HONOLULU— For many US soldiers in Iraq, it may take years to understand the full impact of the physical and psychological wounds they might incur. Following previous wars, posttraumatic stress disorder has been a frequent complaint of veterans, though the association with brain injuries suffered in combat has not been well investigated. But in a recent study, researchers found that nearly one in ten soldiers who suffered a traumatic brain injury were also diagnosed with posttraumatic stress disorder. These soldiers had significant psychiatric comorbidity and were less likely to be fit for duty in twelve months, compared with those who did not have posttraumatic stress disorder.

“The posttraumatic stress disorder group had significantly higher rates of comorbid depression, generalized anxiety disorder, obsessive-compulsive disorder, and panic attacks and greater sleep disturbances, including changes in sleep onset and waking,” reported Deborah L. Warden, MD. “Additionally, poorer military work retention demonstrates the functional limitations of individuals with posttraumatic stress disorder after traumatic brain injury. Dr. Warden is National Director of the Defense and Veterans Brain Injury Center at the Walter Reed Army Medical Center in Washington, DC. She presented her findings at the 14th Annual Meeting of the American Neuropsychiatric Association.

A total of 148 soldiers participated in a trial of home-versus-inpatient rehabilitation at Walter Reed Army Medical Center after having moderate-to-severe traumatic brain injury and posttraumatic amnesia of at least 24 hours. One hundred twenty-nine patients who received complete psychiatric evaluations were ultimately included in the study. Diagnosis of posttraumatic stress disorder was derived from the Present State Examination and other psychiatric interview questions corresponding to DSM-IV criteria. Individuals who developed posttraumatic stress disorder based on the included criteria were compared with those who did not develop the disorder on baseline measures of psychiatric symptoms, prior history, and demographic measures.

Dr. Warden’s team found that 12 (9.3%) soldiers met all criteria for the computed diagnosis of posttraumatic stress disorder. Demographically, this group was more likely to be non-Caucasian and married. However, no significant differences were found between groups, nor was there a history of traumatic brain injury/ abuse, early loss/traumatic event, substance abuse, or psychiatric illness. Review of MRI scans revealed no group differences in the total number of frontotemporal or other lesions. “Individuals with posttraumatic stress disorder were significantly less likely to remain at military duty at 12 months postinjury,” she emphasized.

“This study confirms that posttraumatic stress disorder following traumatic brain injury does occur, even when utilizing criteria more restrictive than the current DSM-IV diagnosis requires,” continued Dr. Warden. Although an earlier report by her group found that none of the first 47 patients in a randomized controlled trial met the re-experiencing criteria, subsequent patients did endorse re-experiencing phenomena and met computed DSM-IV diagnosis for posttraumatic stress disorder. “The inherent variability in research subjects underscores the need for larger samples in descriptive studies,” she added. “Future research may identify treatments to alleviate symptoms and improve functional outcome.”

—Colby Stong

Suggested Reading
Salazar AM, Warden DL, Schwab K, et al. Cognitive rehabilitation for traumatic brain injury: a randomized trial. Defense and Veterans Head Injury Program (DVHIP) Study Group. JAMA. 2000;283:3075-3081.
Warden DL, Labbate LA, Salazar AM, et al. Posttraumatic stress disorder in patients with traumatic brain injury and amnesia for the event? J Neuropsychiatry Clin Neurosci. 1997;9:18-22.

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