Chapter 13: Post-Traumatic Stress Disorder

Thomas Moore, Jr.; Carol North, Adam Starr

Chapter Outline

Introduction

Post-traumatic stress disorder (PTSD) has evolved as a diagnosis both in name and in its description of signs and symptoms. Its first formal diagnostic criteria came in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980), which detailed characteristic psychiatric symptoms following exposure to a traumatic event. The evolution of this diagnosis can be traced back to physicians describing acute combat reactions ranging from sleep disturbances to loss of appetite to palpitations. In 1678, Norwegian physicians called this constellation of symptoms nostalgia. PTSD has also been called neurasthenia, combat exhaustion, gross stress reaction, irritable heart syndrome, shell shock, and stress response syndrome, and this condition has been suspected in many historical and literary figures. This psychiatric disorder was well documented in World War II and Vietnam combat forces, but more recently PTSD has also been recognized in association with noncombat-related traumatic events, including motor vehicle collisions and other orthopedic traumas. 
The DSM-IV1 criteria for the diagnosis of PTSD describe symptoms following an experienced or directly witnessed event that involves actual or threatened death or serious injury or a threat to the physical integrity of oneself or others. The individual’s response to this traumatic event is fear, helplessness, or horror. In addition, specific manifestations of the disorder from three symptom groups are required for the diagnosis of PTSD. The first symptom group is intrusive re-experience, including recurrent dreams, a sense of reliving the traumatic experience (such as flashbacks), and psychological distress in response to reminders of the traumatic event. The second symptom group is avoidance and numbing, involving efforts to avoid activities, places, memories, or thoughts associated with the traumatic event. The third symptom group is hyperarousal, including sleep difficulties, irritability, poor concentration, and exaggerated startle response. After exposure to a qualifying traumatic event, PTSD may be diagnosed in individuals who develop one or more intrusion symptoms, three or more avoidance/numbing symptoms, and two or more hyperarousal symptoms in association with the event, with the symptoms continuing for more than a month and resulting in impairment of social or occupational life or clinically significant distress. 
Although the formal inclusion of the diagnosis of PTSD in official diagnostic criteria is relatively recent, possible examples of PTSD can be found throughout history. In the Old Testament, the book of Job tells of a man in mental agony after being tested by Satan, and many believe this story describes the characteristic signs and symptoms of PTSD.17 Also, in Jonathan Shay’s book Achilles in Vietnam, Combat Trauma and the Undoing of Character, the similarity between “the wrath of Achilles” in the Iliad and the experience of many Vietnam veterans with PTSD is described. Achilles’ grief after Hector kills his friend Patroclus and his reaction of finding, killing, and defiling Hector’s body are also postulated examples of post-traumatic emotional responses including PTSD.39 
The diagnosis of PTSD was established with the combat experiences of soldiers and war veterans, but there are also examples of noncombat-related PTSD in history as well. The author Charles Dickens had what many people think is PTSD after a train he was on derailed, killing 10 people and injuring many more. He tended to the dead and injured, later describing the scene as “unimaginable”; he recollected his “presence of mind … and steady hand” during the incident. Afterward, when writing about the incident, he explains “I am not quite right within, but believe it to be an effect of the railway shaking … I am getting right, though still low in pulse and very nervous.” Dickens developed a phobia of railway traveling, and wrote after the incident, “I am curiously weak—weak as if I were recovering from a long illness.” This affected his occupation and productivity, which is known to occur in patients with PTSD.43 
The stereotypical image of a person with PTSD is a war veteran struggling with nightmares and flashbacks after returning home, as portrayed by countless Hollywood motion pictures. Approximately 15% of Vietnam War veterans were found to meet diagnostic criteria for combat-related PTSD.19 A more recent study estimates PTSD rates in soldiers returning from the war in Iraq as between 12% and 20%.18 The burden of PTSD on military veterans is immense. 
Traumatic incidents experienced by orthopedic trauma patients represent life-changing events not only in time lost due to hospitalization, surgery, or rehabilitation, but also in the loss of ability to function and work. Orthopedic trauma patients commonly have injuries in multiple organ systems, including the brain, abdomen, and genitourinary tract, often leading to chronic pain, sexual dysfunction, disability, and psychological distress. There is a wide range of emotional reactions to traumatic events and pain, and people vary in their ability to cope with these events. Those who struggle to cope may have unrecognized symptoms of PTSD. 
PTSD is a diagnosis in evolution partly because it is a relatively new disorder and also because of the complexity of the components of the diagnosis. The definition of a traumatic event, how it is experienced, and related symptoms have all changed throughout the different editions and text revisions of the DSM since the first inclusion of the diagnosis. At the same time, orthopedic trauma care is evolving as well. Psychological distress, including PTSD, is being increasingly recognized in these patients, and efforts to improve the diagnosis, treatment, and even prevention of psychopathology in these patients are ongoing. 

