The influence of traumatic brain injury on acute stress disorder and post-traumatic stress disorder following motor vehicle accidents

Long-term cognitive, emotional, and functional outcomes in trauma intensive care unit survivors without intracranial hemorrhage

BACKGROUND

Trauma patients without intracranial hemorrhage or focal neurologic deficits are typically considered low risk for lasting neuropsychological and emotional deficits, and such sequela may be overlooked, especially in those with skull fractures and concussions. We undertook this study to determine the prevalence of and risk factors for persistent cognitive impairment and emotional and functional difficulties in a sample of adult trauma intensive care unit survivors without intracranial hemorrhage.

METHODS

We queried the Vanderbilt University Trauma Registry for all patients admitted during 2003 with an Injury Severity Score >25 and a head computed tomography scan showing no intracranial hemorrhage. Of the 97 patients identified, 58 were evaluated, in person between 12 to 24 months after hospital discharge, with a comprehensive battery of cognitive, emotional, and functional instruments. The Informant Questionnaire of Cognitive Decline in the Elderly-Short Form (IQCODE-SF) was used to evaluate for pre-existing cognitive deficits in patients suspected of having cognitive impairment before their trauma.

RESULTS

A total of 33 (57%) patients were determined to have cognitive impairment, which was most pronounced in the domains of attention and executive functioning/verbal fluency. Of these patients, one (3%) was determined by the IQCODE-SF to be cognitively impaired before trauma intensive care unit hospitalization. Of the 58 patients studied, 21 (36.2%) had a concussion or skull fracture and 37 (63.8%) had neither. Cognitive impairment was significantly more likely to occur in patients who sustained a concussion or skull fracture than in trauma patients who did not (81% versus 43%; p = 0.006). Patients reported significant depressive symptoms (56%), significant symptoms of posttraumatic stress disorder (38%), and significant symptoms of anxiety (29%). Quality of life scores were lower than in the general United States population and employment difficulties were widespread. A total of 34% of patients reported being unemployed at follow-up, and cognitive impairment was more common among these patients compared with patients in the workforce (p = 0.03). Neither cognitive impairment nor emotional dysfunction was associated with age, sex, race, Injury Severity Score, blood loss, ventilatory days, or intramedullary nailing of long-bone fractures.

CONCLUSIONS

The majority of trauma survivors without intracranial hemorrhage display persistent cognitive impairment, which is nearly twice as likely in those with skull fractures or concussions. This cognitive impairment was associated with functional defects, poor quality of life, and an inability to return to work. Future research must delineate modifiable risk factors for these poor outcomes, especially in patients with skull fractures and concussions, to help improve long-term cognitive and functional status.

The relationship of psychological and cognitive factors and opioids in the development of the postconcussion syndrome in general trauma patients with mild traumatic brain injury

The relationship of psychological and cognitive factors in the development of the postconcussion syndrome (PCS) following mild uncomplicated traumatic brain injury (mTBI) has received little study. This may be because of the widely held belief that neurological factors are the cause of early PCS symptoms, whereas psychological factors are responsible for enduring symptoms. To further understand these relationships, the association between PCS and neuropsychological and psychological outcome was investigated in 122 general trauma patients, many of whom had orthopedic injuries, around 5 days following mTBI. Apart from verbal fluency, participants with a PCS did not differ in their performances on neuropsychological measures compared to those without a PCS. Individuals with a PCS reported significantly more psychological symptoms. Large effect sizes present on the psychological measures showed that the difference between participants with a PCS and without was greater on psychological than on neuropsychological measures. Analyses also revealed a relationship between opioid analgesia and depression, anxiety and stress, and opioids and reduced learning. The results suggest that psychological factors are present much earlier than has previously been considered in the development of the PCS.

Symptoms of post-traumatic stress: intrusion and avoidance 6 and 12 months after TBI

PRIMARY OBJECTIVES

(1) To examine survivors with traumatic brain injury (TBI) for symptoms of avoidance and intrusion, two dimensions of post-traumatic stress (PTS) at 6 and 12 months post-injury. (2) To identify risk factors associated with these symptoms.

RESEARCH DESIGN

Prospective follow-up study.

METHODS AND PROCEDURES

Georgia and North Carolina Model Brain Injury Systems participants (n = 198) with mild (19%), moderate (21%) and severe (60%) TBI were interviewed by telephone at 6 and 12 months post-injury. The Impact of Event Scale (IES) was used to identify intrusion and avoidance symptoms.

RESULTS

Symptoms consistent with severe PTS increased from 11% at 6 months to 16% 12 months post-injury (p < 0.003). African-Americans (p < 0.01) and women (p < 0.05) reported greater symptomatology at 12 months compared to their counterparts. TBI severity and memory of the event were not associated with PTS-like symptoms. Symptoms increased over time when examined by race, injury intent, gender and age (p < 0.05).

