© Springer-Verlag Berlin Heidelberg 2016
Hans-Christoph Pape, Roy Sanders and Joseph Borrelli, Jr. (eds.)The Poly-Traumatized Patient with Fractures10.1007/978-3-662-47212-5_2828. Psychological Sequelae After Severe Trauma
(1)
Department of Psychiatry, Psychotherapy, and Psychological Medicine, RWTH Aachen University, Medical School, Pauwelsstr. 30, Aachen, 52074, NRW, Germany
(2)
Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Pauwelsstr. 30, 52074 Aachen, Germany
(3)
JARA – Translational Brain Medicine, RWTH Aachen University & Research Centre Jülich, Jülich, Germany
Keywords
Post-traumatic stress disorderAccidentMild traumatic brain injuriesScreeningMental illnessPsychosocial impairments28.1 Introduction
Events that bear the risk for traumatization include threat (esp. threat of death) or injuries. Especially, long-term psychological consequences after major traumas (also due to illness-related impairments) can have serious effects on the patient’s quality of life resulting in heightened psychological morbidity. As of today, the psychological and psychiatric consequences of major trauma incidences are only superficially explored although psychological consequences of traumatic injuries represent a major public health burden.
A large influence on the current knowledge and literature regarding traumatic injuries to date originate from a specific field of research, the military personnel. Concerning German military personnel a recent study by Wittchen et al. [29] included 1599 German soldiers deployed to Afghanistan during the ISAF mission and demonstrated a significantly heightened risk of traumatic experiences and the development of a post-traumatic stress disorder (PTSD) in deployed soldiers compared to soldiers stationed in Germany. Furthermore, they showed that a high percentage of these persons concerned were not diagnosed nor treated after their return.
In general, research concerning the psychological sequelae of major trauma is limited by methodological constraints, e.g., the frequent lack of a control group in most study settings based in emergency care departments. Therefore, results have to be discussed against the background of general population-wide prevalence rates rather than an injury-specific comparison group.
Among the possible psychological diagnoses following major trauma, post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) are of particular relevance. For PTSD, the three most important symptoms include intrusions, avoidance and arousal.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5, [2]) requires a history of exposure to a traumatic event that fulfills symptoms from four clusters: intrusion, aversion, negative alterations in cognition and mood and alterations in arousal and reactivity. Two additional criteria require duration of the symptoms for more than 1 month and the presence of a significant symptom-related distress or functional impairment.
ICD-10 criteria for ASD and PTSD are listed below [30].
F43.0 Acute Stress Reaction
A transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress and that usually subsides within hours or days. Individual vulnerability and coping capacity play a role in the occurrence and severity of acute stress reactions. The symptoms show a typically mixed and changing picture and include an initial state of “daze” with some constriction of the field of consciousness and narrowing of attention, inability to comprehend stimuli, and disorientation. This state may be followed either by further withdrawal from the surrounding situation (to the extent of a dissociative stupor – F44.2), or by agitation and over-activity (flight reaction or fugue). Autonomic signs of panic anxiety (tachycardia, sweating, flushing) are commonly present. The symptoms usually appear within minutes of the impact of the stressful stimulus or event, and disappear within two to three days (often within hours). Partial or complete amnesia (F44.0) for the episode may be present. If the symptoms persist, a change in diagnosis should be considered.
F43.1 Post-traumatic Stress Disorder
Arises as a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone. Predisposing factors, such as personality traits (e.g. compulsive, asthenic) or previous history of neurotic illness, may lower the threshold for the development of the syndrome or aggravate its course, but they are neither necessary nor sufficient to explain its occurrence. Typical features include episodes of repeated reliving of the trauma in intrusive memories (“flashbacks”), dreams or nightmares, occurring against the persisting background of a sense of “numbness” and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma. There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia. Anxiety and depression are commonly associated with the above symptoms and signs, and suicidal ideation is not infrequent. The onset follows the trauma with a latency period that may range from a few weeks to months. The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change (ICD-10, F62.0).
28.2 Post-traumatic Stress Disorder
The lifetime experience of an event that fulfills criteria for a trauma is rather frequent within the general population [12], but the pure exposure to a trauma is not sufficient for the development of a PTSD. Four weeks after a traumatic event, the prevalence of PTSD is estimated as high as 41 % [17]. Lukaschek et al. identified several risk factors which constitute a higher risk for PTSD. Inter alia accidents, nonsexual assault and life-threatening illness are associated with a higher risk for a full and partial PTSD. These results are interpreted as evidence that the impact or consequences following a traumatic event depends on characteristics of the event as well as individual factors of the victim. Regarding clinical and emergency care, victims of motor vehicle accidents or other forms of traumatic injuries (e.g., burn victims, head injuries, orthopedic traumatic injuries) are at heightened risk for development of mental disorders (e.g., PTSD, depression), but studies examining these factors still produce heterogeneous results [26, 20, 24]. Regarding the occurrence of PTSD after a major traumatic experience it is important to keep in mind that PTSD is often associated with other comorbid psychiatric disorders [21]. The most frequent comorbidity is major depressive disorder (MD) followed by generalized anxiety disorder.
