Unconsciousness, Amnesia and Psychiatric Symptoms Following Rta Injury

BRITISH JOURNAL OF PSYCHIATRY 2000), 177, 177, 540^545 540^545

Unconsciousness, amnesia and psychiatric the accident they were also sent postal follow-up questionnaires, which included symptoms following road traffic accident injury the Post-Traumatic Stress Symptom PSS) scale FoascaleFoa et aletal, 1993), the Hospital Anxiety and Depression HAD) scale Zigmond & RICHARD A. MAYOU, JOHN BLACK and BRIDGET BRYANT Snaith, 1983) and questions about phobic travel anxiety derived from previous research Mayou et aletal, 1993).,1993).

Measures Unconsciousness This was rated by an emergency medicine Background Although road traffic This paper presents findings from a prospec- physician J.B.), who examined all available tive study of consecutive attenders at an emer- accidentinjuryis the mostcommon cause information from the medical records for gency department following a road traffic of traumatic brain injury, little is known of all patients for whom there was any indica- accident Ehlers et al, 1998), who were re- tion that they might have been unconscious, the prevalence of psychiatric complications cruited for a self-report study of psychological reported impaired memory of the accident, or the significance of unconsciousness and consequences. It considers two main issues: or had been recorded as suffering an injury amnesia.amnesia. a)a)thethe prevalence of head injury and features to the head above the hairline) or face. Three categories were devised: Aims Todescribe amnesia and of possible traumatic brain injury such as unconsciousness and amnesia; unconsciousness following a road traffic a)a)definitelydefinitely unconscious: a witnessed accident and to determine whether they b)b)thethe prevalences of immediate psycho- statement of unconsciousness; logical distress and of psychological are associated withlaterwith later psychological b)b)probablyprobably unconscious; not witnessed; complications at 3 months and 1 year ± the nature of the injury and other symptoms. post-traumatic stress disorder PTSD), reports strongly suggested that the travel anxiety, anxiety and depression, patient was unconscious ± a high MethodMethod Information was obtained post-concussional symptoms ± in those degree of probability; from medical and ambulance records for who were briefly unconscious minor 1441consecutive attenders at an head injury) as compared with those c)c)notnot unconscious: no evidence for who did not lose consciousness. emergency department aged17^69aged 17^69 who unconsciousness, and in many cases specific comments that the patient had had beenbeeninvolvedin involvedin a road traffic not been unconscious. accident. Atotal of1148 $80%) subjects METHOD completed a self-report questionnaire at The sample was based on 1534 consecutive Head injury baseline andandwere were followedfollowedup up at 3 months patients aged 17±69 who attended the Having excluded major head injury, we and1year.and1year. emergency department of the John Radcliffe classified all cases with head injury and un- Hospital, Oxford, after a road traffic acci- consciousness of less than 15 minutes as ResultsResults Altogether,1.5% suffered dent. We excluded those who were minor. The emergency physician also noted major head $and traumatic brain) injury unconscious for more than 15 minutes. whether patients had suffered a soft tissue and 21% suffered minor headheadinjury.Post- injury.Post- or fracture head injury. Injuries to the head traumatic stress disorder $PTSD) and Data collection above the hairline were distinguished from those to the face. Evidence of brain injury Information about the accident and injuries anxiety and depression were more from abnormal computed tomography was collated on standard data sheets from common at 3 months in those who had CT) scans was noted. ambulance, triage and emergency depart- definitely been unconscious than in those ment records, and any in-patient notes, by who had not, butthere were no Self-report rating of loss of consciousness a research worker who had previously been and memory of the accident differences at1year.at 1year. a senior trauma nurse in the department. Where possible, subjects were approached On the questionnaire, subjects were asked to Conclusions PTSD and other by a nurse and invited to take part; the say whether they thought they had been un- psychiatric complications are as common remainder were sent information and conscious or not, or were not sure. Similarly, they were asked to rate their memory of the inthosewhowerebrieflyunconscious asin questionnaires by post. Patients completed a questionnaire accident as `clear', `patchy' or `no memory'. those who were not. which included questions on their initial Psychological outcome measures Declaration of interest The emotional reactions to and memory of the accident, whether they thought they had research was supported by a grantgrantfrom from a)a)PTSD:PTSD: this was the minimum number of been unconscious, or to blame for the acci- symptoms on the PSS scale required by the WellcomeTrust. dent, previous travel, and emotional and DSM±IV American Psychiatric Associ- social adjustment. At 3 and 6 months after ation, 1994) criteria.

