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Original Investigation |

A Multisite Analysis of the Fluctuating Course of Posttraumatic Stress Disorder

Richard A. Bryant, PhD1,2; Meaghan L. O’Donnell, PhD3; Mark Creamer, PhD4; Alexander C. McFarlane, MD5; Derrick Silove, MD6
[+] Author Affiliations
1School of Psychology, University of New South Wales, New South Wales, Australia
2Brain Dynamics Centre, University of Sydney and Westmead Millennium Institute, Sydney, Australia
3Australian Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, National Trauma Research Institute, Melbourne, Australia
4Australian Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Melbourne, Australia
5Centre for Military and Veteran Health, Queensland, Australia
6School of Psychiatry, University of New South Wales, New South Wales, Australia
JAMA Psychiatry. 2013;70(8):839-846. doi:10.1001/jamapsychiatry.2013.1137.
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Importance  Delayed-onset posttraumatic stress disorder (PTSD) accounts for approximately 25% of PTSD cases. Current models do not adequately explain the delayed increases in PTSD symptoms after trauma exposure.

Objective  To test the roles of initial psychiatric reactions, mild traumatic brain injury (MTBI), and ongoing stressors on delayed-onset PTSD.

Design, Setting, and Participants  In this prospective cohort study, patients were selected from recent admissions to 4 major trauma hospitals across Australia. A total of 1084 traumatically injured patients were assessed during hospital admission from April 1, 2004, through February 28, 2006, and 785 (72.4%) were followed up at 3, 12, and 24 months after injury.

Main Outcome and Measure  Severity of PTSD was determined at each assessment with the Clinician-Administered PTSD Scale.

Results  Of those who met PTSD criteria at 24 months, 44.1% reported no PTSD at 3 months and 55.9% had subsyndromal or full PTSD. In those who displayed subsyndromal or full PTSD at 3 months, PTSD severity at 24 months was predicted by prior psychiatric disorder, initial PTSD symptom severity, and type of injury. In those who displayed no PTSD at 3 months, PTSD severity at 24 months was predicted by initial PTSD symptom severity, MTBI, length of hospitalization, and the number of stressful events experienced between 3 and 24 months.

Conclusions and Relevance  These data highlight the complex trajectories of PTSD symptoms over time. This study also points to the roles of ongoing stress and MTBI in delayed cases of PTSD and suggests the potential of ongoing stress to compound initial stress reactions and lead to a delayed increase in PTSD symptom severity. This study also provides initial evidence that MTBI increases the risk of delayed PTSD symptoms, particularly in those with no acute symptoms.

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Figure.
Posttraumatic Stress Disorder

Diagnoses of full-blown, subsyndromal, and no posttraumatic stress disorder and changing diagnoses during the first 2 years after trauma exposure. Size within diagram and arrow reflect proportion of participants in each grouping and changing course from one grouping to another.

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