CONCLUSIONS

Regardless of severity, survivors with TBI are at risk for developing symptoms consistent with PTS. Amnesia for the injury event was not protective against developing these symptoms. African-Americans appear to be at greatest risk.

Mild traumatic brain injury and anxiety sequelae: a review of the literature

There is scattered but significant psychological and neuropsychological evidence to suggest that mild traumatic brain injury (mild TBI) plays a notable role in the emergence and expression of anxiety. Conversely, there is also empirical evidence to indicate that anxiety may exert a pronounced impact on the prognosis and course of recovery of an individual who has sustained a mild TBI. Although the relationship between mild TBI and anxiety remains unclear, the present body of research attempts to elucidate a number of aspects regarding this topic. Overall, the mild TBI research is rife with inconsistencies concerning prevalence rates, the magnitude and implications of this issue and, in the case of PTSD, even whether certain diagnoses can exist at all. This review obviates the need for greater consistencies across studies, especially between varying disciplines, and calls for a shift from studies overly focused on categorical classification to those concerned with dimensional conceptualization.

Amnesia, traumatic brain injury, and posttraumatic stress disorder: a methodological inquiry

This study explored the relationship between mild traumatic brain injury (MTBI), amnesia, and posttraumatic stress disorder (PTSD). MTBI status and amnesia for the event were assessed in 307 consecutive admissions to a Level 1 Trauma Center. Amnesia did not always occur concurrently with MTBI: 18% of those with MTBI had full recall and over half had partial recall of the event. Just over 10% of participants developed PTSD by 12 months post-injury, with prevalence comparable across MTBI and non-MTBI groups. Non-significant differences in incidence of PTSD were apparent between those with full recall (9%), partial recall (14%) and no recall (7%). These data highlight the fact that PTSD may develop following trauma despite amnesia for the event, and illustrate the importance in both clinical and research settings of carefully examining the extent of amnesia.

Coping with serious accidental injury: a one-year follow-up study

BACKGROUND

The aim of this study was to analyze changes of coping strategies in severely injured accident victims over time and to compare patients with high and low posttraumatic stress disorder (PTSD) symptom levels with regard to their coping patterns and accident-related cognitions.

METHODS

106 consecutive patients with severe accidental injuries admitted to a trauma surgery intensive care unit (ICU) were assessed within 1 month after the trauma and 6 and 12 months later. Assessments included a clinical interview, the Freiburg Questionnaire of Coping with Illness, the patients' accident-related cognitions, the Clinician-Administered PTSD Scale, the 90-item revised Symptom Checklist (SCL-90-R), and the Sense of Coherence Questionnaire (SOC). Patients who met the criteria for either full or subsyndromal PTSD at least once over the observation period (36 subjects; 34.0%) were assigned to a highly symptomatic group (HSG), the remainder (70 subjects; 66.0%) to a less symptomatic group.

RESULTS

Overall, active problem-focused coping was predominant immediately after the accident and declined over time, with a stronger decrease in the HSG. Patients in the HSG scored higher on the SCL Global Severity Index and lower on the SOC. The patients' subjective appraisal of accident severity was higher in the HSG, whereas there was no group difference with regard to accident-related variables such as type of accident, injury severity and mild to moderate traumatic brain injury.

CONCLUSIONS

Active problem-focused coping, although utilized most frequently and often regarded as protective, might be an inadequate strategy in face of acute stress following a severe accident. Clinicians should not expect their patients to cope very actively in the acute ICU phase. In the subsequent rehabilitation, active coping seems to be more adaptive.

Traumatic brain injury, dissociation, and posttraumatic stress disorder in road traffic accident survivors

This study investigated the symptom profiles of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) in participants who did and did not sustain traumatic brain injury (TBI), following a road traffic accident. The participants were assessed at three time points: as soon as possible posttrauma as well as at 6 weeks and 3 months posttrauma. At the first assessment, fewer participants from the TBI group recalled feeling fear and helplessness at the time of the trauma, fewer TBI participants reported recurrent intrusive thoughts and images, and more TBI participants reported dissociation since the trauma, relative to the non-TBI group. At the second assessment, fewer participants from the TBI group recalled feeling intense helplessness at the time of the trauma. Fewer TBI participants also reported reliving and physiological reactions on trauma reminders relative to the non-TBI group. At 3 months posttrauma, there was no difference in PTSD symptom profile between non-TBI and TBI groups. Our findings indicate that the presence of TBI is likely to influence the distribution of certain symptoms, but need not be a significant barrier to diagnosing ASD and PTSD.

The relation between memory of the traumatic event and PTSD: evidence from studies of traumatic brain injury

OBJECTIVE

This paper focuses on the relation between memory and posttraumatic stress disorder (PTSD). More specifically, it addresses the debate regarding the role of memory of the traumatic event in the development of PTSD. Traumatic brain injury (TBI) is used as a naturally occurring model for traumatic exposure that is often associated with memory impairment.

