Posttraumatic stress disorder in patients with traumatic brain injury and amnesia for the event, E Martin

Tags: head injury, PTSD criteria, PTSD, traumatic event, posttraumatic amnesia, amnesia, PTSD symptoms, WRAMC, PTSD diagnosis, avoidance, traumatic brain injury, DSM-III-R criteria, TBI patients, closed head injury, Ranchos Los Amigos, intrusive distressing recollections, acute stress response, Squire LR, Walter Reed Army Medical Center, head-injured patients, Present State Examination, declarative memory, Deborah L. Warden, reexperiencing, physical injuries, Physical injury, emotional memories, brain-injured patients, Neurogenic amnesia, brain injury, PTSD and depression, The relationship
Content: REGULAR
ARTICLES
Frequency of DSM-III-R posttraumatic
stress dis-
order (PTSD) was studied in 47 active-duty ser-
vice members (46 male, 1 female; mean age 27± 7)
with moderate traumatic Brain Injury and neuro-
genic amnesia for the event. Patients had attained
"oriented and cooperative" recovery level. When
evaluated with a modified Present State Examina-
tion and other questions at various points from
study entry to 24-month follow-up, no patients
met full criteria for PTSD or met criterion B (reex-
perience); 6 (13%) met both C (avoidance) and D
(arousal) criteria. Five of these 6 also had organic
mood disorder, depressed type, and/or organic anxi-
ety disorder. Posttraumatic
amnesia following mod-
erate Head injury may protect against recurring
memories and the development of PTSD. Some pa-
tients with neurogenic amnesia may develop a
form of PTSD without the reexperiencing
symp-
toms.
(THE JOURNAL Neurosciences
of Neuropsychiatry 1997; 9:18-22)
and Clinical
Posttraumatic
Stress
Disorder in Patients With
Traumatic
Brain Injury and
Amnesia for the Event?
Deborah L. Warden, M.D.
Lawrence A. Labbate, M.D.
Andres M. Salazar, M.D.
Rachael Nelson, M.D.
Emd Sheley, M.D.
James Staudenmeier,
M.D.
Elisabeth Martin, R.N.
p osttraumatic
stress disorder
(PTSD) is a psycho-
biologic
syndrome
involving
reexperiencing
phenomena,
avoidance
behavior,
and heightened
auto-
nomic responses
following
an extremely
severe stressor.
PTSD may develop in the context of bodily injuries as
well as emotional
trauma. Physical injury, in particular,
may be a risk factor for PTSD. For example, PTSD has
been commonly
described
among burn patients1 and in
Vietnam veterans with physical injuries compared
with
noninjured
veterans controlled
for equal combat expo-
sure.2 Epidemiologic
data also support
higher preva-
lence of PTSD in Vietnam veterans wounded
in Vietnam
compared
with noninjured
Vietnam veterans.3
Among patients with accidental
injury, results have
varied. Although
Malt4 found that 22% of patients de-
veloped psychiatric
sequelae after accidental
injury, he
found that only 1 of 107 patients
developed
PTSD.
Mayou et al.,5 however,
found that among 188 road
traffic accident victims, 19 met PTSD criteria.
Although
head injury may be associated
with PTSD,
loss of consciousness
(LOC) during the injury, with its
attendant
amnesia for the trauma, may be protective.
For example,
Mayou noted that among 51 traffic acci-
dent patients who had sustained
LOC for more than 5
Received September
29, 1995; revised February 5, 1996; accepted Febru-
ary 13, 1996. From the Defense and Veterans
Head Injury Program,
Walter Reed Army Medical Center, Washington,
DC. Address corre-
spondence
to Dr. Warden, Defense and Veterans Head Injury Program,
Building 1, Room 209B, Walter Reed Army Medical Center, Washington,
DC 20307-5001.
The opinions or assertions
contained
herein are the private views of
the authors and are not to be construed
as official or as reflecting the
views of the Department
of the Army or the Department
of Defense.
Copyright
© 1997 American Psychiatric
Press, Inc.
18
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WARDEN
et at.
minutes, none developed
PTSD. In fact, strongly predic-
tive of PTSD was the recurrence
of "horrific memories"
after the event.
Head injury differs from other physical injuries in that
the head injury itself may interfere with memories
for
the accident.
