BRIEF REPORTS

Posttraumatic Stress Disorder

After Severe Traumatic Brain Injury

Richard A. Bryant, Ph.D., Jeno E. Marosszeky, M.B., B.S.,

Jenelle Crooks, R.N., and Joseph A. Gurka, M.B., B.S.

Objective: This study indexed the profile of posttraumatic stress disorder (PTSD) after
severe traumatic injury to the brain. Method: Patients who sustained a severe traumatic
brain injury (N=96) were assessed for PTSD 6 months after the injury with the PTSD Inter-
view, a structured clinical interview based on DSM-III-R criteria. Results: PTSD was diag-
nosed in 26 (27.1%) of the patients. While only 19.2% (N=5) of the patients with PTSD re-
ported intrusive memories of the trauma, 96.2% (N=25) reported emotional reactivity.
Intrusive memories, nightmares, and emotional reactivity had very strong positive predic-
tive values for the presence of PTSD. Conclusions: These findings indicate that PTSD can
develop after severe traumatic brain injury. The predominance of emotional reactivity and
the relative absence of traumatic memories in patients with PTSD who suffered impaired
consciousness during trauma suggest that traumatic experiences can mediate PTSD at an
implicit level.
(Am J Psychiatry 2000; 157:629–631)

I t has traditionally been assumed that posttraumatic

stress disorder (PTSD) cannot develop after severe
METHOD

traumatic brain injury because the pervasive loss of Over a 36-month period, 161 patients were admitted to a brain
injury rehabilitation unit. We attempted to assess each patient 6
consciousness that occurs after a severe traumatic
months after hospital discharge. Patients were excluded because of
brain injury precludes encoding of the traumatic expe- the inability to speak English (N=4), insufficient cognitive ability to
rience (1). Numerous case studies, however, have de- understand the interview (N=22), refusal to participate (N=27), and
scribed PTSD after severe traumatic brain injury (2, inability to contact the patient (N=12). Thus, 96 patients (77 men
3). Biological theories propose that a conditioned fear and 19 women) were included in the study. The duration of post-
traumatic amnesia was established by use of the Westmead Posttrau-
of traumatic experiences can be mediated in subcorti-
matic Amnesia Scale (5). The mean value for posttraumatic amnesia
cal structures that are independent of higher cortical was 36.97 days (SD=30.65), with a range of 7–143 days. The mean
processes (4). This view predicts that damage to the Glasgow Coma Scale (6) score was 8.00 (SD=3.78). Age ranged
cortex would not preclude the symptoms of trauma from 16 to 71 years (mean=34.26, SD=12.82). Mean posttraumatic
reexperiencing. The aim of this study was to investi- amnesia and Glasgow Coma Scale scores indicated that the average
level of traumatic brain injury was very severe and that on average,
gate the profile of PTSD after severe traumatic brain
these patients had no cohesive recall of events that occurred in the
injury. We predicted that patients who develop PTSD first month after the trauma. These assessments took place between
after severe traumatic brain injury would suffer the 5 and 7 months posttrauma (mean=6.27 months, SD=1.27). After a
symptoms of trauma reexperiencing in the form of complete description of the study was given to the patients, written
emotional and physiological reactivity rather than as informed consent was obtained.
intrusive memories. The patients were interviewed by a rehabilitation consultant who
was trained in the assessment procedures by the first author
(R.A.B.). A diagnosis of PTSD was made by means of the PTSD In-
Received Sept. 9, 1998; revisions received March 25 and Aug.
terview (7), which is based on the DSM-III-R criteria and has good
25, 1999; accepted Sept. 25, 1999. From the School of Psychol-
ogy, University of New South Wales; and the Department of Reha- construct validity (sensitivity=0.92) and test-retest diagnostic agree-
bilitation Medicine, Westmead Hospital, Sydney, Australia. ment (kappa value: r=0.61). Dissociative amnesia was excluded as a
Address reprint requests to Dr. Bryant, School of Psychology, possible symptom of PTSD because of the confound between disso-
University of New South Wales, Sydney 2052, Australia; r.bryant@ ciative amnesia and amnesia related to traumatic train injury. Addi-
unsw.edu.au (e-mail). tional information was obtained from medical records—including
Supported by the National Health and Medical Research Council age, duration of posttraumatic amnesia, duration of hospital stay,
and the Motor Accident Authority of New South Wales, Australia. and Glasgow Coma Scale score.

