be on the move in the real world, yet always hooked into an alternative time and place. The subsequent transformation of how we might all be living very soon is a vitally important issue, perhaps even the most important issue of our time. Why? Because it may be that a daily existence revolving around smartphone, iPad, laptop, and Xbox is radically changing not just our everyday lifestyles but also our identities and even our inner thoughts in unprecedented ways.2 As a neuroscientist, I’m fascinated by the potential effects of a screen-oriented daily existence on how we think and what we feel, and I want to explore how that exquisitely adaptable organ, the brain, may now be reacting to this novel environment, recently dubbed the “digital wildfire”3.

In the developed world, there is now a one in three chance that children will live to 100 years of age.4 Thanks to the advances of biomedicine, we can anticipate longer and healthier lives; thanks to technology, we can foresee an existence increasingly freed from the daily domestic grind that characterized the lives of previous generations. Unlike so much of humanity in the past and still in many nightmare scenarios around the world, we take it as the norm and as our entitlement not to be hungry, cold, in pain, or in constant fear for our lives. Unsurprisingly, therefore, there are many in our society who are convinced that we’re doing just fine, that these digital technologies are not so much a raging wildfire but more of a welcoming hearth at the heart of our current lifestyles. Accordingly, various reassuring arguments are ready at hand to counter reservations and concerns that might otherwise be viewed as exaggerated, even hysterical. 

One starting premise is that surely everyone has enough common sense to ensure that we don’t let the new cyber-culture hi-jack daily life wholesale. Surely we are sensible and responsible enough to self-regulate how much time we spend online and to ensure that our children don’t become completely obsessed by the screen. But the argument that we are automatically rational beings does not stand the test of history: when has common sense ever automatically prevailed over easy, profitable, or enjoyable possibilities? Just look at the persistence of hundreds of millions worldwide who still spend money on a habit that caused a hundred million fatalities in the twentieth century and which, if present trends continue, promises up to one billion deaths in this century: smoking.5 Not much common sense at work there.

Then again, the reliability of human nature might work in our favor if only we could assume that our innate genetic makeup leads most of us to do the right thing, regardless of any corrupting external influences. Yet in itself, this idea immediately runs counter to the superlative adaptability of the human brain, which allows us to occupy more ecological niches than any other species on the planet. The Internet was initially created as a way for scientists to contact each other, and this invention spawned phenomena such as 4chan, a collection of message boards where people post images and short text comments, mostly anonymously and with no holds barred. This form of self-expression is a new niche to which we may adapt, with consequences as extreme as the medium itself. If it is the hallmark of our species to thrive wherever we find ourselves, then the digital technologies could bring out the worst in human nature rather than being rendered harmless by it. 

Another way of dismissing out of hand the concerns that the effects of digital technology may bring is a kind of solipsistic stance in which the screen enthusiast proudly points to his or her own perfectly balanced existence, which combines the pleasures and advantages of cyber-culture with life in three dimensions. Yet psychologists have been telling us for many years that such subjective introspection is an unreliable barometer of mental state. In any case, it should be obvious enough that just because a single individual may be able to achieve an ideal mix between the virtual and the real, it does not automatically mean that others are capable of exercising similar restraint and sound judgment. And even those individuals who think they’ve got everything just right will often admit in an unguarded moment that “It’s easy to waste a lot of time on Facebook,” that they are “addicted” to Twitter, or that, yes, they do find it hard to concentrate long enough to read a whole newspaper article. In the United Kingdom, the advent of I, an abbreviated version of the national quality paper The Independent, and the introduction on the BBC of the 90 Second News Update stand as testimony to the demands of an ever larger constituency of readers and viewers — not just the younger generation — who have a reduced attention span and are demanding print and broadcast media to match. 

Another consolation is the conviction that the next generation will work out just fine, thanks to parents who take control and intervene where necessary. Sadly, this idea has already proved to be a nonstarter. For reasons we shall explore shortly, parents often complain that they cannot control what their offspring do online, and many already despair at their inability to prize their children away from the screen and back into a world of three dimensions. 

Marc Prensky, an American technologist, coined the term “Digital Native” for someone defined by his or her perceived outlook and abilities, based on an automatic facility and familiarity with digital technologies.8 By contrast, “Digital Immigrants” are those of us who, according to Prensky, “have adopted many aspects of the technology, but just like those who learn another language later in life, retain an accent because we still have one foot in the past.” It is unlikely that anyone reading these words will not have strong views as to which side of the divide he or she belongs and whether the distinction is cause for unalloyed celebration or deep anxiety. Generally speaking, it corresponds to age, although Prensky himself did not pinpoint a specific line of demarcation. The date of birth of the Digital Native seems therefore to be uncertain: we could start as far back as the 1960s, when the term “computer ” entered into common parlance, or as late as 1990, for by the time a young Digital Native born then could read and write, email (which started around 1993) would have become an inescapable part of life. 
The important distinction is that Digital Natives know no other way of life other than the culture of Internet, laptop, and mobile. They can be freed from the constraints of local mores and hierarchical authority and, as autonomous citizens of the world, will personalize screen-based activities and services while collaborating with, and contributing to, global social networks and information sources. 

But a much gloomier portrait of the Digital Native is being painted by pundits such as the British American author Andrew Keen: 
MySpace and Facebook are creating a youth culture of digital narcissism; open-source knowledge sharing sites like Wikipedia are undermining the authority of teachers in the classroom; the YouTube generation are more interested in self-expression than in learning about the world; the cacophony of anonymous blogs and user-generated content is deafening today’s youth to the voices of informed experts.9 

Then again, perhaps the Digital Native doesn’t actually exist after all. Neil Selwyn, of the Institute of Education in London, argues that the current generation is actually no different from preceding ones: young people are not hardwired to have unprecedented brains. Rather, many young people are using technology in a far more sporadic, passive, solitary, and, above all, unspectacular way than the hype of the blogosphere and zealous proponents of cyber-culture might have us believe. 

Irrespective of whether the digital age has spawned a new type of super-being or just ordinary humans better adapted to screen life, suffice it to say that, for the moment, parents are most likely to be Digital Immigrants and their children Digital Natives. The former are still learning the enormous potential of these technologies in adulthood, while the latter have known nothing else. This cultural divide often makes it hard for parents to know how best to approach situations that they intuitively perceive to be a problem, such as seemingly excessive time spent on computer-based activities; meanwhile, children may feel misunderstood and impatient with views they regard as inappropriate and outdated for present-day life.