METHOD

We present a critical review of the literature on studies assessing the relation between TBI and PTSD, with a focus on memory of the traumatic event as a critical factor. We also discuss results from recent studies conducted by our group.

RESULTS

The literature review offers an inconclusive picture wherein a significant proportion of the studies indicate that PTSD and TBI are mutually exclusive, especially in individuals who exhibit lack of memory for the traumatic event. This finding supports the possibility that lack of memory may protect against the development of PTSD. However, some studies show that PTSD does occur in patients with head injury, suggesting that PTSD may develop in TBI survivors--even in those who cannot remember the traumatic event. Generally speaking, though, the overall balance of the findings (including our own findings) seems to support the possibility that, in subjects with TBI, impaired memory of the traumatic event is associated with reduced prevalence of PTSD.

CONCLUSIONS

The suggestion that amnesia regarding the traumatic event may protect against the development of PTSD has both theoretical and practical importance. This review focused on the case of traumatic brain injury as a model for impaired memory for the traumatic event. However, it still remains to be proven that the conclusions based on these findings are generalizable beyond the case of TBI. While some patients with posttraumatic amnesia do develop PTSD despite lack of memory for the traumatic event, the majority of those who lack memory for the event seem to be protected from developing the disorder. Nevertheless, based on this assumption, we suggest that pharmacologic disruption of newly acquired--or even old--traumatic memories, which has been shown to be possible in animals, might therapeutically benefit trauma survivors.

Posttraumatic stress disorder and traumatic brain injury: can they co-exist?

The possibility that posttraumatic stress disorder (PTSD) can develop following traumatic brain injury (TBI) has been the subject of considerable debate. The traditional view has held that impaired consciousness that occurs with TBI precludes encoding of the traumatic experience, and this prevents subsequent reexperiencing symptoms. This paper critically reviews available, empirical studies on PTSD in TBI populations and suggests that these two conditions can co-exist. The various mechanisms that may mediate PTSD following TBI are discussed, and special attention is given to issues that recognize the distinctive features of PTSD following TBI. These processes include implicit processing, biologically mediated fear conditioning, and reconstruction of trauma memories. Finally implications for assessment, treatment, and forensic investigation of PTSD in TBI populations are, addressed. This review concludes that TBI populations provide a useful means by which the role of traumatic memories (and impaired memories) in posttraumatic adjustment can be studied.

Reconstructing trauma memories: a prospective study of "amnesic" trauma survivors

The purpose of this study was to investigate memory for trauma in patients who were initially amnesic of the trauma as a result of mild traumatic brain injury (MTBI). Motor vehicle accident survivors who sustained a MTBI were assessed for their memory within 1-month posttrauma (n = 79) and again at 2-years posttrauma (n = 50). Consistent with their brain injury, all patients reported significant amnesia of their accident at initial assessment. At 2-year posttrauma, 40% were able to remember their accident. Reporting memory for the trauma was associated with shorter duration of posttraumatic amnesia. These findings suggest that people reconstruct memories of trauma in the absence of complete encoding of the experience. Possible mechanisms for memory reconstruction are considered.

Errors in diagnosing post-traumatic stress disorder after traumatic brain injury

Evidence to support the view that post-traumatic stress disorder (PTSD) can occur after traumatic brain injury (TBI) continues to grow. However, the reported incidence of cases with both diagnoses ranges widely, from less than 1% to more than 50%. Given that the incidence of TBI is high, a more precise incidence has to be established if screening and treatment resources are to be considered. Are cases being missed or are they over-diagnosed? The single case report presented here does not definitively answer this question, but illustrates the potential shortcomings of diagnosing PTSD using questionnaire measures alone (Impact of Events Scale, Post-traumatic Stress Diagnostic Scale and General Health Questionnaire) and indicates a need for a conjoint interview which takes into account the common effects of TBI and the symptom overlap between PTSD and TBI.

Postconcussive symptoms and posttraumatic stress disorder after mild traumatic brain injury

Postconcussive symptoms after mild traumatic brain injury (MTBI) may be exacerbated by anxiety associated with posttraumatic stress. The aim of this study was to investigate the relationship between postconcussive symptoms and posttraumatic stress disorder (PTSD) in an MTBI population. Survivors of motor vehicle accidents who either sustained an MTBI (N = 46) or no TBI (N = 59) were assessed 6 months posttrauma for PTSD and postconcussive symptoms. Postconcussive symptoms were more evident in MTBI patients with PTSD than those without PTSD, and in MTBI patients than non-TBI patients. Further, postconcussive symptoms were significantly correlated with PTSD symptoms. These findings indicate that postconcussive symptoms may be mediated by an interaction of neurological and psychological factors after MTBI.