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b)b)AnxietyAnxiety or depression case: the recom- Neither minor head injury nor loss of con- Unconsciousness was not associated mended cut-off score of 10 or more on sciousness was associated with response. with subsequent involvement in compen- the HAD sub-scales of anxiety and sation proceedings. Claims were pursued depression.depression. by 36% of those definitely unconscious, c)c)PhobicPhobic travel anxiety: a measure Head injury 52% of those probably unconscious and combining increased nervousness and Of the 1148 respondents, 261 23%) were 45% of those not unconscious. avoidance of travel situations, with rated as having a minor head injury and 25 cut-off points consistent with the 2%) had had fractures. Twelve were investi- Amnesia DSM±IV criteria for phobia. gated by computed tomography CT) scan, Many of those for whom there was definite d)d)Post-concussionalPost-concussional syndrome symptoms: of whom four were reported as abnormal. self-ratings of the frequency of loss of medical evidence of unconsciousness concentration or irritability in the reported that they had no memories of the previous two weeks, from 0, `not at Evidence of minor traumatic brain accident 44%), but two 7%) reported that all', to 3, `very often 5+ times a week)'. injury they could remember the accident clearly and 13 48%) described patchy memories Loss of consciousness Table 2). Most reported continuing amne- Statistical analysis There were 124 respondents 11%) who re- sia for parts of the accident at 3 months and The relationship between unconsciousness ported they had been unconscious and 144 1 year Table 4). Emergency department and categorical variables was tested using 13%) who were not sure ± a total of 268. medical records rarely recorded the dura- thethe ww22 test. Analysis of variance was used Review of the records suggested that only tion of post-traumatic amnesia, but review for the continuous variable `age'. Most of two of the 874 patients who indicated on of medical notes and subjects' comments the scores on the variables measuring the self-report questionnaire that they had suggest that amnesia was usually brief and emotional reaction to the accident were not been unconscious had, in fact, been that many subjects had memories for events rather skewed, so the Kruskal±Wallis one- observed by others to be unconscious. Of shortly before and after the road accident. way analysis of variance was used. those who said they had been unconscious, Amnesia was also less frequent in those only 19 15%) had been definitely, and 29 who had not suffered any head injury. RESULTSRESULTS 23%) probably, unconscious as indicated by recorded evidence from bystanders and rescuers. In most of the remainder, rescue Amnesia without traumatic loss Figure 1 shows how many of the consecu- of consciousness tive series were excluded for various reasons, and emergency department notes clearly and how many participated at various cited evidence that subjects had not lost It was common for patients who had not suf- stages. Seven people died in the emergency consciousness although there were some fered any head injury to report that their department. Another 23 1.5%) were ex- comments about `confusion' Table 2). memories of the accident were `patchy'. cluded because they were unconscious for Subjects classified as having been uncon- There were 28 subjects 2% of the eligible longer than 15 minutes; all these subjects scious reported the accident as less frighten- sample) who had no memory of the were admitted, suffered prolonged un- ing, felt less angry and were less likely to accident but who were thought not to have consciousness all more than five days) accept blame for the accident Table 3). suffered any unconsciousness; only two- and satisfied clinical criteria for `major These subjects were also more likely to report thirds were drivers. Five of these had traumatic brain injury'. themselves as numb and dazed in the first suffered head injury above the hairline; of A total of 1441 patients were eligible for questionnaire immediately after the accident. these it is possible that at least two subjects the study and were given the questionnaire; their characteristics are summarised in 15341534 Table 1. There were 309 22%) who were Died in emergency department 77 33 diagnosed as having had minor head injury Excluded by design criteria: 33 which we defined as unconsciousness ofof Unconscious for 15 minutes+ 23

less than 15 minutes), of whom 34% were Excluded for other reasons: 33 admitted and 25% were rated as having Overseas visitors32 been definitely or probably unconscious. Language or psychiatric reasons 8 The great majority of these injuries were Too ill to complete questionnaire 11 abrasions or lacerations, but five people Did not want to take part 12 !! had skull fractures and 21 had facial fractures one had both). Eligible for study and received first questionnaire 1441 The remainder of this paper concentrates !! on data on the 1148 80%) of those eligible Completed first questionnaire 1148 patients who completed the initial assess- !! ment, of whom 865 75%) replied at 3 Completed 3-month questionnaire 865 months and 773 67%) at 1 year. Those !! who responded were significantly more likely Completed 1-year questionnaire 773773 to be women, to be older, to have suffered fracture and been admitted to hospital. Fig. 11Fig. Consecutive road traffic accident attenders at accident and emergency department aged17^69.