Although reports and surveys have focused largely on the next generation, the concerns I want to flag are not limited to the Digital Native alone. Far from it. But a generational divide has undoubtedly arisen from the vertiginous increase in the pace of ever smarter digital devices and applications. What will be the effects on each generation, and on the relationship between them? 

In a 2011 report, Virtual Lives, researchers for the U.K. children’s charity Kidscape assessed the online activities of more than two thousand children between the ages of eleven and eighteen. Just under half of the children questioned said they behaved differently online compared to their normal lives, with many claiming it made them feel more powerful and confident. One explained: “It’s easier to be who you want to be, because nobody knows you and if you don’t like the situation you can just exit and it is over.” Another echoed this sentiment, noting: “You can say anything online. You can talk to people that you don’t normally speak to and you can edit your pictures so you look better. It is as if you are a completely different person.” These findings, the report argues, “suggest that children see cyberspace as detachable from the real world and as a place where they can explore parts of their behavior and personality that they possibly would not show in real life. They seem unable to understand that actions online can have repercussions in the real world.”11 The easy opportunity of alternative identity and the notion that actions don’t have consequences have never previously featured in a child’s development, and they are posing unprecedented questions as to what might be for the best. While the brain is indeed not hardwired to interface effectively with screen technologies, it has evolved to respond with exquisite sensitivity to external influences — to the environment it inhabits. And the digital environment is getting ever more pervasive at an ever younger age. Recently Fischer-Price introduced a potty-training seat complete with an iPad holder,12 presumably to complement an infant life-style where the recliner in which the baby may spend many hours is also dominated by a screen.

This is why the question of the impact of digital technologies is so very important. Hardened captains of industry or slick entrepreneurs will often sidle up to me during the coffee break at corporate events and let their professional mask slip as they recount in despair the obsessional fixation of their teenage son or daughter with the computer. But these anxieties remain unchanneled and unfocused. Where can these troubled parents share their experiences with others on a wider platform and articulate them in a formal and cogent way? At the moment, nowhere. In the following pages, we’ll be looking at many studies on preteens as well as teenagers; unfortunately, there are far fewer studies on adults, perhaps because they are less cohesive and identifiable as a group than a volunteer student body or a captive classroom. But, in any event, it’s important to view the data not as a self-help guide for bringing up kids but rather as a pivotal factor in the bigger picture of society as a whole. 


Assessment and treatment of PTSD after a motor vehicle collision: Empirical findings and clinical observations
J. Gayle Beck and Scott F. Coffey

Individuals who experience a serious motor vehicle accident (MVA) are at increased risk for psychological problems, particularly Posttraumatic Stress Disorder (PTSD). In this article, we review the literature on PTSD among MVA survivors, with particular attention to available instruments to screen for and assess symptomatology of the disorder. Approaches to the treatment of PTSD in this population are reviewed, separated into interventions designed to prevent PTSD in unselected samples, treatment targeting individuals with Acute Stress Disorder that are designed to prevent subsequent development of PTSD, and therapy for individuals with chronic PTSD. Treatment process issues are discussed, in an effort to integrate empirical findings with clinical observations. The empirical literature suggests several approaches to treatment that have good potential outcomes, although continued work is needed to identify factors that predict treatment response, as well as augment individual-based treatment formats.

Keywords: Trauma, Road traffic accidents, Cognitive Behavior Therapy, Supportive Psychotherapy, Acute Stress Disorder
As Cathy sat at the traffic light thinking about the errands she was running, she could hear her two year-old singing in the backseat. Suddenly, a violent blow from behind launched her car forward approximately 15 feet. Immediately, she felt a sharp pain in her neck. With her ears ringing from the noise of the collision, she at once thought, “my baby is dead”. Whipping her head around despite the intense pain, she saw her baby wide-eyed and surprised, but completely uninjured as he sat buckled in his car seat. For months following the collision she asked herself, “It was just a wreck- like people have every day … Why am I having bad dreams about it, a hard time driving, and I can’t seem to relax anymore”. If you have a patient in your office who sounds like this, you are not alone. Millions of motor vehicle accidents (MVAs) occur each year, many with serious consequences (U.S. Department of Transportation, 2004), For example, in 2004 just under 6.2 million traffic accidents were reported to police departments in the United States resulting in approximately 2.8 million injuries. Despite the large number of MVAs and injuries that result from these accidents, only recently have the psychological consequences of MVAs been fully recognized (see Blanchard & Hickling, 2004). In this article, we will review the available knowledge about emotional after-effects of serious collisions, with particular emphasis on the assessment and treatment of PTSD.

Psychological consequences of a serious motor vehicle accident

One serious psychological consequence often associated with serious MVAs is posttraumatic stress disorder (PTSD). PTSD is an anxiety disorder that often follows a traumatic event involving actual or threatened death, serious injury, or threat to the physical integrity of oneself or others (American Psychiatric Association, 2000). For many individuals, the symptoms of PTSD following a serious MVA may include psychologically re-experiencing the trauma (e.g., intrusive thoughts about the accident, distressing dreams about the accident), persistent avoidance of thoughts or situations associated with the accident (e.g., reluctance or refusal to drive, actively avoiding thoughts about the MVA), numbing of emotional responsiveness (e.g., greatly reduced or absence of emotions, feeling detached from others), and increased physical arousal (e.g., exaggerated startle, irritability, disturbed sleep).
Reported rates of MVA-related PTSD can vary across studies depending on methodologies employed in the various studies. However, from the approximately two dozen studies assessing samples consisting largely of MVA survivors (often recruited from emergency room admissions or hospital wards) and using well validated structured interviews, the presence of PTSD at least 30 days post-MVA is approximately 25-33% (e.g., Bryant, Harvey, Guthrie, & Moulds, 2000; Harvey & Bryant, 1998; Ursano et al., 1999). Although these samples may be seeking medical attention, the presenting problem in these studies typically is not psychological in nature so they would not be classified as psychological treatment seekers. As might be expected, the rates of PTSD found in assessment or psychological treatment-seeking samples of MVA survivors tends to be higher (e.g., Blanchard & Hickling, 2004). In looking at the general population, Norris (1992) conducted a large survey of four Southern cities (n = 1,000; response rate 71%) and found the lifetime prevalence rate of PTSD to be 7.4% and that MVAs were among the leading cause of PTSD in her sample. These data, along with a lower rate of MVA-related PTSD found in a survey of relatively young Americans (Breslau et al., 1991), leads to a conservative estimate that MVA-related PTSD may affect 2.5 to 7 million people in the United States, reflecting a significant public health problem (Blanchard & Hickling, 2004).