Magnitude of the Problem

Orthopedic surgeons are not specifically trained to identify PTSD in their patients and are therefore unlikely to treat it. The focus of attention of orthopedic surgeons is on the physical injury and tissue damage, and recognizing psychiatric illness such as PTSD is often difficult. The focus on the visual (or palpable) is apparent even in the early descriptions of traumatized populations. During a historical period of rapid increases in mass transit and railroad injuries, there was a rise in cases of “railway spine disorder.” Later called Erichson disease, this syndrome was considered a neurologic injury, and it could persist long after other physical injuries had healed. Its manifestations varied, but had many similarities to those of current descriptions of PTSD.14 A disorder known as “shell shock” in military personnel was initially attributed to neurologic injury sustained during proximity to an explosive detonation. Myers28 wrote about shell shock in 1940, suggesting that it stemmed from a psychological insult rather than from physical or neurologic injury. 
Biologic explanations for this psychological condition have been proposed. Understanding the chemical processes and brain functions involved in the development of PTSD can help to elucidate treatment options and possibly even help prevent the disorder. Yehuda et al.47 suggested that PTSD represents an aberrant physiologic response to stress or trauma that is rooted in “disruptions in the normal cascade of the fear response and its resolution.” These researchers found lower cortisol levels and a higher heart rate both in the emergency room and 1 week later among patients who eventually developed PTSD.47 They proposed that aberrations in the hypothalamic–pituitary–adrenal (HPA) axis may play a pivotal role in the development of PTSD. Highly stressful events precipitate the release of cortisol and epinephrine, which act to heighten arousal and prepare for action in a “fight-or-flight response.” Alterations in HPA axis functioning are thought to be central in the pathology of PTSD, but research to date has not demonstrated a consistent model of disturbance in this system. 
From an anatomic standpoint, the parts of the brain involved in the fear conditioning response are postulated to be involved in the pathophysiology of PTSD. The amygdala and other paralimbic structures, including the prefrontal cortex and anterior cingulate cortex, have been shown to be involved in the emotional response and are also dysregulated in PTSD. Positron emission tomography (PET) scans, functional MRI, and single photon emission CT scans have been used to identify active or hypoactive areas of the brain in patients with PTSD, confirming that the amygdala is involved in emotional memory in the development of PTSD. Reduced MRI hippocampal volume has been demonstrated in patients with pretraumatic vulnerability to PTSD, though this finding is nonspecific and can be found in many diverse conditions.16 
Proinflammatory processes have also been suggested as having a role in PTSD development. A study comparing inflammatory markers in the serum of patients with PTSD and healthy individuals showed that IL-1β and TNF-α, both proinflammatory markers, were elevated in PTSD patients. In addition, levels of IL-4, an anti-inflammatory cytokine, were found to be lower in PTSD patients compared to healthy individuals.45 
Genetic predispositions have also been postulated in PTSD. For example, a family history study of 6,744 male twins from the Vietnam era found that the risk of exposure to traumatic events was associated with family history of mood disorder, pre-existing mood disorder, or a history of substance abuse. The study also showed that risk for PTSD after exposure to a traumatic event did not follow a family history of PTSD, but PTSD was instead related to a lack of education and a history of conduct disorder, generalized anxiety disorder, or major depression.20 Thus there is a complex interplay between other psychiatric disorders and PTSD, and the specific neurobiologic pathways and genetic contributors that lead specifically to PTSD have not been entirely elucidated. Genetic predisposition to PTSD has also been suggested in altered gene expression patterns in the HPA axis. For example, lower levels of the glucocorticoid signaling proteins, FKBP5 and STAT5B, and certain major histocompatibility complex type II proteins have been found in patients with PTSD compared to healthy controls suggesting heightened genetically expressed sensitivity of glucocorticoid receptors in PTSD.48 
PTSD symptoms and psychological distress have been found to be quite prevalent among orthopedic trauma patients, as illustrated in a brief review of the literature summarized in Table 13-1. Estimates of PTSD prevalence in trauma patients has been found to range from 15% to 42% at 6 months post trauma15,26 and from 21% to 51% at 1-year post trauma.41,49,51 These studies all used self-reported symptom measures which are known to overestimate PTSD prevalence; studies are needed with full diagnostic assessment methods to provide more definitive prevalence estimates. 
 
