Clarifying the presence of posttraumatic stress symptoms following orthopaedic trauma [1] (multiple letters)

Letters to The Editor Clarifying the Presence of Posttraumatic Stress Symptoms Following Orthopaedic Trauma To The Editor: Posttraumatic stress disorder is a serious psychological condition that has received increasing attention over the past decade. Starr et al. should be commended for their attempt, in their article “Symptoms of Post- traumatic Stress Disorder After Orthopaedic Trauma” (2004;86:1115-21), to alert ortho- paedic surgeons to the fact that psychologi- cal consequences of a severe orthopaedic injury are possible and important. None- theless, the percentage of respondents who “met the criteria” for posttraumatic stress disorder (as measured with the Revised Civilian Mississippi Scale for Posttraumatic Stress Disorder) was startlingly high. Be- cause the presence of a serious psychiatric disorder in more than one-half of a trauma- tized sample is exceedingly rare, it led me to examine the methods and analytic strategy used in this report. There are a number of issues that deserve mention. 1. Posttraumatic stress disorder can- not be diagnosed until at least one month after the traumatic episode. The authors noted that some respondents had been in- jured as few as two days prior to assessment. Individuals seen less than four weeks after the trauma should have been excluded from the sample. 2. For a diagnosis of posttraumatic stress disorder to be made, the person’s re- sponse to the event must involve intense fear, helplessness, or horror (Criterion A2 of the DSM [Diagnostic and Statistical Man- ual of Mental Disorders]-IV). These re- sponses do not appear to have been assessed. 3. According to the DSM-IV, symp- toms must be present for one month (Crite- rion E). The duration of symptoms does not appear to have been measured in the present investigation. 4. Criterion F—that the disturbance must cause clinically important distress or impairment in social, occupational, or other important areas of functioning—is consid- ered by many to be the hallmark of the dis- order. Again, it does not appear to have been assessed. Thus, it is clear that, while the in- vestigators measured symptoms that were consistent with criteria B, C, and D of the DSM-IV, the absence of a full assessment of posttraumatic stress disorder required the investigators to be extremely circumspect about their terminology. In fact, because all DSM-IV criteria were not assessed (e.g., de- gree of functional impairment and duration of symptoms), respondents should not have been assumed to have posttraumatic stress disorder. Moreover, an important historical event occurred very close to the assessment of posttraumatic stress disorder among the respondents in this study. The September 11, 2001, terrorist attacks had a substantial impact on the psychological state of individ- uals across the country—not simply those who lived in a directly affected community 1 . Moreover, these attacks had a clear, demon- strable impact over the six months after the attacks, with substantial numbers of indi- viduals from a nationally representative sample showing posttraumatic stress symp- toms and elevated levels of distress 1 . The fact that the assessment of posttraumatic stress disorder was conducted within weeks after the attacks at one of the study sites and within months after the attacks at the sec- ond site may have inflated the results. In fact, many of the items on the Revised Civil- ian Mississippi Scale for Posttraumatic Stress Disorder assess trauma symptoms that are not specific to the orthopaedic trauma or injury (e.g., items 1, 4, 10, 11, 12, Finally, a more traditional way to an- alyze these data in order to examine demo- graphic and injury-related predictors of the presence or absence of posttraumatic stress symptoms would have been to use logistic regression. The nontraditional analytic strategy employed in this study may have masked factors that, in combination, could have assisted the orthopaedic surgeon in identifying at-risk individuals who might benefit from psychological referral. —Roxane Cohen Silver, PhD Department of Psychology and Social Behavior and Department of Medicine University of California, Irvine 3340 Social Ecology II Irvine, CA 92697-7085 rsilver@uci.edu In support of the research or preparation of this work, the author received grants or outside funding from the National Science Foundation. She did not receive payments or other benefits or a commitment or agreement to provide such ben- efits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any re- search fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated. A.J. Starr, W.H. Frawley, and C.M. Reinert reply: Dr. Silver raises several good points. First, she points out that, according to the DSM- IV, posttraumatic stress disorder cannot be diagnosed until at least one month after the trauma, and she suggests that patients who were evaluated less than four weeks after the trauma should have been excluded from our sample. We considered excluding such pa- tients but decided against it. In our sample, patients who were seen at a longer interval after the injury had more symptoms of post- traumatic stress disorder. Exclusion of pa- tients seen less than four weeks after the trauma would have made the apparent prev- alence of the illness even higher. If we ex- cluded those assessed less than thirty days after the injury, the rate of posttraumatic stress disorder would have jumped to 55%. If a 50% rate of the illness seems startlingly high, 55% would be even worse. Since our goal was to measure the prevalence of illness among orthopaedic trauma outpatients, we decided to include those assessed soon after injury. Patients who return to their orthopaedic surgeon’s office two weeks after injury with symp- toms of posttraumatic stress disorder may not meet rigid criteria for the illness, but the L ETTERS TO THE E DITOR MUST BE SUBMITTED ELECTRONICALLY ; I NSTRUCTIONS ARE AT WWW . JBJS . ORG / LETTERS