In addition to PTSD, a number of other psychological problems often are present after a MVA. Mood disturbances are particularly common, with one report indicating that 53% of patients with PTSD have concurrent mood disorders (Blanchard et al., 1995). In a sample of MVA survivors seeking an assessment and treatment for trauma-related symptoms at the University at Buffalo (n = 237), 25% of the overall sample reported symptoms consistent with a major depressive episode. However, of those meeting criteria for PTSD (n = 103), 41% reported symptoms consistent with a major depressive episode. These data are somewhat consistent with a larger epidemiological study (National Comorbidity Survey, NCS) examining psychiatric comorbidity among individuals with PTSD in which approximately 48% of those with PTSD also experienced a major depressive episode (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). However, the rates of co-occurrence of PTSD and depression in the Buffalo sample may be higher than rates reported in the NCS because the NCS assessed lifetime comorbidity while the Buffalo MVA sample represents current comorbidity. Additional anxiety disorders also can be present, with rates ranging from 7% to 31%, depending on gender and the specific disorder in question (Kessler et al., 1995). In addition, the presence of PTSD increases an individual’s risk of meeting criteria for a substance use disorder. For example, Helzer et al. (1987) reported that men and women with PTSD were 5 and 1.4 times more likely, respectively, to have a substance use disorder compared with the general population. In contrast, rates of a current drug or alcohol abuse disorder (0% and 1.6%, respectively) among MVA survivors with PTSD are relatively low and did not differ between MVA survivors with PTSD, MVA survivors without PTSD, and non-MVA controls (Blanchard et al., 1995). So while MVA survivors with PTSD appear to present for treatment with high rates of depression, substance use disorders may be somewhat lower in this PTSD population compared to other PTSD populations. Further research is needed to test this hypothesis.

Chronic pain
Among the issues that are associated with MVA-related PTSD, the presence of chronic pain may be the single most defining characteristic. For example, in a psychometric study assessing PTSD in 229 MVA survivors, Coffey, Gudmundsdottir, Beck, Palyo, & Miller (2006) found that 69% of the sample reported chronic pain that could be attributed to their MVA. For an individual to be described as having MVA-related chronic pain, it was required that pain symptoms be attributed to injuries sustained during their MVA and that the pain symptoms had not responded to standard medical treatment after one month. In addition, the reported pain caused significant lifestyle limitations, impairment, or significant distress, determined on the basis of behavioral restriction (e.g., unable to work), continued utilization of health care for pain relief, or consistent use of pain medication. In a study of a MVA survivors presenting with chronic headache and other pain, Hickling and Blanchard (1992) found a 50% prevalence rate for PTSD. In another study of MVA survivors by this research group (Blanchard et al., 1995), physical injury was associated with the development of PTSD (and subsyndromal PTSD). Finally, in a sample of litigating MVA survivors with chronic pain and posttraumatic stress symptoms, Duckworth and Iezzi (2005) found that high posttraumatic stress symptoms were related to physical impairment, psychological distress, and maladaptive pain coping strategies. In sum, it is clear that pain often co-occurs in assessment and treatment seeking MVA survivors. The role that chronic pain may play in treatment will be discussed below.

MVAs, symptom presentation, and litigation
Litigation is a ubiquitous feature of working with MVA survivors. Clinical lore suggests that litigation markedly affects symptom presentation among MVA survivors. Specifically, many believe that litigation is the driving force behind complaints of PTSD symptoms in MVA survivors and once litigation is concluded (e.g., a favorable ruling is won by the litigant), symptom presentation will improve. As cogently reviewed in Blanchard and Hickling (2004), there is little evidence that litigation affects symptoms among assessment or treatment seeking MVA survivors. Although a number of researchers have investigated the effects of litigation on symptom presentation and an individual’s willingness/ability to return to work, Mayou and colleagues have produced the largest body of work to date (e.g., Mayou, 1995, 2002; Mayou, B. Bryant, & Duthie, 1993). Following a group of 171 MVA accident survivors seen at an emergency room in England, Mayou and colleagues, at three-year follow-up, found no differences in symptom presentation between the 96 individuals who were involved in MVA-related litigation and the 75 who had not filed claims (Mayou, 1995; Mayou et al., 1993). At 6 year follow-up, 81 of the 96 individuals pursuing litigation were located and re-assessed (B. Bryant, Mayou, & Lloyd-Bostock, 1997). Sixty-nine of the 81 cases had been settled but there were no dramatic improvements in physical complaints, mental state, or social functioning among those with settled cases compared to those whose cases were still active. These data have been largely replicated in an Australian sample (n = 106) of MVA survivors who were hospitalized because of their injuries (R. A. Bryant & Harvey, 2003). Although it is always possible that an individual involved in an MVA may be less than genuine when describing psychological or physical symptoms attributed to the MVA, at this point, the available data does not support that contention that there is widespread deceit among assessment or treatment seeking MVA survivors.

Assessment of MVA-Related PTSD
PTSD screening and treatment outcome measures
Given the high prevalence of MVA-related PTSD described above, it is prudent to screen clients who report a serious MVA for PTSD. Shrout and colleagues have recommended a two-step approach to identifying PTSD (Shrout, Skodol, & Dohrenwend, 1986). In the first step, individuals are administered self-report measures relevant for a particular disorder. If a predetermined cutoff score is exceeded, a more extensive and time-consuming diagnostic evaluation can be conducted. By administering a self-report measure first to identify cases that are most likely to require additional assessment and possibly treatment, clinicians can efficiently allocate services where they are potentially most needed. In the case of MVA survivors, easy to administer self-report screening tools may help to identify individuals in both psychological and medical settings who are suffering serious psychological sequelae of an MVA and increase referrals to effective MVA-PTSD treatment (e.g., Blanchard & Hickling, 2004; Taylor & Koch, 1995).

Although, there are a number of psychometrically sound measures of PTSD symptoms, three measures may be particularly useful in screening clients for MVA-related PTSD; one because of its excellent psychometric properties and widespread use and two others because they are psychometrically sound and have established screening scores specific for MVA-related PTSD. These three measures also can be used to index change during the course of treatment, as they have been shown to be sensitive to change in this population.