Table 13-1
Psychiatric Problems in Orthopedic/Trauma Patients
View Large
Table 13-1
Psychiatric Problems in Orthopedic/Trauma Patients
Study Patient Population Assessment Tool Prevalence Psychological Effect on Outcome
Adult Samples
Zatzick et al. (2002) 73 trauma patients PTSD checklist 30% had elevated PTSD symptoms at 1 yr Screening positive for PTSD was the strongest predictor of adverse SF-36 outcome measure
Michaels et al. (1999) 100 trauma patients Civilian Mississippi Scale for PTSD, BSI 42% had elevated PTSD symptoms at 6 mos Screening positive for PTSD was independently and inversely related to general health outcome as measured by SF-36
Feinstein and Dolan (1991) 48 patients with femur, tibia, or fibula fracture Impact of Event Scale, PTSD Checklist 14% screened positive for PTSD at 6 mos Not studied
Starr et al. (2004) 580 orthopedic trauma patients Revised Civilian Mississippi Scale for PTSD 51% (295/580) screened positive for PTSD at 1 y Not studied
METALS Doukas et al. (2013) 324 military service members with severe lower-extremity trauma PTSD Checklist—military version 18% had PTSD symptoms and 38% had depressive symptoms Not studied
NSCOT Zatzick et al. (2008) 2,707 trauma surgical inpatients across the United States PTSD Checklist 21% had screened positive for PTSD and 7% screened positive for depression at 12 mos Odds ratio for not returning to work was 3.2 in patients with positive PTSD screen and 5.6 in those with positive depression screen
Crichlow et al. (2006) 161 orthopedic trauma patients Beck Depression Inventory 45% screened positive for depression at 3–12 mos Positive depression screen was related to poorer functional outcomes
LEAP study McCarthy et al. (2003) 385 severe lower-extremity trauma patients BSI 20% had severe phobic anxiety and 42% had a positive screen for a likely psychological disorder at 24 mos Not studied
Daubs et al. (2010) 400 patients presenting to tertiary care spine center Distress and Risk Assessment Method 64% had psychological distress Not studied
Pediatric Samples
Wallace et al. (2012) 76 pediatric trauma patients or patients with isolated upper extremity fractures Child PTSD Symptom Scale 33% had high levels of PTSD symptoms Children who screened positive for PTSD had significantly more functional impairment than those without PTSD
Sanders et al. (2005) 400 pediatric orthopedic patients Child PTSD Symptom Scale 33% had high levels of PTSD symptoms Not studied
Onen et al. (2005) 49 pediatric patients with posterior urethral rupture due to pelvic trauma Diagnostic Psychiatric Interview 43% with psychiatric disorder at 12 yrs post injury on average. PTSD in 12% and major depression in 4% Not directly assessed
Subasi et al. (2004) 55 pediatric patients treated nonoperatively for unstable pelvic fractures Diagnostic Psychiatric Interview 56% with psychiatric disorder at 7.4 yrs post injury on average. PTSD in 11% and major depression in 7% of patients Not directly assessed
 

PTSD, post-traumatic stress disorder; METALS, Military Extremity Trauma Amputation/Limb Salvage; NSCOT, national study of the costs and outcomes of trauma; BSI, Brief Symptom Inventory; SF-36, Short Form Health survey.