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TaTable b l e 1 Demographic and hospital factors by loss of consciousness :eligible samplenn1441)14 41)11 or probably unconscious, but other symptoms usually said to be part of the post-

Definitely unconsciousProbably unconsciousNot unconscious ww22 PP concussional syndrome and also of anxiety disorder, PTSD and depression) ± for ex- nn :%) nn %% nn %% ample, irritability, anxiety, lack of energy and depression ± were not associated with Gender 550.01 unconsciousness. Table 4 includes the prev--prev Male 19 :58):58) 4545 :80):80)749 :55) alence at 3 months and 1 year of two symp- FemaleFemale 14:42) 1111 :20):20) 603603:45) toms often associated with concussional Age, mean :s.d.) 27.6 :8.6):8.6)33.7 :12.9) 32.1 12.8 550.1 syndrome.syndrome. Social class NS Non-manual 14:61) 2828 :65):65) 609609 :60):60) Post-traumatic stress disorder ManualManual 9:39)9 :39) 1515 :35):35)415 :40) Table 5 shows the main psychiatric syn- Accident group NS dromes at 3 months and 1 year in those Driver 15:46) 32 :57) 704 :52) who were definitely and probably uncon- Passenger 6:18)6 :18)10 :18) 291291 :22):22) scious and those who were not unconscious. Motorcyclist 6:18)6 :18)5:9) 5 :9)160 :12) PTSD was significantly more common at 3 CyclistCyclist 2:6)2 :6)6:11) 6 :11)138 :10) months among those who had been defi- Pedestrian 4:12)4 :12)3:5) 3 :5)59 :4) nitely unconscious than in the remainder. Admitted 550.01 Specific symptoms in each category of Yes 26 :79):79) 3737 :66):66) 251251:19) PTSD criteria were checked in those who No 7:21)7 :21) 1919 :34):34)110 1101 1:81) had been unconscious as wellas the symp- Injury 550.001 toms of being unable to remember the accident. However, there was no significant BonyBony 12 :36):36) 1616 :29):29)219 :16) difference at 1 year. Examination of com-ofcom- Soft tissue 19 :58):58) 3636 :64):64) 844844 :63):63) ments on questionnaires, the information NoneNone 2:6)2 :6)4:7) 4 :7) 288288 :21):21) from an interview subgroup and medical re- Head injury 550.001 cords all suggest that the intrusive mem- Head only :above hairline)13 :39):39)24 :43) 96 :7) ories of the unconscious patients usually Face onlyonlyFace 8:24)8 :24) 1818 :32):32) 105105 :8):8) related to events just before or shortly after Head and face 4:12)4 :12)9:16) 9 :16)32 :2):2) the accident, including being rescued, Neither 8:24)8 :24)5:9) 5 :9)1118 :82) receiving emergency treatment and then Not knownknownNot 1 being rushed to hospital. Eleven of the 21 DrunkDrunk 550.001 subjects who were amnesic without being Definite/probable 5:15)5 :15)6:11) 6 :11)47 :4) unconscious and who replied at follow-up No/not known 2828 :85):85) 5050 :89):89)1301 :97) suffered PTSD during the year. When we compared those with minor Seat belt/helmet22 550.001 head injury i.e. unconsciousness of less Yes16 :62):62) 3737:86) 972 :90):90) than 15 minutes) with those who had no No10 :39):39)6:14) 6 :14)107 :10) head injury, there were no differences in Not knownknownNot 141 47722 psychological consequences. 1. Hospital notes were missingfor one person. We examined case notes for the 23 sub- 2. Vehicle occupants/motorcyclists :nn12 29 ). jects with major brain injury i.e. prolonged unconsciousness) excluded from the self- had been briefly unconscious, and three were alcohol+`confusion', 1; prosecution+`confu- report study, of whom 14 had been assessed described in notes as having been `confused'. sion', 2.2.sion', by the specialist neurological rehabilitation Six more suffered facial injuries, one of Twenty-one of the 28 subjects who, service and two by the psychiatric consulta- whom may have been unconscious and two without loss of consciousness, had no mem- tion service. Both these services routinely of whom were `confused'. In 17 there were ory of the accident at baseline replied at 3 assess for symptoms of PTSD and travel anxi- clear written ambulance or emergency months; three said they could now clearly ety.ety.There were three clearly described cases department records of their not being un- remember the accident. At one year four of subsequent travel anxiety but no evidence conscious at any time. In these cases, exam- out of the 19 who replied had full memories. that any subject had suffered PTSD. The num- ination of records suggested that other bers were too small for statistical analysis. reasons ± medical, psychological dissocia- Psychological complications tion, alcohol intoxication and concerns at 3 and 12months about prosecution ± could have been im- Other psychiatric complications portant causes: medical diabetes, epilepsy), Post-concussional syndrome symptoms Those who had been unconscious were also 2; fell asleep, 1; alcohol intoxication, 3; Poor concentration was more commonly significantly more likely to score as psychi- alcohol intoxication+later conviction, 8; reported by those who had been definitely atric cases of anxiety and depression on the