One of the most widely used PTSD screening measures is the PTSD Checklist (PCL; Weathers, Litz, Huska, & Keane, 1994). The items of the PCL correspond to the 17 symptoms of PTSD in DSM-IV (APA, 2000). Respondents rate each item in terms of how much the symptom has bothered them in the past month using a 1 (not at all) to 5 (extremely) scale. Internal consistency coefficient of the PCL total score has been reported to be 0.94 (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; Ruggiero, Del Ben, Scotti, & Rabalais, 2003) and two-week test-retest reliability correlation coefficient has been reported to be 0.68 (Ruggiero et al., 2003). When the PCL is used as a screening tool, perhaps the most commonly reported scoring strategy is to simply sum the scores of the 17 items into a total score. Individuals whose total score fall at or above the cutoff score, likely will meet diagnostic criteria for PTSD and should be assessed with a diagnostic interview. Various cutoff scores for the PCL have been identified in the literature but the two most commonly reported are 50 and 44. Weathers et al. (1994), using a sample of combat veterans, identified a total score of 50 as an appropriate cutoff score for screening purposes. In contrast, Blanchard and colleagues evaluating a small sample of MVA and sexual assault survivors (n=40; 92% female) recommend a cut off score of 44 (Blanchard et al., 1996). Blanchard and Hickling (2004) hypothesize that the difference in recommended cutoff score in these two studies may be due to the sharp gender difference in the two samples (and the chronicity of PTSD in the Vietnam veteran sample used by Weathers et al.). The PCL is available from the National Center for PTSD at http://www.ncptsd.va.gov/index.html.

In addition to the PCL, two other self-report PTSD symptom scales, the Impact of Event Scale (IES; Horowitz, Wilner, & Alvarez, 1979) and the PTSD Symptom Scale-Self Report (PSS-SR; Foa, Riggs, Dancu, & Rothbaum, 1993), have been used as screening tools with MVA survivors. The PSS-SR contains 17 items, reflecting the DSM-IV symptoms of PTSD, which are rated on a 4-point Likert scale, ranging from not at all to 5 or more times/week - almost always. The highest possible score on the PSS-SR is 51. Foa et al. (1993) evaluated the psychometric properties of the PSS-SR with 46 female rape victims and 72 female non-sexual assault victims, noting that the scale showed high internal consistency (α = .91), good one-month test-retest reliability (r = .74), and adequate convergent validity (.52 to .81) (Foa et al., 1993). The IES contains 15 items that are distributed across two subscales, which assess intrusion (7 items) and avoidance (8 items). The frequency of each item is rated on a 4-point scale: 0 (not at all), 1 (rarely), 3 (sometimes), or 5 (often). The highest possible total score on the IES is 75. The IES has been shown to have high internal consistency with alpha coefficients of .78 for the intrusion subscale and .82 for the avoidance subscale in a sample of 66 outpatients (Horowitz et al., 1979). Split-half reliability of the total scale was .86 and the one-week test-retest reliability was .89 for the intrusion subscale and .79 for the avoidance subscale (Horowitz et al., 1979). For a recent review on the psychometric properties of the IES, please see Joseph (2000).

Using a sample of 229 men and women who suffered a serious MVA and responded to recruitment flyers at health clinics, newspaper advertisements, and referrals from health care providers, Coffey and colleagues compared various total scores on the IES and PSS for their ability to identify those individuals with and without PTSD (Coffey et al., 2006). A widely used and psychometrically sound diagnostic interview (i.e., Clinical Administered PTSD Scale) was used to establish a PTSD diagnosis. By comparing total scores on the self-report measures with results from a diagnostic interview (i.e., the “Gold Standard”), three useful metrics can be calculated to assess the utility of the self-report measure: sensitivity, or the chance that a condition that is present will be detected, specificity, or the chance that a condition that is not present will be found to be absent, and overall correct classification, or the proportion correctly diagnosed by an instrument (Kessel & Zimmerman, 1993). For the IES using a cutoff score of 27, sensitivity was .91, specificity was .72 and overall correct classification was .80. For the PSS-SR using a cutoff score of 14, sensitivity was .91, specificity was .62 and overall correct classification was .74.
It is important to note that use of the recommended cutoff scores for the PCL, IES, or PSS-SR will produce a relatively high rate of false positive cases. That is, the total score for an individual may exceed the recommended cutoff score but, using a diagnostic interview, the individual may not meet criteria for MVA-related PTSD. Relatively high false positives rates are seen as acceptable on screening measures given that the self-report measures only take a few minutes to complete and the primary goal of the screener is to have a measure with high sensitivity (i.e., capture the vast majority of true positive cases) that can then be followed by a more stringent, but time consuming, structured interview.
Diagnosing MVA-related PTSD

Following a positive screening for PTSD symptoms, a well established structured interview should be administered. While general structured interviews provide reliable and valid diagnoses, discussion within this article will be limited to a well established structured interview specifically designed to assess PTSD, the Clinician-Administered PTSD Scale (CAPS; Blake et al., 1995). The CAPS is a structured interview developed at the Boston branch of the National Center for PTSD, a multisite research, clinical, and education center within the Veterans Administration. The CAPS assesses the 17 symptoms of PTSD identified in DSM-IV. The CAPS includes standardized questions to determine the frequency and intensity of PTSD symptoms in the preceding month, using a 5-point Likert scale (e.g., 0 indicates that the symptom does not occur or does not cause distress and 4 indicates that the symptom occurs nearly every day or causes extreme distress and discomfort). The CAPS also includes standardized questions assessing subjective distress and impairment in social and occupational functioning due to these problems. Because of the prevalence of pain in MVA survivors, it is helpful to add probes to the interview to determine whether each symptom is related to PTSD or if it is better attributed to chronic pain. For example, if a patient reported difficulty sleeping, a clinician can assess whether this symptom is due to pain. If the symptom can be attributed to pain, a clinician may decide to not count the symptom toward a diagnosis of PTSD. This more conservative scoring approach of the CAPS has been used by researchers developing treatments and assessment approaches for MVA-related PTSD (e.g., Beck & Coffey, 2005). The CAPS has strong psychometric properties (e.g., Weathers, Keane, & Davidson, 2001) and has been shown to be sensitive to the detection of PTSD in individuals following a MVA (Blanchard, Hickling et al., 1996). A common scoring procedure is to count a symptom toward a diagnosis of PTSD if both a rating equal to or greater than 1 is provided for the frequency of the symptom and a rating equal to or greater than 2 is provided on the severity of the symptom. A diagnosis of PTSD can be given if the number of positive symptoms meet or exceeds DSM-IV criteria and the participant reports distress or interference due to these symptoms. The CAPS is available from the National Center for PTSD at http://www.ncptsd.va.gov/publications/assessment/adult_interviews.html.
Exposure to trauma is a relatively common human experience. Trauma exposure was experienced by 60.7% of men and 51.2% of women in the NCS and 34.2% of men and 24.9% of women experienced exposure to more than one traumatic event (Kessler et al., 1995). Therefore, in addition to assessing for MVA-related PTSD, it also recommended that MVA survivors be assessed for non-MVA potentially traumatic events (PTE). Although a number of measures are available to assess PTE, one reliable broad spectrum trauma assessment tool is the Traumatic Life Events Questionnaire (TLEQ; Kubnay et al., 2000). The TLEQ is a self-report measure that enables a clinician to assess a broad range of PTE and to establish whether the event satisfies the requisite stressor (i.e., Criteria A) for PTSD according to DSM-IV (APA, 2000).