A period of confusion
and posttraumatic
amnesia (PTA), may occur after head trauma. A briefer
period of retrograde
amnesia
typically
occurs in pa-
tients with PTA, thus often rendering
patients amnestic
not only for the injury, but also for the minutes or hours
prior to the injury. The duration
of PTA has been used
as a measure of severity of head injury.6 PTA can occur
without loss of consciousness
both in penetrating
head
injury7 and closed head injury.8
Reexperiencing
of the trauma is one of the hallmarks
of PTSD. If recollection
of the event is critical to devel-
oping PTSD, then amnesia for the event may protect
against PTSD. We hypothesized
that among head-in-
jured patients
with amnesia
for the event, PTSD by
DSM-III-R criteria should rarely develop. However,
pa-
tients could develop avoidance
and arousal phenomena
independent
of recalling the event. If so, this part of the
syndrome
(avoidance
and arousal symptoms)
would
seem independent
of memory for the event. We sought
to evaluate
a cohort of head-injured
individuals
with
posttraumatic
amnesia for the presence of PTSD.
METHODS
Forty-seven
consecutive
active-duty
service members
who sustained
moderate
traumatic
brain injury (TBI),
defined as posttraumatic
amnesia lasting more than 24
hours or evidence
of intracranial
lesion on MRI, and
who had recovered
to Ranchos Los Amigos level 7 (ori-
ented and cooperative)9
within 90 days of injury were
enrolled
in an outcome
study at Walter Reed Army
Medical Center (WRAMC).
The Ranchos
Los Amigos
scale is commonly
used to describe the functional
status
of TBI patients in the acute and postacute
settings.
The etiology of injury was as follows: motor vehicle
accident
(MVA), 33 patients;
fall, 9 patients;
assault, 4
patients; and industrial
accident,
1 patient. The indus-
trial accident was a closed head injury from a piece of a
gas canister that had exploded
near the patient.
Patients underwent
comprehensive
multidisciplinary
evaluations,
including
speech and language,
occupa-
tional therapy, 8 hours of neuropsychological
testing, a
neurologic
exam, EEC, MRI, neuro-ophthalmology
exam, and psychiatric
exam, as detailed previously.10
Patients were administered
a semistructured
psychiat-
ric interview,
the Present State Examination1'
(PSE),
modified
for use with head-injured
patients, plus addi-
tional questions
regarding
posttraumatic
stress symp-
toms. Modification
of the PSE has previously
been used
in TB! research)2 Interviews
were conducted
by a neuro-
psychiatrist
(D.W.), a board-certified
staff psychiatrist
(L.L.), one of two master's-level
psychiatric
nurses, or
one of three psychiatric
residents (PGY-III and PGY-IV).
All exams and diagnoses
were reviewed
by the neuro-
psychiatrist.
Patients were evaluated
at entry into the
study and at completion
of an 8-week in-hospital
or
home program.
Follow-up
evaluations
at WRAMC were
scheduled
for 6, 12, and 24 months after program com-
pletion.
Questions
that contained
items relevant to DSM-III-R
diagnostic
criteria for PTSD were extracted
from the
Present State Examination.
One question concerned
in-
trusive thoughts
(serving as a screen for the B criterion
item "intrusive
distressing
recollections").
Four ques-
tions concerned
avoidance
(C criteria), querying
lost
interests; feelings of estrangement
from others; feelings
of having lost one's emotions
(similar to "restricted
range of affect; e.g., unable to have loving feelings");
and patient's view of the future (to inquire about "sense
of a foreshortened
future"). Seven questions
concerned
arousal, querying five of the six D criteria: difficulty with
sleep; irritability;
difficulty
concentrating;
being upset
by noise (screening
for "exaggerated
startle response");
and experience
of anxiety, panic symptoms,
or feelings
that something
terrible might happen
(screening
for
physiologic
reactivity
to events symbolizing
an aspect
of the trauma). Because the PSE does not address all
criteria of PTSD diagnosis,
two questions
were added
specifically
to address the reexperience
(B) and avoid-
ance (C) criteria: "At any time since this injury, have you
experienced
recurrent,
distressing
recollections,
or
dreams of the event?" and "Since this injury, have you
made efforts to avoid thoughts
or feelings associated
with the trauma, or tried to avoid activities or situations
that remind you of the event?"
We report on the findings
for all patients
who re-
ceived the PSE with these additional
questions.
The
time from TB! to these interviews
ranged from 4 to 29
months after the injury. The initial evaluation
was not
considered
for this study because feelings reported
at
that time could be considered
an acute stress response
and not PTSD.