Am J Psychiatry 157:4, April 2000 629

BRIEF REPORTS

TABLE 1. Rates of PTSD Symptoms in Patients With and With- claim that PTSD cannot occur after a severe traumatic
out PTSD 6 Months After Severe Traumatic Brain Injury
brain injury (1). Our participants were not drawn from
PTSD a consecutive patient group; therefore, the 27.1% inci-
Patients Patients dence of PTSD does not reflect the rate of PTSD in
With Without
(N=26) (N=70) Predictive Power populations with traumatic brain injury. The finding
Symptom N % N % Positivea Negativeb that only 19.2% of the patients with traumatic brain
Intrusive memories 5 19.2 0 0.0 1.00 0.77
injury who met the criteria for PTSD reported intrusive
Nightmares 6 23.1 0 0.0 1.00 0.78 memories is consistent with our prediction that trauma
Sense of reliving reexperiencing is mediated by emotional (96.2%) and
trauma 8 30.8 3 4.3 0.73 0.79
Emotional reactivity 25 96.2 4 5.7 0.86 0.98
physiological reactivity (50.0%). The low incidence of
Physiological intrusive memories in our participants contrasts with
reactivity 13 50.0 6 8.6 0.68 0.83 the rate of intrusive memories in PTSD after assault
Avoidance of thoughts 17 65.4 15 21.4 0.53 0.86 (93%) (9), terrorist activity (85%) (10), and motor ve-
Avoidance of places 17 65.4 14 20.0 0.55 0.86
Diminished interest 19 73.1 23 32.9 0.45 0.87 hicle accidents (65%) (11). Our finding is consistent
Detachment 19 73.1 24 34.3 0.44 0.91 with proposals that trauma reexperiencing can be me-
Restricted affect 17 65.4 19 27.1 0.47 0.85 diated by fear conditioning or perhaps by mental rep-
Sense of
foreshortened future 19 73.1 23 32.9 0.45 0.87 resentations of the experience that are not accessible to
Insomnia 18 69.2 17 24.3 0.51 0.87 conscious awareness (4, 5). It is interesting that the
Irritability 22 84.6 22 31.4 0.50 0.92 content of intrusive memories in the few patients who
Concentration deficits 24 92.3 32 45.7 0.43 0.95
Hypervigilance 19 73.1 19 27.1 0.50 0.88
reported them was of trauma-related images that they
Startle response 19 73.1 11 15.7 0.63 0.89 had apparently reconstructed on the basis of informa-
a Probability of PTSD when symptom is present. tion acquired after remittance of posttraumatic amne-
b Probability of absence of PTSD when symptom is absent. sia. For example, one patient reported that his intru-
sions were of images that he had seen in a photograph
RESULTS of his wrecked car.
The presence of PTSD was very strongly indicated by
The 96 patients who participated in the 6-month as- the presence of intrusive memories, nightmares, or
sessment did not differ from the 65 who did not partic- emotional reactivity. These findings contrast with
ipate in terms of age, years of education, or severity of those in previous reports in which the symptoms of
posttraumatic amnesia. Those who did not participate trauma reexperiencing had only moderate positive pre-
had lower Glasgow Coma Scale scores (mean=5.48, dictive power (9). It is possible that the deficient cop-
SD=3.62) than those who participated (mean=8.00, ing skills associated with severe traumatic brain injury
SD=3.78) (t=2.96, df=124, p<0.01). resulted in patients who suffered trauma reexperienc-
PTSD was diagnosed in 26 (27.1%) of the patients. ing being unable to manage the distress caused by the
Table 1 presents the percentage of patients who re-
symptoms. Alternately, the numerous problems associ-
ported individual PTSD symptoms. Chi-square analy-
ses (with Yates’s correction) of each PTSD symptom ated with severe traumatic brain injury may have com-
between patients with (N=26) and without (N=70) pounded the anxiety caused by trauma reexperiencing,
PTSD were conducted with a Bonferroni adjustment, and this may have contributed to PTSD.
in which the alpha level was set at 0.003 to provide an We recognize a number of limitations in this study.
overall rejection level of 0.05 (8). More patients who First, our patients were not selected consecutively, and
met the criteria for PTSD endorsed each PTSD symp- their responses may not be representative of popula-
tom than did those who did not meet the criteria. tions with severe traumatic brain injury. Second, we
The power of each PTSD symptom to predict PTSD did not obtain neuropsychological information on
diagnostic status was calculated (table 1). Positive pre- each patient. The role of cognitive deficits in the medi-
dictive power was defined as the probability of PTSD ation of the symptoms of PTSD would have been clar-
developing when a PTSD symptom was present. Nega- ified by relating symptoms to documented cognitive
tive predictive power was defined as the probability of deficits. Third, the diagnosticians (R.A.B. and J.C.)
not developing PTSD when a PTSD symptom was ab-
were aware that all patients had sustained a traumatic
sent. The symptoms that had the highest positive pre-
dictive powers were intrusive memories (1.00), night- brain injury. These limitations notwithstanding, these
mares (1.00), and emotional reactivity (0.86). findings indicate that patients with a severe traumatic
brain injury are a useful population in which to study
implicit memories of traumatic experiences. Further-
DISCUSSION more, these findings indicate that assessments of and
interventions in PTSD after severe traumatic brain in-
The finding that 27.1% of our study group met the jury may need to address the specific symptom profile
criteria for PTSD provides strong evidence against the displayed by these patients.

630 Am J Psychiatry 157:4, April 2000

 BRIEF REPORTS

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