There are a number of other assessment devices available in the literature, in addition to the measures that are reviewed here. Although not all of these measures have been used with MVA survivors, a good starting point for an overview to these measures is Wilson and Keane (2004). In reviewing the available assessment instruments, it may be useful to consider which ones would be helpful to re-administer during the course of treatment, in order to index the impact of intervention on an individual’s symptomatology.

Treatment of PTSD among MVA survivors
Within the empirical literature on psychological treatments of MVA survivors, one can find information about several different types of therapy. One collection of treatment approaches is designed to prevent the development of PTSD in individuals who have experienced a serious MVA. The second collection of treatments address diagnosed PTSD in MVA survivors. Each of these approaches will be reviewed below. An interesting aspect of treating MVA-related PTSD is that to receive standard psychosocial treatment, it is very likely the patient must engage in his or her most feared activity: driving or being driven in a motor vehicle. Engaging in the trauma-related activity so as to attend therapy is unique in the PTSD treatment field and in the section below entitled “Anxiety during treatment session” we describe attempts to cope with the in-session distress elicited by driving a motor vehicle to treatment.
Can early intervention prevent the development of PTSD in MVA survivors?

Several different preventative approaches have been examined with MVA survivors. The first approach includes studies that have applied one-session interventions to injured MVA survivors within a short interval following the traumatic accident. For example, Conlon, Fahy, and Conroy (1999) examined the impact that a single counseling session had on individuals presenting to a trauma center immediately following a MVA. In this trial, none of the participants sustained injuries serious enough to warrant hospitalization. Half of the participants were given a 30-minute counseling session, which encouraged the expression of emotions and thoughts about the MVA, as well as education about PTSD and possible coping strategies (psychological debriefing). The other participants did not receive debriefing. All individuals were re-assessed 65-210 days after the MVA. No differences were noted between individuals who had received debriefing and those who did not with respect to PTSD-related morbidity. Similar results were reported by Hobbs, Mayou, Harrison, and Worlock (1996), who worked with more seriously injured MVA survivors. In this trial, the 1-hour debriefing was administered 24 to 48 hours after the MVA in the hospital and again, did not appear to have helped participants. A 3-year follow-up with individuals who were involved in the Hobbs et al. (1996) study indicated that participants who had received debriefing had a significantly worse outcome (e.g., more self-reported psychiatric symptoms, greater anxiety about auto travel, greater pain, lower overall levels of functioning, and more financial problems, Mayou, Ehlers, & Hobbs, 2000). These studies, in combination, suggest that single session debriefing is not advised in the immediate aftermath of a serious MVA. It is salient to note that clinical researchers continue to seek effective prevention methods (e.g., Litz, Gray, R.A. Bryant, & Adler, 2002), an effort that needs to be conducted carefully, in light of the potential for negative outcomes. Based on the small available database, psychological first aid is an appropriate initial intervention although it does not serve a preventative or a therapeutic function (Litz et al., 2002). Clearly this is an area that deserves much greater attention.

Although intervention immediately following a traumatic accident is not advisable, some studies suggest that in those instances where an individual is reporting Acute Stress Disorder (ASD), a brief cognitive behavioral treatment (CBT) may be helpful. The diagnosis of ASD is used to codify posttraumatic responses that occur between 2 and 28 days after a traumatic event (APA, 2000). Although diagnostic criteria for ASD are somewhat similar to PTSD, they include greater emphasis on dissociative symptoms. Research suggests that individuals who develop ASD are at a substantially higher risk for PTSD, relative to those without ASD in the immediate aftermath of a trauma (e.g., Harvey & R. A. Bryant, 1998). Thus, it is salient to consider whether treatment can reduce the likelihood that an individual with ASD will develop PTSD.

To address this issue, R. A. Bryant, Harvey, Dang, Sackville, and Basten (1998) compared a brief CBT with brief nondirective supportive counseling for 24 individuals with ASD following a serious MVA or industrial accident. Both treatments involved 5 sessions (once weekly). CBT included education about expected reactions to trauma, relaxation training, imaginal and in-vivo exposure, and cognitive re-structuring. Supportive counseling included education about trauma reactions, in addition to general problem-solving skills and unconditional support. Following treatment, only 8% of the CBT group was diagnosed with PTSD, in contrast with 83% of those who had received supportive counseling. The relative ineffectiveness of supportive counseling in the prevention of PTSD suggests that although support and understanding may be appreciated by individuals with ASD, these elements alone do not seem to constitute an effective intervention. A related study by R. A. Bryant, Sackville, Dang, Moulds, and Guthrie (1999)examined a similar CBT package, in comparison with prolonged exposure and supportive counseling. Individuals in the prolonged exposure condition received treatment that concentrated on imaginal and in-vivo exposure, supplemented by supportive counseling. Participants included 45 survivors or either a serious MVA or a nonsexual assault, who were diagnosed with ASD and were treated within two weeks of their trauma. Fewer patients developed PTSD following prolonged exposure (14%) and CBT (20%), in comparison with supportive counseling (56%). These two studies when taken together strongly suggest that treatment that is oriented at trauma-related symptoms such as re-experiencing, hyperarousal, avoidance, and emotional numbing, has greater success at preventing individuals with ASD from developing PTSD in the aftermath of a serious auto accident. Clearly, more information about individual differences that might enhance or diminish the effects of CBT would be very useful.

Following from these studies, Hickling, Blanchard, and Kuhn (2005) describe an abbreviated CBT for individuals with ASD that is designed to reduce direct contact time for both therapist and client. As noted by these authors, it can be somewhat difficult to engage individuals in psychotherapy shortly after their accident. Although there are no clear reasons for this difficulty, it is possible that a brief intervention which reduces the demands placed on clients may be more acceptable and tolerated to a greater extent, in the immediate aftermath of a MVA. Hickling and colleagues included two sessions, of 60 to 90 minutes’ duration each, with a scheduled telephone session in-between. In the first session, CBT included psychoeducation about reactions to a trauma, instruction in the use of exposure-based techniques, relaxation training, and practice in developing and using coping self-statements. The second session began with a review of practice homework and included in-session exposure to the audiotaped description of the MVA. A series of three cases suggests that this abbreviated CBT may hold promise, although it deserves considerably more research prior to large-scale dissemination.

