Mild TBI may predict PTSD, not postconcussion syndrome

Patients with certain symptoms after mild traumatic brain injury should be considered to have a form of posttraumatic stress disorder, rather than postconcussion syndrome, a prospective study of more than 1,300 patients shows.

Several published diagnostic criteria exist for postconcussion syndrome (PCS), but it is defined in the DSM-IV as a head trauma causing concussion followed by cognitive problems and at least three of eight symptoms – among them headache, dizziness, and personality change – lasting 3 months or longer. Several studies have questioned the specificity of the PCS diagnosis, finding overlap of symptoms among patients with head injuries and other types of injuries. And as traumatic brain injury is strongly associated with PTSD, researchers have suggested that certain symptoms thought to be indicative of brain injury might instead reflect stress reactions stemming from trauma.

In a study published online July 16 in JAMA Psychiatry (doi:10.1001/jamapsychiatry.2014.666), Emmanuel Lagarde, Ph.D., of the INSERM Research Center in Bordeaux, France, and colleagues, analyzed data from 1,361 patients recruited from a hospital emergency department, of whom 534 had head injuries and 827 had injuries to other parts of the body. At 3 months’ follow-up, 21.2% of the mild traumatic brain injury (MTBI) patients and 16.3% of controls without head injuries could be diagnosed with PCS based on the DSM-IV criteria.

Moreover, 8.8% of patients with head injuries fulfilled diagnostic criteria for PTSD, compared with only 2.2% of controls. In the study group as a whole, MTBI was seen as a strong predictor of PTSD (odds ratio 4.47; 95% CI 2.38-8.4) but not of PCS (OR, 1.13; 95% CI 0.82-1.55). MTBI predicted PTSD regardless of whether the injury occurred as a result of a road crash, assault, or fall.

Assault was seen as a predictor of PCS as defined by DSM-IV, while severity of injury was not, suggesting that "psychological stress, and not potential brain injury, causes these symptoms, reinforcing the idea that they should be considered part of PTSD and not PCS," the researchers wrote.

They also found that symptoms suggestive of PCS under the DSM-IV criteria clustered in a way that paralleled a group of PTSD symptoms categorized as hyperarousal.

"The rationale to define a PCS that is specific to head-trauma patients is weak," Dr. Lagarde and colleagues wrote in their analysis. "Our results also suggested that the misunderstanding related to the relevance of defining such a syndrome could be explained by the overlapping pattern with symptoms of the PTSD hyperarousal dimension."

Available evidence does not support the use of PCS, they concluded, adding that clinicians should consider PTSD risk and treatment for patients with MTBI.

Dr. Lagarde and colleagues acknowledged as limitations of their study the fact that PTSD diagnoses were not made through formal clinical exams and that researchers focused on the traumatic events that landed subjects in the emergency department without capturing information on past traumatic events.

INSERM, the REUNICA Group, and Bordeaux University Hospital funded the study. None of the authors disclosed conflicts of interest.

Patients with certain symptoms after mild traumatic brain injury should be considered to have a form of posttraumatic stress disorder, rather than postconcussion syndrome, a prospective study of more than 1,300 patients shows.

Several published diagnostic criteria exist for postconcussion syndrome (PCS), but it is defined in the DSM-IV as a head trauma causing concussion followed by cognitive problems and at least three of eight symptoms – among them headache, dizziness, and personality change – lasting 3 months or longer. Several studies have questioned the specificity of the PCS diagnosis, finding overlap of symptoms among patients with head injuries and other types of injuries. And as traumatic brain injury is strongly associated with PTSD, researchers have suggested that certain symptoms thought to be indicative of brain injury might instead reflect stress reactions stemming from trauma.

In a study published online July 16 in JAMA Psychiatry (doi:10.1001/jamapsychiatry.2014.666), Emmanuel Lagarde, Ph.D., of the INSERM Research Center in Bordeaux, France, and colleagues, analyzed data from 1,361 patients recruited from a hospital emergency department, of whom 534 had head injuries and 827 had injuries to other parts of the body. At 3 months’ follow-up, 21.2% of the mild traumatic brain injury (MTBI) patients and 16.3% of controls without head injuries could be diagnosed with PCS based on the DSM-IV criteria.