Feelings of anxiety and sometimes dissociation in the immediate aftermath of a traumatic experience are common among injury victims. These symptoms are short-term and can be regarded as normal. Although still heterogeneous, literature results show PTSD prevalence rates of 10–30 % after traumatic experiences [24, 10, 20]. Using the Impact of Event Scale (IES, [14]), Haagsma et al. [10] could show that 1 year after a major trauma, 23 % of the participants had probable PTSD, after 2 years 20 % reported symptoms of probable PTSD. Due to the fact that in this study the prevalence of PTSD was exclusively assessed via the IES, the authors use the term “probable PTSD” to indicate the lack of further diagnostic evaluations. Furthermore, female gender and comorbid diseases were strong predictors of probable PTSD after 1 year, whereas head injury and injury of extremities were predictors of PTSD after 2 years. Of the probable PTSD patients after 1 year, 79 % had persistent PTSD after 2 years.
An interesting differentiation was made by Alarcon et al. [1]. In their study, they showed a general prevalence rate of 25 % of PTSD after trauma using the PTSD Checklist-Civilian (PCL-C). Further analyses confirmed an association between the mechanism of injury and the risk of developing symptoms of PTSD with the highest correlation after assault (43 %) and younger age, female gender and motor vehicle collision as significant independent risk factors for subsequent PTSD.
In 2010, an Australian research group published results of a prospective study including over 1000 victims of traumatic injuries [4]. Interested in the extent of psychiatric diagnoses as a consequence of traumatic injuries, they concluded that after 12 month 31 % of their participants developed a psychiatric disorder and 23 % developed a psychiatric disorder that they never had in their life prior to the accident. Psychiatric diagnoses not only included PTSD but a wide range of disorders, most frequently major depression and generalized anxiety disorder next to PTSD.
An Israeli study showed that even noninjured victims of trauma show elevated heart rates at admission to emergency care facilities [25]. According to the authors, these physiological responses in combination with skin conductance (PTSD patients show impaired habituation in skin conductance rates after startling stimuli) and left lateral frontalis electromyogram levels (PTSD patients show increased responses) can distinguish between patients who will develop PTSD later on and patients who will not. The fact that these physiological responses will often recur if a patient re-experiences traumatic memories (flashbacks) during the day can reinforce the memories and thereby impair the treatment of the symptoms.
28.2.1 Association of PTSD and Traumatic Brain Injuries
Against the background of elevated prevalence rates of mental illness after traumatic brain injuries (TBI), Bryant et al. [4] examined the connection between TBI and psychiatric illnesses as a consequence of TBI using a multi-center prospective study design in Australia. Besides the fact that they could repeat an estimated prevalence of 23 % for incidental psychiatric illnesses 12 months after the traumatic event, they documented depression as the most frequent consequence, followed by generalized anxiety disorder and PTSD. These results emphasize the notion that psychological consequences after major traumas can take shape in various diagnoses, not only PTSD. The authors concluded that PTSD may pose a major threat after traumas in connection with violent incidents, while traumatic incidences that involve traumatic brain injuries seem to trigger a broader range of psychiatric consequences.
Recently, Roitman et al. [23] could show that accident victims who suffered head injury in combination with loss of consciousness had a higher prevalence of PTSD 10 days and 8 months after the accident than accident victims without loss of consciousness. In addition, patients with traumatic brain injury and loss of consciousness showed slower recovery rates from early PTSD symptoms. In their discussion, the authors hypothesize that the loss of consciousness may suppress the victims’ ability to form a coherent memory of the accident or the traumatic event. Furthermore, they hypothesized that subsequent damage (e.g., headache, confusion) may interfere with processes of fear distinction and therefore act as a reinforcer of traumatic memory processes. Altogether, there seems to be a heightened risk of PTSD if the accident or traumatic event is associated with traumatic brain injury and loss of consciousness, events with a high likelihood regarding polytraumatic injuries. Therefore the medical personnel should be instructed and prepared to consider psychological consequences after polytraumatic incidents as well as physical consequences.
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