What are effective treatments for PTSD in MVA survivors?
Although preventative efforts ultimately may reduce the emotional toll of MVAs, the majority of patients do not seek help shortly after their MVA. More typically, individuals do not understand the emotional symptoms of PTSD and may not seek help for several years, which at that point, PTSD has become chronic and may be difficult to treat. Although four types of psychological interventions have been endorsed by a panel of experts (Foa, Keane, & Friedman, 2000), only one of these treatments, (CBT) has been examined for its efficacy with individuals who have survived a serious MVA. In the next section, we review the treatment literature, which illustrates that CBT and to a lesser extent, supportive psychotherapy appear to be helpful for reducing PTSD in this population.


Pain and the course of treatment
As cogently discussed by Sharp and Harvey (2001), pain and PTSD seem to create a synergy when present together. In the course of treatment, this synergy may manifest in several ways. First, individuals may have difficulty distinguishing between pain complaints and PTSD symptoms, given that both types of problems originated from the same event. Our clinical experience suggests that most patients regard their pain and PTSD symptoms as a common “lump” that was caused by the MVA. It is important for therapy to help the MVA survivor to differentiate between pain and PTSD, particularly since these two types of problems respond to different interventions. Additionally, there appears to be little generalization of treatment effects between these two problem areas (e.g., Shipherd, Beck, Hamblen, Lackner, & Freeman, 2003). Second, pain-related problems may be responsible for lifestyle changes that can occur to MVA survivors. These changes may include loss of physical mobility and strength, permanent disability from employment, and inability to perform everyday tasks. Changes in physical abilities often compound the person’s perception of the MVA, in particular the “awfulness” of the accident. Because CBT focuses on helping the MVA survivor to strengthen coping skills and re-interpret dysfunctional cognitions, it is critical to differentiate between the actual accident and its aftermath (e.g., disability, on-going pain complaints). As noted, Blanchard and Hickling’s CBT includes the option of discussing existential issues, which may include helping the individual come to terms with changes in their physical functioning, using cognitive therapy techniques.

Pain also can impact the process of treatment in other ways. Although early writers felt that pain may interfere with a patient’s ability to engage in CBT for PTSD (e.g., Koch & Taylor, 1995), this fortunately has not been the case in published studies. For example, 91% of the sample in Blanchard et al. (2003) had lingering physical problems related to injuries sustained during the MVA. An examination of variables that might predict treatment response did not highlight chronic pain as salient in the outcome of either CBT or supportive psychotherapy (Blanchard & Hickling, 2004). Shipherd et al. (2003) explicitly examined the influence of pain on CBT for MVA-related PTSD. In this multiple baseline report, five of six chronic pain patients did not meet criteria for PTSD after treatment. Four patients reported some decrease in pain, although continued to indicate discomfort. A notable decrease in time spent in bed was found, although this could have resulted from accompanying decreases in depression, PTSD, or general distress. Thus, the presence of pain complaints is not necessarily a sign that an individual will have a poor response to psychosocial treatment. However, pain-related problems require the therapist to carefully ascertain the reason(s) behind specific limitations. For example, some types of limitations may be functionally related to pain (e.g., back pain that prevents an individual from driving for long distances) whereas others may be related to PTSD (e.g., avoidance of driving on an interstate due to exposure to semi-trucks, a trigger for PTSD symptoms). As well, it is important for therapists to remember that chronic pain may necessitate adjustments such as allowing a patient to stand or lie down during treatment sessions.

Anxiety during the treatment session
MVA-related PTSD requires that the individual confront their trauma triggers in order to attend treatment. This makes treatment of this disorder particularly challenging, as individuals may arrive at treatment in a heightened state of anxiety or agitation. Our work in developing a Group CBT (Beck & Coffey, 2005) suggested the utility of adding training in mindfulness meditation (e.g., Kabat-Zinn, 1990). Briefly, mindfulness meditation stresses the importance of focusing deliberate concentration on a chosen target (e.g., one’s own breathing), in order to reduce acute distress and distraction. The goal is to direct attention to an event that is presently occurring, rather than attending to thoughts about past or future events. Although mindfulness meditation is not necessarily the only way to accomplish this goal, this skill also can be useful for improving focus in other arenas, such as when driving a car. In our clinical work, we have found that individuals with MVA-related PTSD need explicit assistance in re-directing their thoughts to be able to focus on treatment. In the absence of this assistance, it is difficult for many individuals to work effectively. When this occurs in group treatment, the group process can become chaotic and potentially harmful to patients.

When the MVA involved a fatality
When the individual was involved in a MVA that caused a fatality, additional issues may be present during treatment. Included among these issues are enhanced perceptions of responsibility, protracted feelings of guilt, and survivor guilt. Although this issue has not received extensive empirical study, Blanchard and Hickling (2004) suggest that individuals who are involved in a MVA that caused a fatality are at heightened risk of developing PTSD, even if the individual was not responsible for the accident (e.g., was not the driver). Intuitively, this is not surprising, although greater study of this issue is warranted before more solid conclusions can be made. When treating an individual who experienced a MVA that involved a fatality, the first step is to ascertain the specific role that perceptions of the fatality play within the individual’s PTSD symptom picture. Clinically, we have observed individuals who are primarily focused on the existential facets of the fatality, including thoughts such as “it could have been me”. These kinds of perceptions can be worked with using various aspects of cognitive therapy, including an examination of probabilities and in particular, over-estimation errors (see Ehlers et al., 2005). We also have observed individuals who are preoccupied with inflated notions of responsibility for the fatality, including perceptions that somehow they “should” have died instead of the individual(s) who did. Although poorly defined in the literature, these perceptions can be conceptualized as survivor guilt (e.g., Wayment, 2004). Gentle Socratic questioning can help the individual begin to question this type of belief, with particular emphasis on real versus imagined responsibility. Clinically, this is one of the more difficult issues for therapists in work with this population.