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Ta b l e 22Tab Patients'reports of unconsciousness and clarity of memories by emergency medicine specialist's Major or minor head injury occurred in ratingof loss of consciousness :participants at baseline nn114 8 ) 23% of all attenders between the ages of 17 and 69 over the 1-year period, of whom 39% were admitted. Emergency physician's ratingDefinitely unconsciousProbably unconsciousNot unconscious Major traumatic brain injury with pro- nn :%) nn :%):%) nn :%) longed unconsciousness in all cases five days or more) and post-traumatic amnesia Patient thought he/she had been occurred in 1.6%. unconsciousunconscious Minor traumatic brain injury, as de- Yes 19:70) 2929 :64):64)76 :7) fined by loss of consciousness of less than Not sure 6 :22):22) 1313 :29):29)125 :12) 15 minutes, was medically rated as defi- No 2:7)2 :7)3:7) 3 :7)869 :81) nitely occurring in 2% of subjects and probably in a further 4%. Within this group Not knownknownNot 6 unconsciousness and amnesia were usually Patient's memory of the accident very brief ± seconds rather than minutes. Clear 2:7)2 :7)5:11) 5 :11)791 :74) PatchyPatchy 13:48) 2424:53) 249 :23) NoneNone 12:44) 16 :36) 2828 :3):3) Minor traumatic brain injury Not knownknownNot 8 In accordance with clinical experience, the definition of minor traumatic brain injury HAD scale at 3 months, although there impairment of consciousness and post- with evidence of impairment of conscious- were no differences at 1 year Table 5). traumatic amnesia) and that definitions areare ness and post-traumatic amnesia was not difficult to apply in emergency clinical care. easy. Patients were frequently uncertain The principal limitations are: about whether they had lost consciousness, DISCUSSION a)a)TheThe lack of reliable evidence about and they substantially overestimated this as post-traumatic amnesia the most compared with evidence in emergency service This prospective study is the first of its kind useful clinical indication of traumatic records. It is clearly very difficult for subjects for road accident victims. It also provides a brain injury), which was not routinely to distinguish brief unconsciousness, acute different kind of evidence from other pub- recorded in the case notes. However, concussion and peritraumatic psychological lished traumatic brain injury series in that emergency department evidence was dissociation. However, although most clini- it enables a comparison to be made in a reviewed at the time of the accident cal records did refer specifically to lack of large representative sample between those by a senior and experienced research evidence of impaired consciousness, they who were and were not briefly unconscious. nurse and subsequently by a specialist inevitably underestimate transient impair- Most cases in which there is evidence of in emergency medicine. ment of consciousness which may not be brain injury are medically minor, but funda- b)b)TheThe reliance on self-report data. witnessed or clearly described by the subject. mental difficulties are that there is no Brief amnesia is difficult to assess and agreed definition of minor head injury or may not always be due to brain injury. Mem- of minor traumatic brain injury McMillan, Frequency of head injury ories were frequently reported as `patchy' by 1997; Kushner, 1998) a term which refers and unconsciousness those in whom there was no question of head to trauma to the head with no major brain By combining figures for different numbers injury, a probable reflection of psychological damage but associated with symptoms of subjects for the various categories of avail- dissociation which is a frequent accompani- or signs of brain injury as indicated by able data we can summarise prevalences. ment of road accidents and other trauma

TaTable b l e 3 Post-accident reactions of participants by loss of consciousness

Post-accident reactionDefinitely unconsciousProbably unconscious Not unconscious PP11