Although
the PTSD diagnosis
includes
persistent
reexperiencing
of the traumatic
event, our patients
without memory of their head injury might fail to meet
reexperiencing
criteria by definition,
and we would by
circular argument
exclude them. We thus considered
satisfying
the A, C, and D criteria (stressor plus three
avoidance
and two arousal symptoms)
as presumptive
evidence of PTSD.
JOURNAL
OF NEUROPSYCHIATRY
PTSD IN HEAD INJURY WITH AMNESIA
RESULTS
DISCUSSION
Forty-seven
patients,
all active-duty
soldiers, 46 men
and I woman, were evaluated
for PTSD at least once.
Mean age (± SD) was 27± 7 years. Table 1 describes the
timing of evaluations.
Table 2 displays the lengths of
LOC and PTA. Eighteen patients were evaluated
more
than once for PTSD. None of the patients recalled the
traumatic
event.
None of the patients met full criteria for DSM-III-R
PTSD. Six (13%) met criteria A, C, and D (the stressor,
avoidance,
and arousal clusters), as well as the E (dura-
tion) criterion during at least one evaluation
point.
Five of these 6 patients
were evaluated
more than
once. Only 1 patient met criteria at more than one
evaluation
point. The timing of meeting the criteria in
these 6 patients was as follows: 3 were evaluated
at 2
months
and 6 months;
of these, 2 were positive
at 2
months only and 1 was positive both times; 1 was evalu-
ated at 2 months only; I was evaluated
at 2, 6, and 12
months and was positive only at 6 months; and 1 was
seen at 12 and 24 months and was positive only at 24
months.
Common
symptoms
reported
in patients
who met
these modified
PTSD criteria included
hypersensitiv-
ity to noise, social withdrawal,
loss of interests,
irrita-
bility, poor concentration,
and the feeling of having
lost their emotions.
In addition,
5 of the 6 patients
meeting C and D criteria for PTSD also received clini-
cal DSM-III-R
diagnoses
of organic Mood Disorders,
depressed
type, and/or organic anxiety disorder at the
same evaluation.
___________________________________________________ _T_A__B__L__E________1_.______T__i_m__e_s_______a_n__d_____r_e__s_u_lts
of PTSD
interviews
8 Weeks
Time of Interviews
6 Months
12 months
Number of PTSD
28
15
18
evaluations
performed
Number of PTSD-
3
3
0
positive ?atets
(A, C, D)
24 Months 7 1
Note: PTSD = posttraumatic
stress disorder.
aSiz patients met PTSD criteria (A, C, 0) a total of seven times.
We found that among 47 head-injured amnesia for the trauma, none suffered III-R criteria. When we used DSM-LII-R
patients with PTSD by DSMcriteria modified
for patients (specifically,
who have amnesia secondary
to head injury
meeting the A, C, D, and E criteria, but not
the reexperiencing
B criterion),
6 patients met the modi-
fied criteria for PTSD, and 1 of those 6 met criteria on
two separate
interviews.
with the report of Mayou
These results are consistent et al.,5 in which LOC and lack
of memory were seen as protective
for the development
of PTSD. Our results extend this finding to a cohort of
consecutive
admissions
for moderate
TBI where pa-
tients had no recall of the trauma.
Thus, even in the face of potentially
life-threatening
injuries,
amnesia
for the event greatly decreases
the
likelihood
of developing
PTSD. Inability to recall the
injury is characteristic
of moderate
and severe head
injury and can be seen in mild head injury.8 Patients in
our study of moderate
posttraumatic
amnesia
TBI all experienced
a period of
of at least 1 hour; most had PTA
for more than 24 hours, and the remainder
had intracra-
nial pathology
on MRI. Amnesia for events occurring
shortly prior to the injury (retrograde
amnesia) typically
accompanies
PTA; most of the patients in our study had
no memories
of the several minutes to hours prior to the
injury. The pathophysiology
of traumatic
unconscious-
ness may involve injury to basal structures,
including
the reticular activating
system, as well as diffuse hemi-
spheric injury.7"16
Because of posttraumatic
amnesia
occurring
in all
these patients, no declarative
memory would have been
established
for the events of the injury. Indeed, Mayou
et al.5 noted that the presence
of "horrific
predicted
the development
of PTSD. These
memories
may be critical to the development
memories" traumatic of the
syndrome
of PTSD.