When conducting CBT within a group setting, the presence of a fatality is an extremely sensitive issue. In particular, this issue has the potential to increase other group member’s anxiety, as it validates their worse fear, namely that they could have been killed. Although Group CBT for MVA-related PTSD does not emphasize sharing details of each group member’s MVA (see Beck and Coffey, 2005), information about a fatality may be disclosed inadvertently. Such disclosure requires that the group therapists recognize the terrible nature of the individual’s MVA and the associated emotions that it produces in the entire group. Handling this issue clinically takes precedence over the structured information for that session, particularly given the elevated anxiety that will consume the group atmosphere. Often, imaginal exposure (or exposure using an expanded version of the MVA description) can be helpful for the individual whose MVA included a fatality.

Practice outside of the treatment session
When using exposure therapy to treat MVA-related PTSD, we have observed a number of issues that may arise when individuals are asked to practice outside of the treatment session. Ideally, the individual should understand the principles behind exposure-based techniques and have some in-session experience with exposure prior to their practice outside of the treatment environment. Clinically, we have found it helpful to begin with therapist-assisted imaginal exposure during a session. Often, several practice exercises are necessary for anxiety reduction to occur, particularly for items at the upper end of the hierarchy (see Foa & Rothbaum, 1998 for a step-by-step description of how to conduct ET).

Once the individual is ready for exposure practice outside of the treatment environment, handouts that illustrate the anticipated rise and fall of anxiety during exposure can remind the individual to stay with the exposure exercise until their anxiety has reduced by half. We have observed some patients who try to “push the envelope” when practicing exposure in-between treatment sessions. In essence, these individuals select a practice item that is fairly high up on their hierarchy, feeling that if they just “tough it out”, this will somehow facilitate their recovery. Typically, the opposite occurs, with the person feeling overwhelmed and perhaps a bit pessimistic about the outcome of treatment. Although appreciative of the motivation behind this approach to exposure, we actively discourage patients from taking on exposure items that are too far up their hierarchy, particularly during the beginning treatment sessions. It is essential for patients to remember to take exposure one step at a time, particularly when selecting items to practice outside of treatment. Because exposure can be difficult, particularly exposure that involves driving situations which are not always able to be planned or choreographed, careful selection of homework items can result in greater benefits from this important treatment ingredient. For a full discussion of the clinical issues involved in using exposure therapy to treat MVA-related PTSD, please see Beck and Coffey (2005) or Blanchard and Hickling (2004).

There are occasions when patients do not seem to be able to comply with homework and as such, do not derive a large measure of help from treatment. As discussed more thoroughly (Beck & Coffey, 2005), we cite the example of a woman who was inconsistent with her exposure-based homework throughout the course of Group CBT. While group was in-session, she was also experiencing a number of serious life stressors (e.g., her husband lost his job, one of her children left the home to attend college in another state, her disability claim was denied), which distracted her from exposure practice. At the post-treatment assessment, this woman showed some reduction in PTSD symptomatology yet was clearly reporting notable re-experiencing, avoidance, and hyperarousal symptoms. One month after this assessment, she completed a self-report battery and reported very low levels of these symptoms. When we contacted her by phone, she indicated that some of the life stressors had resolved and stated that she had begun to do her homework, with particular emphasis on exposure-based exercises. In considering this example, it is salient that this woman clearly had learned the principles of exposure, as she was applying these effectively in her own post-treatment homework. Although perhaps a bit unusual, we feel strongly that teaching the principles behind CBT is an important aspect of treatment, particularly given the possibility that an individual can be exposed to a serious MVA again in their life, which would necessitate use of these skills to prevent a relapse.

Summary and conclusions
As highlighted throughout this article, MVAs can have serious psychological consequences. We have focused on PTSD, with particular emphasis on the assessment and treatment of this disorder in this population. In our work with individuals diagnosed with MVA-related PTSD, we have noted that their mental health needs may not have been recognized by other health care providers. Certainly, given emerging evidence concerning the psychological consequences of MVAs, this lack of awareness is likely to change. Fortunately, the empirical literature on the treatment of PTSD after a collision provides some good information with respect to interventions that have proven efficacy, as well as those that may cause harm. The treatment of PTSD in MVA survivors can be a clinically rewarding experience, particularly given the extent of lifestyle restriction that these individuals experience as a result of this disorder. Although work in this area has made substantial progress, many issues remain, including determination of individual difference factors that may influence treatment response, development of alternative modes for the delivery of exposure-based interventions and expanding available models of care for individuals who do not respond to the available treatments. We hope that this review can facilitate continued clinical research in this arena

The Pressurestat Model of the CranioSacral System

published in Massage Today Vol 8. Issue 11.    http://www.massagetoday.com/mpacms/mt/article.php?id=13894
by John Rollinson, D.Eu, CST

The Pressurestat Model describes the inflow, circulation and outflow of cerebrospinal fluid in the semi-closed hydraulic system of the craniosacral system. It is an explanation for the palpable, rhythmic expansion and contraction of the boundary of the craniosacral system which we know as the craniosacral rhythm.

The brain and spinal cord are surrounded by cerebrospinal fluid, which transports nutrients, hormones and peptides of all kinds; removes metabolic waste products and toxic substances from brain tissue; serves as a shock absorber in jolts to the head; floats the brain, thus counteracting the forces of gravity; and influences respiration and cerebral blood flow through its pH, to name some of its known functions. In fact, "because of its singular and continuous fluid system, in order to bathe the neurons and glial cells of the brain, it is essential that cerebrospinal fluid flow not be impaired. If an area of brain tissue is even partially deprived of optimally effective cerebrospinal fluid motion and flow, that brain area will be forced into some degree of functional compromise." i.

The cerebrospinal fluid is held within the dural membrane, a tough (hence "dura"-ble) and watertight sack which takes, for the most part, the shape of the interior of the cranium and intervertebral canal. Though the dura mater does not stretch much, it is flexible and allows for changes in pressure of the cerebrospinal fluid-container-system. If pressure increases, the container-membrane expands and the bones of the cranium plus the sacrum move along with it. The reverse occurs when pressure decreases. It is thus that the craniosacral rhythm can be readily palpated at any of these bones; the alternation between increase and decrease in pressure occurs rhythmically.

The filling of the craniosacral system is known a flexion, and the emptying of the same as extension. (Sutherland’s terms) The craniosacral system proceeds through cyclical flexion and extension at a rate of approximately 6 – 12 cycles per minute under normal circumstances. Flexion is an extreme range of motion during which the head becomes wider transversely and shorter in its anterior-posterior dimension. During flexion, the whole body externally rotates and widens. After flexion, this motion passes through a neutral zone on its way into extension, during which the head narrows and elongates, the whole body internally rotating.