Moreover, 8.8% of patients with head injuries fulfilled diagnostic criteria for PTSD, compared with only 2.2% of controls. In the study group as a whole, MTBI was seen as a strong predictor of PTSD (odds ratio 4.47; 95% CI 2.38-8.4) but not of PCS (OR, 1.13; 95% CI 0.82-1.55). MTBI predicted PTSD regardless of whether the injury occurred as a result of a road crash, assault, or fall.

Assault was seen as a predictor of PCS as defined by DSM-IV, while severity of injury was not, suggesting that "psychological stress, and not potential brain injury, causes these symptoms, reinforcing the idea that they should be considered part of PTSD and not PCS," the researchers wrote.

They also found that symptoms suggestive of PCS under the DSM-IV criteria clustered in a way that paralleled a group of PTSD symptoms categorized as hyperarousal.

"The rationale to define a PCS that is specific to head-trauma patients is weak," Dr. Lagarde and colleagues wrote in their analysis. "Our results also suggested that the misunderstanding related to the relevance of defining such a syndrome could be explained by the overlapping pattern with symptoms of the PTSD hyperarousal dimension."

Available evidence does not support the use of PCS, they concluded, adding that clinicians should consider PTSD risk and treatment for patients with MTBI.

Dr. Lagarde and colleagues acknowledged as limitations of their study the fact that PTSD diagnoses were not made through formal clinical exams and that researchers focused on the traumatic events that landed subjects in the emergency department without capturing information on past traumatic events.

INSERM, the REUNICA Group, and Bordeaux University Hospital funded the study. None of the authors disclosed conflicts of interest.

Patients with certain symptoms after mild traumatic brain injury should be considered to have a form of posttraumatic stress disorder, rather than postconcussion syndrome, a prospective study of more than 1,300 patients shows.

Several published diagnostic criteria exist for postconcussion syndrome (PCS), but it is defined in the DSM-IV as a head trauma causing concussion followed by cognitive problems and at least three of eight symptoms – among them headache, dizziness, and personality change – lasting 3 months or longer. Several studies have questioned the specificity of the PCS diagnosis, finding overlap of symptoms among patients with head injuries and other types of injuries. And as traumatic brain injury is strongly associated with PTSD, researchers have suggested that certain symptoms thought to be indicative of brain injury might instead reflect stress reactions stemming from trauma.

In a study published online July 16 in JAMA Psychiatry (doi:10.1001/jamapsychiatry.2014.666), Emmanuel Lagarde, Ph.D., of the INSERM Research Center in Bordeaux, France, and colleagues, analyzed data from 1,361 patients recruited from a hospital emergency department, of whom 534 had head injuries and 827 had injuries to other parts of the body. At 3 months’ follow-up, 21.2% of the mild traumatic brain injury (MTBI) patients and 16.3% of controls without head injuries could be diagnosed with PCS based on the DSM-IV criteria.

Moreover, 8.8% of patients with head injuries fulfilled diagnostic criteria for PTSD, compared with only 2.2% of controls. In the study group as a whole, MTBI was seen as a strong predictor of PTSD (odds ratio 4.47; 95% CI 2.38-8.4) but not of PCS (OR, 1.13; 95% CI 0.82-1.55). MTBI predicted PTSD regardless of whether the injury occurred as a result of a road crash, assault, or fall.

Assault was seen as a predictor of PCS as defined by DSM-IV, while severity of injury was not, suggesting that "psychological stress, and not potential brain injury, causes these symptoms, reinforcing the idea that they should be considered part of PTSD and not PCS," the researchers wrote.

They also found that symptoms suggestive of PCS under the DSM-IV criteria clustered in a way that paralleled a group of PTSD symptoms categorized as hyperarousal.

"The rationale to define a PCS that is specific to head-trauma patients is weak," Dr. Lagarde and colleagues wrote in their analysis. "Our results also suggested that the misunderstanding related to the relevance of defining such a syndrome could be explained by the overlapping pattern with symptoms of the PTSD hyperarousal dimension."

Available evidence does not support the use of PCS, they concluded, adding that clinicians should consider PTSD risk and treatment for patients with MTBI.

Dr. Lagarde and colleagues acknowledged as limitations of their study the fact that PTSD diagnoses were not made through formal clinical exams and that researchers focused on the traumatic events that landed subjects in the emergency department without capturing information on past traumatic events.

INSERM, the REUNICA Group, and Bordeaux University Hospital funded the study. None of the authors disclosed conflicts of interest.