Clearly, not all individuals
or develop PTSD. In a study
who sustained
a DSM-III-R
exposed of young stressor,
to a severe stressadults in Detroit 23.6% met criteria
for PTSD.17 However,
that is a substantially
greater pro-
portion than the 13% of individuals
in this study who
met the modified PTSD criteria with no reexperience
(B)
criterion required. Our findings are not applicable
to patients with head
injury and memory
for the injury. Also, we have not
TABLE 2. Length Event LOC PTA
of loss of consciousness Unknown 6 0
(LOC) and posttraumatic
None
<1 hr
4
7
0
0
amnesia (PTA) in 47 patients
1-24 hrs
1-3 days
7
12
5
10
4-7 days 8 17
> 7 days 3 15
20
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WARDEN
et at.
studied patients with severe head injury who may have
PTA lasting more than 1 month, although
we suspect
these patients would have similar findings.
A strength
of the PSE is the semistructured
design.
Prior to the asking the structured
questions,
the inter-
viewer talked with the patient about the accident. The
study was initiated after interviewers
noted the lack of
distress during discussions
about the head injury. In-
deed, patients often remarked
about having returned
to
the scene of the accident in the hope that this would
stimulate
additional
memories.
However,
memory for
the event did not return, showing
that these patients
were unable to use geographic
cues to regain memory.
A limitation
of this study is that not all patients were
evaluated
for PTSD at the same intervals over the 2-year
period. Although
many were interviewed
within sev-
eral months of the injury, a few were not interviewed
for PTSD until more than 1 year later. Some patients
may have had PTSD that remitted
before our evalu-
ation, and others may yet develop
PTSD. However,
patients were asked the additional
questions
on intru-
sion, reexperiencing,
and avoidance
of thoughts
or ac-
tivities reminding
the patient
of the trauma
with
reference
to any time since the accident. This was done
specifically
to decrease the possibility
of missing intru-
sion and reexperiencing
PTSD symptoms
because of the
timing of the interview.
No pattern was noted in the
times at which these 6 patients
met modified
PTSD
criteria.
Another limitation
of the study is that we did not use
a standardized
PTSD instrument
to ascertain
PTSD
symptoms.
None of those instruments
is normed on
brain-injured
patients.
Our semistructured
interviews
(PSE plus additional
questions)
queried two of the reex-
periencing
(B) symptoms,
6 of the 7 avoidance
(C) symp-
toms, and 5 of the 6 arousal (D) symptoms.
The PSE
asked about aspects of the DSM-III-R criteria; however,
the PSE questions
did always not correspond
exactly to
the criteria as stated in DSM-III-R.
Also, DSM-III-R
specifies a duration
of more than I month for PTSD
symptoms.
The PSE questions
(primarily
on arousal!
References
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stress
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are based on experiences
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Five of the 6 patients also met DSM-III-R
criteria for
organic mood disorder, depressed
type, and/or organic
anxiety disorder.
Comorbidity
of PTSD and depression
or other anxiety diagnoses
has been noted previously.'7
The relationship
of other anxiety and depressive
symp-
toms (that is, some of the B and C criteria of PTSD) to
the TBI remains
to be clarified.
LeDoux and others'8
suggest distinct pathways
involving lateral amygdala
in
establishing
adversive
emotional
memories,
distinct
from neuronal
circuits subserving
explicit, declarative
memory. Their work suggests that psychological
effects
of extremely
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may not be depen-
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ditioned behavior, such as avoidance
and arousal symp-
toms, could possibly occur. A recent report of 2 patients
with neurogenic
amnesia and PTSD also discusses
this
hypothesis.19
Neurogenic
amnesia
for a traumatic
event and the
subsequent
development
of PTSD symptoms
is still a
new area of study. Despite the limitations
mentioned
above, the data obtained from this consecutive
series of
brain-injured
patients may offer insights into this area.
CONCLUSIONS
DSM-III-R amnestic the lack nomena research traumatic
PTSD is very uncommon
in TBI patients
for the events of their injury. We conclude that
of intrusive
memories
and reexperiencing
phe-
is due to the neurogenic
amnesia. Additional
may clarify the pathophysiology
of other post-
symptoms
that do occur in this population.
This research was approved by the WRAMC Clinical Investiga-
tion Committee and Human Use Committee/Institutional
Re-
view Board. All subjects enrolled into the study voluntarily
agreed to participate and gave written informed consent.
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brain injury: a case series (abstract). Neurology
1994; 44:A401
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OF NEUROPSYCHIATRY
21
PTSD IN HEAD INJURY WITH AMNESIA
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17. Breslau N, Davis GC, Andreski
P, et al: Traumatic
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18. LeDoux J: Emotional
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stress disorder
with
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