It is believed that the reason we can feel the rhythm elsewhere on the body, in fact anywhere, is that "this whole-body response is probably due to the pumping effect of the cerebrospinal fluid upon the motor system, (increase or decrease of cerebrospinal fluid pressure upon the brain) which causes a rhythmical tonification and detonification of the myofascial system in response to rhythmically fluctuating nerve signals." ii.

So, we have a hydraulic system. In order for it to be "semi closed", we must now describe how cerebrospinal fluid enters and leaves the system. In the ventricles of the brain, but chiefly in the lateral cerebral ventricles is found a capillary network called the choroid plexus which produces cerebrospinal fluid by filtration and secretion. The choroid plexus is a projection of the arachnoid mater into the cerebrospinal fluid filled ventricles. Blood circulating through the choroid plexus is "turned into" cerebrospinal fluid and enters the craniosacral system.

The choroid plexus has stretch and compression sensing receptors within the Saggital suture of the cranium, connected to it by nerve tracts running through the falx cerebri. As cerebrospinal fluid is added to the system and its volume increases, the dural container expands, spreading the bones of the head. The parietal bones move apart, spreading the saggital suture, from whence the neuromechanism signals the choroid plexus to stop or greatly reduce the production of cerebrospinal fluid. As the cerebrospinal fluid drains from the system (see below), the dura and the cranium along with it shrink again and the parietals come together, compressing the saggital suture. The pressure sensing nerve endings connected to the choroid plexus send a signal to resume production of cerebrospinal fluid, and the cycle repeats. Normally, the system seems to operate on a cycle of about six seconds – cerebrospinal fluid is produced for about three seconds and then production ceases for about three seconds. This creates the rhythmical rise and fall of fluid pressure within the system.

From the lateral ventricles the cerebrospinal fluid enters the 3rd ventricle via the foramina of Monro, then the 4th via the cerebral aquaduct. It then enters the subarachnoid space and the central canal of the spinal cord via the foramina of Luschka and of Magendie and joins the cerebrospinal fluid already bathing the brain and spinal cord; bathing all neural tissue enclosed by the dura mater. Fluid then circulates down and around the spinal cord and up and around the brain.

Cerebrospinal fluid passes out of the semi-closed hydraulic system via folds, called arachnoid granulation bodies or arachnoid villae, of the arachnoid layer of the cranial meninges which project through the inner layer of dura mater into the venous sinuses of the brain. iii. Cerebrospinal fluid is reabsorbed into the venous blood through these arachnoid villae, which are found mostly in the saggital venous sinous. The rate of reabsorption is fairly constant, but seems nevertheless to be regulated (as the idle of your car) by a cluster of arachnoid granulation bodies found at the anterior end of the straight sinus. From this position at the crossroads, so to speak, of the intracranial membranes this cluster is aware of any tension within this membrane system and may regulate the outflow of cerebrospinal fluid accordingly.

To summarize, the craniosacral system is like a leaking toilet with the tank cracked into pieces and lined with a giant exam glove (the Dural membrane). The float-switch in the toilet tank is the saggital suture, which causes an inflow whenever enough water/CSF leaks away down the drain (sinuses).


  1. The nervous system
  2. The musculoskeletal system
  3. The vascular system
  4. The lymphatic system
  5. The endocrine system
  6. The respiratory system

Abnormalities in the structure or function of any of these systems may influence the craniosacral system. Abnormalities in the structure or function of the cranio sacral system will necessarily have profound, and frequently deleterious effects upon the development or function of the nervous system, especially the brain. iv.

There are also ways in which the craniosacral system may have a direct influence on important, ongoing physiological processes. For example, the continuing rhythmical movement of the craniosacral system may serve to "milk" the pituitary gland, with all the implications this would hold for the neuroendocrine system. It is also possible that this rhythmic motion is also an important stimulus for the development of the brain. Similarly, the motion around the skull sutures may pump the newly formed red blood cells out of the flat bones of the skull and into the general circulation. v.

Of course, any abnormality of the craniosacral rhythm, whatever its cause, may have an effect upon the body or any part of it via the central nervous system; any deficiency in the circulation of cerebrospinal fluid may affect brain and nervous functioning, any restriction of nerves passing out of the craniosacral system due to restrictions in cranial sutures or membranes may affect their end organs. The same sutural restrictions may affect blood flow into the cranial vault, in turn impinging on brain function. Malfunction within the pessurestat model itself, such as hydrocephaly, where the fluid cannot escape quickly enough, obviously has drastic effects upon the body.

The anatomical components of the craniosacral system are:

  1. The meningeal membranes
  2. The osseous structures to which the meningeal membranes attach
  3. The other non-osseous connective tissue structures which are intimately related to meningeal membranes
  4. The cerebrospinal fluid
  5. All structures related to production, resorption and containment of the cerebrospinal fluid
The meningeal membrane and its contents form the hydraulic system. This membrane is composed of: The pia mater, which faithfully follows the contours of the brain and spinal cord and contains a vascular network. External to that, the arachnoid mater, internal to which is the subarachnoid space, in which circulates the cerebrospinal fluid and external to which is the subdural space. The two fluid filled spaces allow some independent movement of the three membranes. External to that, the dura mater, which is fused with the internal aspect of the skull. Its inner layer forms vertical sheets, the falx cerebri and cerebelli, which separate the hemispheres of the cerebrum and cerebellum respectively. It also forms the horizontal tentorium cerebelli, bilaterally, which separate the cerebellum from the cerebrum. At the foramen magnum the outer dura becomes the endosteum of the vertebral canal and the inner dura becomes the dural tube and extends from its attachment at the foramen magnum (it is also said to attach to the posterior bodies of the 2nd and 3rd cervical vertebra, however we were unable to find these attachments in our CS Dissection class and it is postulated that they could be a result of the embalming process) into the sacrum. At the level of the 2nd sacral segment it again attaches firmly and then, blending with the other layers, exits at the sacral hiatus at S4 to become the periosteum of the coccyx. It is via these bony attachments that tensions can be transmitted from the extraCSS connective tissues into the dural membrane system and vice versa. As the spinal nerves exit the vertebral canal, they are covered by extensions of the dural sheath (as are the optic nerves) which blends into the paravertebral fascia. All that enjoys enclosure within the dura mater belongs to the cranio sacral system.

i. John Upledger, "Cerebrospinal fluid: what it is and where to find it", 1998 by The Upledger Institute
ii. Ibid
iii. Tabor's Cyclopedic Medical Dictionary, 2001 by F.A. Davis Co
iv. John Upledger, Craniosacral Therapy, 1983 by Eastland Press
v. John Upledger, Craniosacral Therapy-2, 1987 by Eastland Press