X
In a study of major lower limb trauma among combat personnel returning from Afghanistan and Iraq, 18% screened positive for PTSD and 38% screened positive for depression.12 Patients who received amputations were 57% less likely to screen positive for PTSD and were almost three times more likely to be engaged in vigorous sports or recreational activity than patients who underwent limb salvage. The emphasis on inpatient rehabilitation in the military and a structured and readily available prosthetics program may help explain why the amputees fared better than those who underwent limb salvage. 
Pediatric trauma patients represent a separate category of trauma patients who have been studied separately from adult trauma patients because their PTSD prevalence and risk factors may differ from those in adults. About one-third of pediatric trauma patients screened positive for PTSD in two studies using symptom scales.35,46 Pediatric trauma patients did not differ in post-traumatic symptom levels from children with isolated nonoperative upper extremity fractures.46 Hospital admission for injuries has been found to represent an independent risk factor for post-traumatic symptoms in pediatric patients.35 
Mental health consequences of trauma can come in different forms, and several studies have documented evidence of high rates of depressive and other psychiatric disorders after trauma as well as PTSD. In one study, 45% of orthopedic trauma patients screened positive for depression on a symptom scale10 and another study of lower extremity orthopedic trauma using a symptom scale estimated that 42% of patients had a psychological disorder 24 months post injury.24 Two studies of pediatric patients with pelvic fractures estimated that 43% and 56%, respectively had a psychiatric disorder based on diagnostic psychiatric interviews.33,42 These studies have demonstrated that PTSD often coexists with major depression, substance abuse problems, sleep disturbances, and other psychiatric conditions in trauma patients. Multiple psychiatric disorders compound the overall morbidity, with more severe psychopathology and worse psychiatric and medical outcomes than in patients with only one psychiatric disorder. 
The studies to date of orthopedic trauma patients with PTSD have all investigated PTSD in early post-trauma time frames. Delayed-onset PTSD in orthopedic patients has not yet been studied. The duration of PTSD may vary, but it generally tends to follow a chronic course in most orthopedic trauma studies. The time course of PTSD has been studied in populations exposed to disasters.31 A study of survivors of the Oklahoma City bombing found that PTSD symptoms developed on the day of the bombing in 76%, within the first week in 94%, and within the first post-bombing month in 98% of directly exposed survivors.30 Research studies of combat-related PTSD and adult survivors of sexual abuse have found that these populations may be more likely to have delayed-onset PTSD (defined by DSM-IV as PTSD with symptoms beginning more than 6 months after the inciting event), but the definitions of delayed-onset and other methodologic aspects of these studies have varied and may not be directly comparable to the findings from disaster studies. 
The research reviewed above has demonstrated that the prevalence of PTSD, major depression, and other psychiatric illness after orthopedic trauma is substantial. The occurrence of these disorders has often not been well appreciated in orthopedic practice, and consequently the orthopedist’s ability to detect psychiatric illness in patients has historically been lacking.11 The exact pathophysiologic underpinnings of psychiatric disorders in orthopedic trauma patients are not yet fully understood, but now there is a concerted effort to understand, identify, and treat these disorders as they apply to the care of orthopedic trauma patients. 

Impact of the Problem

PTSD is not only surprisingly prevalent in orthopedic trauma patients, but it is also associated with functional disability and significant medical and mental health care utilization that has not been well recognized in the orthopedic treatment literature. Common orthopedic outcome measures include ability to return to work and perform activities of daily living (ADL) and pain scores. These orthopedic outcome measures do not directly measure psychological distress, but these outcome measures are adversely affected in patients with PTSD. Not only is the prevalence of PTSD in orthopedic trauma patients higher than previously recognized, but also the impact of this disorder on functional outcomes is substantial. Psychiatric illness such as major depression and PTSD have been found to correlate strongly with health-related quality of life in trauma patients,2 even more than injury severity, presence of chronic medical conditions, age, or history of alcohol abuse.49 
PTSD in orthopedic trauma patients has been demonstrated to be one of the most predictive variables of functional outcome following orthopedic injury.51 In the National Study on the Costs and Outcomes of Trauma (NSCOT) by Zatzick et al.,51 PTSD was prospectively found to be associated with a 3.2 times higher odds of not returning to work. PTSD was also associated with functional impairment 12 months post trauma in ability to eat, bathe, toilet, grocery shop, prepare meals, and pay bills. Functional impairments in ADLs and instrumental ADLs, high musculoskeletal pain scores, and general health dysfunction are also found in patients with PTSD.34,51 A meta-analysis by Pacella et al.34 found that PTSD symptoms were associated with general health symptoms, cardiorespiratory symptoms, pain frequency and severity, and gastrointestinal upset. A study of VA health care utilization of patients with and without PTSD found a significantly higher general medical and mental health service utilization in patients with PTSD.9 
PTSD and pain problems often co-occur, as demonstrated by a study of musculoskeletal pain complaints in association with PTSD in military veterans25 and a prospective study of trauma patients predicting PTSD at 4 to 8 months from pain symptoms at 24 to 48 hours.29 Other studies have yielded conflicting results related to the association of PTSD and pain.27 Cognitive behavioral therapy has been shown to improve PTSD severity, neck disability, and physical, emotional, and social functioning in patients with chronic whiplash and PTSD even in the absence of documented changes in pain sensitivity or intensity.13 Treatment of PTSD has not been demonstrated to improve pain in orthopedic patients. 
Ultimately, patient-derived outcome measures rely on more than just objective physical examination findings. A patient’s emotional state is important in the interpretation of his or her own outcome. For example, a patient involved in a motor vehicle collision who has nightmares about the accident and a phobia of traveling may not perceive his or her outcome as good, even if the fractures unite in an anatomic position with functional soft tissue healing. The orthopedic surgeon is often the only physician managing these patients after their injury, representing the sole opportunity to recognize the psychiatric sequelae of trauma exposure that are highly pertinent to the patient’s functional outcome. 

