**5. Future directions**

104 Post Traumatic Stress Disorders in a Global Context

disorder (Bryant, 2006). To ask if survivors felt any physical reactions might be a better

The present results also suggested that the Peritraumatic Distress Inventory could predict posttraumatic growth, especially the 3 aspects of appreciation of life, spiritual change, and relating to others at 18 months after the accident. Multivariate regression analysis was not used to examine the predictive value of the Peritraumatic Distress Inventory for the Posttraumatic Growth Inventory because predictors for posttraumatic growth are not well established and our sample size was modest; however, the result was consistent with that of previous studies. According to Janoff-Balman, these 3 subscales can best be understood as existential reevaluation (Janoff-Bulman, 2004), and a previous study showed that they had a positive association with posttraumatic stress disorder (Taku et al., 2007). The author and colleagues also showed that appreciation of life and spiritual change were positively correlated with posttraumatic stress disorder symptoms, which can be regarded as signifying coping effort in the face of enduring distress, rather than an outcome of coping success (Nishi, Matsuoka and Kim, 2010). The predictive value of the Peritraumatic Distress Inventory for appreciation of life was quite high in the present study, so managing peritraumatic distress may need specific coping efforts. This would point to the importance of clinicians and researchers identifying and being attentive to the survivor's own meanings

**4.6 The potential use of the Peritraumatic Distress Inventory in emergency** 

The author and colleagues previously showed that a cut-off score of 23 on the Peritraumatic Distress Inventory maximized the balance between sensitivity (77%) and specificity (82%) (Nishi, Matsuoka, Yonemoto et al., 2010). Further investigation is required to determine its adequate usage bearing in mind its low positive predictive value (53%). However, the early identification of motor vehicle accident survivors who appear not to be at risk of developing posttraumatic stress disorder is one potential use of the Peritraumatic Distress Inventory because of its high negative predictive value (93%). Given the typical limits on the psychiatric resources available, the Peritraumatic Distress Inventory would likely be a useful indicator for posttraumatic stress disorder and psychiatric morbidity in emergency

This study has some limitations. Firstly, the sample size was modest. Secondly, the attrition rate was relatively high, although the patients who dropped out were not significantly different from those who participated in the follow-up assessments in terms of the Peritraumatic Distress Inventory and other covariates. In an earlier publication, we revealed that the factors of being male, unconscious during MVA, low cooperativeness, and less severe injuries were significant predictors of dropout (Nishi et al., 2008). Participants with less severe injuries did not need to come to the National Disaster Medical Center for treatment after discharge which might have affected the attrition rate. Also, those with low

cooperativeness might have been reluctant to continue participating in the study.

alternative to predict subsequent psychiatric morbidity.

**4.5 An indicator for posttraumatic growth** 

and interpretations.

**departments** 

departments.

**4.7 Limitations** 
