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Original Investigation |

Association of Symptoms Following Mild Traumatic Brain Injury With Posttraumatic Stress Disorder vs Postconcussion Syndrome ONLINE FIRST

Emmanuel Lagarde, PhD1,2; Louis-Rachid Salmi, MD, PhD1,2,3; Lena W. Holm, DrMedSc4; Benjamin Contrand, MPH1,2; Françoise Masson, MD1,5; Régis Ribéreau-Gayon, MD1,6; Magali Laborey, PhD1,2; J. David Cassidy, PhD, DrMedSc7,8,9,10
[+] Author Affiliations
1INSERM, ISPED, Centre INSERM U897–Epidemiologie-Biostatistique, Equipe Prévention et Prise en Charge des Traumatismes F-33000, Bordeaux, France
2Université Bordeaux, ISPED, Centre INSERM U897–Epidemiologie-Biostatistique, F-33000, Bordeaux, France
3CHU de Bordeaux, Pole de sante publique, Service d’information medicale, F-33000, Bordeaux, France
4Division of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
5CHU de Bordeaux, Pole d’Anesthésie Réanimation, F-33000, Bordeaux, France
6CHU de Bordeaux, Pole de Médecine, F-33000, Bordeaux, France
7Institute of Sports Science and Clinical Biomechanics, Faculty of Health, University of Southern Denmark, Odense, Denmark
8Division of Health Care and Outcomes Research, Toronto Western Research Institute, University Health Network, University of Toronto, Ontario, Canada
9Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
10Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Ontario, Canada
JAMA Psychiatry. Published online July 16, 2014. doi:10.1001/jamapsychiatry.2014.666
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Importance  A proportion of patients experience long-lasting symptoms following mild traumatic brain injury (MTBI). The postconcussion syndrome (PCS), included in the DSM-IV, has been proposed to describe this condition. Because these symptoms are subjective and common to other conditions, there is controversy whether PCS deserves to be identified as a diagnostic syndrome.

Objective  To assess whether persistent symptoms 3 months following head injury are specific to MTBI or whether they are better described as part of posttraumatic stress disorder (PTSD).

Design, Setting, and Participants  We conducted a prospective cohort study of injured patients recruited at the adult emergency department of the University Hospital of Bordeaux from December 4, 2007, to February 25, 2009.

Main Outcomes and Measures  At 3-month follow-up, we compared the prevalence and risk factors for PCS and PTSD. Multiple correspondence analyses were used to assess clustering of symptoms and their associations with the type of injury.

Results  We included 534 patients with head injury and 827 control patients with other nonhead injuries. Three months following the trauma, 21.2% of head-injured and 16.3% of nonhead-injured patients fulfilled the DSM-IV diagnosis of PCS; 8.8% of head-injured patients fulfilled the diagnostic criteria for PTSD compared with 2.2% of control patients. In multivariate analysis, MTBI was a predictor of PTSD (odds ratio, 4.47; 95% CI, 2.38-8.40) but not of PCS (odds ratio, 1.13; 95% CI, 0.82-1.55). Correspondence analysis suggested that symptoms considered part of PCS behave similarly to PTSD symptoms in the hyperarousal dimension. None of these 22 symptoms showed any pattern of clustering, and no clear proximity with head or nonhead injury status could be found.

Conclusions and Relevance  Persistent subjective symptoms frequently reported 3 months after MTBI are not specific enough to be identified as a unique PCS and should be considered part of the hyperarousal dimension of PTSD.

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Figure 1.
Flowchart of Inclusion Procedures

aThe sum of the following variables is not 255 because some patients had several conditions.

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Figure 2.
Multiple Correspondence Analysis of Dimensions 1 and 2

Two-dimensional projection of the variable coordinates on dimension 1 (22.1% of explained inertia) and dimension 2 (6.3% of explained inertia). The circles represent the variable modalities for the absence of the symptom. The filled symbols for postconcussion syndrome (PCS), avoidance, and intrusion represent the variable modalities for the presence of the symptom. InRecall indicates the inability to recall an important aspect of the trauma; MTBI, mild traumatic brain injury; Rest, restlessness. For full descriptions of the variables, see eTable 1 in the Supplement.

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Figure 3.
Multiple Correspondence Analysis of Dimensions 1 and 3

Two-dimensional projection of the variable coordinates on dimension 1 (22.1% of explained inertia) and dimension 3 (4.8% of explained inertia). The circles represent the variable modalities for the absence of the symptom. The filled symbols for postconcussion syndrome (PCS), avoidance, and intrusion represent the variable modalities for the presence of the symptom. InRecall indicates the inability to recall an important aspect of the trauma; MTBI, mild traumatic brain injury; Rest, restlessness. For full descriptions of the variables, see eTable 1 in the Supplement.

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