Addressing the Problem

Interventions for trauma-related syndromes including PTSD have varied through history. They have ranged from outright neglect to herbal medications and from the placement of clinical psychiatrists at the front lines of battle to berating those affected. General Patton, visiting a military hospital in Sicily, asked a patient about his injuries, and after hearing, “It’s my nerves,” he slapped him across the face and called him a coward. This response clearly reflected a lack of understanding of emotional difficulties following trauma exposure at the time. Similarly, during the Vietnam War, if a soldier had “stress response syndrome” lasting longer than 6 months, it was deemed pre-existing and therefore the diagnosis was not service-connected.38 This mindset persisted until a better understanding of PTSD and more successful ways of treating it were available. 
Addressing PTSD can be accomplished through efforts directed toward prevention and treatment. A long-standing approach to prevention of post-traumatic psychological problems among trauma survivors is the practice of psychological debriefing. Psychological debriefing has not been shown to be effective for the prevention or treatment of PTSD and has the potential to harm those with PTSD.7 In a randomized controlled trial examining road traffic accident victims, psychological debriefing was shown to be ineffective in reducing PTSD symptoms, and at a 3-year follow-up, intrusive and avoidance symptoms were found to be worse in those who underwent psychological debriefing.22 
Identifying patients at risk for PTSD can aid the development of early prevention strategies. Risk factors for PTSD in traumatized populations include trauma severity and intensity of exposure, female gender, low socioeconomic status, lack of social support, and pre-existing psychopathology including polysubstance abuse.6,32,37 Higher Injury Severity Scores (ISS) in orthopedic trauma patients have not reliably been found to correlate with the eventual development of PTSD, but rather patients with early post injury emotional distress and greater physical pain have been found to be susceptible to PTSD symptoms.50 
Identifying patients at risk for PTSD and diagnosis of the disorder are important aspects of the management of orthopedic patients with PTSD. This process can begin with the application of symptom-screening questionnaires. In a study of patients undergoing spine surgery, use of a questionnaire identified more patients with psychological distress than when ordinary clinical observation alone was employed.11 A clinical tool for identification of psychiatric problems in orthopedic trauma patients is how much patients agree with the statement, “The emotional problems caused by the injury have been more difficult than the physical problems.” A study by Starr et al.41 found a 78% probability that patients with potential PTSD had high scores on a 5-point Likert scale to this question. Although screening tools are helpful for identifying PTSD risk, the diagnosis of PTSD requires careful determination of the presence of the criteria for PTSD according to current diagnostic criteria by a qualified mental health professional. 
Although the literature on the treatment of orthopedic trauma patients with PTSD is scant, the more general psychiatric literature contains many treatment options for PTSD. Selective serotonin reuptake inhibitors (SSRI) medications such as paroxetine and sertraline, which are FDA approved for the indication of PTSD, have been shown to reduce PTSD symptoms in patients suffering from PTSD.5,23 Psychotherapy with cognitive behavioral therapy, exposure therapy, and supportive therapy has been shown to significantly reduce PTSD symptom levels.3,4,8 Exposure therapy is a method of desensitizing patients to aspects of the traumatic event in a controlled fashion. Cognitive behavioral therapy helps patients to develop more adaptive responses to fear and thoughts of previous traumatic events. These treatment strategies are administered over time by a mental health professional. Therefore, appropriate referral to a mental health professional is an important intervention in the care of patients with PTSD. 
Other medications used to augment the treatment of certain PTSD symptoms include prazosin to treat post-traumatic nightmares,21 α-2 agonists, α-1 antagonists, anticonvulsants, and lithium in the augmentation of the treatment of PTSD. There have also been studies investigating pharmacologic prevention of PTSD in the immediate postinjury period to prevent or dampen the physiologic cascade of events leading to PTSD, using medications such as β-blockers, SSRIs, benzodiazepines, and corticosteroids to provide “inoculation” or “molecular debriefing” with varying degrees of success.36,40,44 
Psychiatric problems among orthopedic trauma patients are well established in this population. Psychiatric illness in these patients is associated with adverse medical outcomes, yet few orthopedic surgeons have the training or inclination to try to identify and address psychiatric illness in their patients. Attention to the signs, symptoms, and risk factors of PTSD as delineated in this chapter can help physicians to recognize patients at risk for PTSD and other psychiatric disorders among their orthopedic patients, and can affect all aspects of patient care. 

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