Course and predictors of posttraumatic stress among male train drivers after the experience of ‘person under the train' incidents

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Abstract

Objective

The present prospective study aimed to identify the frequency and course of posttraumatic stress symptoms, anxiety, depression, and quality of life in train drivers after the experience of ‘person under the train’ incidents. Furthermore, associations between predictors of posttraumatic stress stratified by pre-, peri- and posttraumatic factors, psychological distress, quality of life (QoL), sense of coherence, lack of meaning in life, and post-trauma thoughts are analyzed.

Methods

Patients (100% male, mean age 48 years) were assessed at the beginning (n = 73), at the end (n = 71) and six months (n = 49) after a four-week rehabilitation program and completed validated self-report questionnaires (e.g. Posttraumatic Diagnostic Scale, Hospital Anxiety and Depression Scale, Short-Form Health Survey).

Results

Train drivers experienced averagely 1.8 ‘person under the train’ incidents (range 1–8); the majority (81%) was involved in a railway suicide. At the beginning of the rehabilitation, 44% of the patients were classified as having moderate to severe PTSD, and 14% as having severe PTSD. Posttraumatic stress decreased significantly over time (p = .003, η² = .17). We found no significant differences in the course of posttraumatic stress, anxiety, depression, distress and QoL between patients who experienced one or more than one railway related accident or suicide. Anxiety, sense of guilt and sense of alienation emerged as the most important factors in predicting posttraumatic stress six months after rehabilitation (R² = 0.55).

Conclusion

Findings emphasize the importance of rehabilitation programs for train drivers after railway-related incidents. However, research is needed to develop effective rehabilitation interventions particularly tailored to this patient group.

Introduction

For train drivers, ‘person under the train’ incidents such as railway accidents and railway suicides are among the most distressing human experiences [1]. The evaluation of specific characteristics of railway suicide outcomes in Germany indicated that the majority of suicides were lethal (90–91%) [2], [3]. Male gender, suicide attempts on open tracks, suicide attempts at night time hours and at main railway lines were associated with a significant higher case fatality [3]. The most frequent types of railway suicide behavior included jumping in front of the train (32%), lying on the track (33%) and wandering along the track (34%) [4].

Train drivers are usually not only confronted with both the suicide or accident and their own inability to act (i.e. to stop the train in time), but also with incriminating pictures such as people on the tracks and mutilated body parts, as well as with intrusive odors during and after the traumatic event. In previous studies, Posttraumatic Stress Disorder (PTSD) prevalence rates of 16–17% were found among individuals experiencing ‘person under the train’ incidents [5], [6], [7]. However, distressing symptoms such as intrusive cognitions were experienced by a much higher percentage of train drivers. A frequency rate of such symptoms of up to 88% has been reported, when acute psychological responses after the traumatic event were included [1], [8], [9]. Studies further demonstrated high overall distress [10], and particularly sleep problems as a frequent stress response [1], [7], [11], [12], as well as long absence time from work [11], [12].

In cross-sectional studies, the presence of PTSD and posttraumatic stress symptoms in train drivers after ‘person under the train’ incidents was associated with a variety of other adverse health outcomes [6], [12], [13]. For instance, in a sample of Norwegian train drivers, Vatshelle and Moen [8] found a significantly higher amount of physical health problems (e.g. musculoskeletal and gastrointestinal problems) as well as other mental health problems compared to controls.

The few existing longitudinal studies indicate conflicting results. No long term differences in health outcomes between train drivers who experienced ‘person under the train’ incidents and controls have been reported by Limosin et al. [14] as well as Cothereau et al. [10]. Karlehagen et al. [12] found levels of posttraumatic stress (intrusion and avoidance) among train drivers between 67 and 71% at one month and between 69 and 76% at one year after the traumatic event. Predictors of negative outcomes such as high levels of posttraumatic stress were the experience of two train accidents or more, as well as worrying about further accidents at baseline, which both adversely affected intrusive recollections at follow up.

Given the limited number of prospective studies among train drivers after ‘person under the train’ incidents, more studies are necessary to investigate the long-term course and predictors of posttraumatic stress symptoms in this group, as well as their impact on quality of life (QoL). The purpose of our study therefore was to examine the history of traumatic events as well as peritraumatic thoughts and trauma-related experiences during the ‘person under the train’ incident; and to identify the frequency of posttraumatic stress symptoms, anxiety, depression, overall distress and QoL at the beginning, the end and six months after a rehabilitation program for train drivers. Changes in posttraumatic stress, anxiety, depression, distress and QoL over the course of time depending on the number of experienced railway incidents are examined: We hypothesize that posttraumatic stress is more severe in patients with a history of traumatic events. Furthermore, associations between predictors of posttraumatic stress stratified by pre-, peri- and posttraumatic factors, psychological distress, QoL, life attitudes (sense of coherence and lack of meaning in life), as well as post-trauma thoughts and attitudes are analyzed.

Section snippets

Study design

Consecutive patients were recruited from an inpatient rehabilitation clinic in Northern Germany specialized in the treatment of PTSD among train drivers experiencing railway accidents and railway suicide attempts. Patients were assessed at the beginning (t1), at the end (t2) and six months after the rehabilitation program (t3). Inclusion criteria contained an age over 18 years and the evidence of a ‘person under the train’ incident such as a railway suicide or railway accident. All patients

History of traumatic events

All participants experienced between one and eight ‘person under the train’ incidents (M = 1.8, SD = 1.5). The majority of train drivers (80.8%) were involved in a railway suicide, 9.6% in a railway accident and 9.6% in both a railway suicide and accident (Table 1). Seventy percent of the sample experienced one ‘person under the train’ incident, whereas 30% experienced more than one incident. Further frequently reported traumatic events were violent personal assault (21.9%), natural disasters

Discussion

To our knowledge, this is the first longitudinal study to examine the frequency and course of posttraumatic stress symptoms as well as the role of pre-, peri- and posttraumatic factors among male train drivers who experienced ‘person under the train’ incidents and participated in a specialized rehabilitation program in Germany. In our sample, the amount of individuals experiencing more than one railway incident was 30.1% with a wide range between 2 and 8 railway accidents or suicides. Due to

Conflict of interest

No conflict of interest is declared.

Acknowledgments

This study was supported by the Vital-Kliniken GmbH Klinik Buchenholm, Bad Malente, Germany.

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