MeanMeans.d. CI Mean s.d. CI Mean s.d. CI

Memory of accident :1^3)2.37 0.63 2.1^2.62.1^2.6 2.242.240.65 2.1^2.4 1.29 0.5 1.26^1.32 550.001 Unconscious :pt) :1^3)1.37 0.63 1.1^1.6 1.42 0.62 1.2^1.61.2^1.6 2.742.74 0.580.58 2.71^2.782.71^2.78 550.001 Frightening :1^4)2.30 1.35 1.8^2.8 2.112.111.21 1.8^2.5 2.902.90 1.041.04 2.8^3.02.8^3.0 550.001 Not to blame :1^3)2.31 0.790.79 2.0^2.62.0^2.6 2.462.46 0.810.81 2.2^2.72.2^2.7 2.592.59 0.700.702.5^2.6 550.05 Angry :0^4) 0.851.38 0.3^1.4 0.830.831.05 1.2^1.41.2^1.41.29 1.43 1.2^1.41.2^1.4 550.05 Guilty :0^4) 0.731.31 0.2^1.3 0.660.661.09 0.3^1.0 0.430.430.94 0.4^0.5 NS Numb :0^4) 1.621.47 1.0^2.21.0^2.2 1.201.201.08 0.8^1.5 0.860.86 1.111.11 0.8^0.90.8^0.9 550.010.01 Dazed :0^4) 1.38 1.201.200.9^1.9 0.95 1.05 0.6^1.3 0.63 0.93 0.6^0.70.6^0.7 550.001 Anxious :0^4) 1.081.02 0.7^1.50.7^1.51.39 1.36 1.0^1.81.0^1.81.32 1.291.291.2^1.4 NS

1. Testof significance Kruskal^Wallis one-way analysis of variance.

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TaTable b l e 4 Frequency of psychological symptoms at 3 months andand1year 1 year by loss of consciousness

Symptom :0^3)Definitely unconsciousProbably unconsciousNot unconscious PP11

Means.d. CI Mean s.d. CI Mean s.d. CI

3 months3months Cannot remember bits2.48 0.87 2.1^2.9 1.69 1.15 1.3^2.1 0.500.500.91 0.4^0.6 550.0010.001 Irritability 0.901.09 0.4^1.4 0.38 0.55 0.2^0.6 0.54 0.870.870.5^0.6 NS Loss of concentration1.33 1.35 0.7^2.0 0.56 0.80 0.3^0.90.3^0.9 0.480.480.80 0.4^0.5 550.01 1year1year Cannot remember bits1.48 1.29 0.9^2.1 1.38 1.211.210.9^1.8 0.360.36 0.790.79 0.3^0.40.3^0.4 550.0010.001 Irritability 0.671.02 0.2^1.1 0.41 0.80 0.1^0.70.1^0.7 0.440.440.79 0.4^0.5 NS Loss of concentration1.10 1.22 0.5^1.70.5^1.7 0.560.560.91 0.2^0.9 0.42 0.77 0.4^0.5 550.01

1. Testof significance Kruskal^Wallis one-way analysis of variance.

Murray, 1997). There were no differences in may be islands of preserved memory Par- have found to predict later PTSD and other psychological outcomes between those who ker, 1996), or it may be that there are psychological consequences: the severity of had injury above the hairline and those with `implicit' memories which result in ``inten- injury and in several aspects of their initial facial injury. sive psychological distress on exposure to response, including the degree to which Despite the difficulties, we have defined internal or external cues that symbolise or the accident was seen as frightening, blame, a subgroup who suffered minor traumatic resemble an aspect of a traumatic event'' anger and feeling guilty. brain injury. Any failure to identify a small DSM±IV) Bryant et aletal, 2000). The higher It is also important to note the small number of other patients who were uncon- prevalence of PTSD in our `definitely un- subgroup of patients who had not suffered scious is unlikely to have significantly conscious' group suggests that `concussion' unconsciousness but had no memories of affected our findings about the prevalence may hinder information processing. the accident and who later suffered higher of later psychological complications. We should consider two further issues prevalences of PTSD than other subjects. in relation to the present series. We should A major factor appeared to be alcohol, note that those who were definitely or which may impair memory and perhaps Psychiatric complications probably unconscious differed from the information processing. It also seemed Discussion of the psychiatric complications remainder in terms of variables which we probable that denial conscious or needs to consider the considerable overlap in the symptom criteria for the disorders Ta b l e 5 Psychological outcomes by loss of consciousness considered in this paper. Thus, many of the symptoms associated with the syndrome Definitely unconsciousProbably unconsciousNot unconscious ww22 PP of chronic concussion are also symptomatic of other psychiatric disorders, including nn :%) nn :%) nn :%) PTSD, anxiety and depression. It should be noted that being unable to remember parts PTSD at 3 months 550.050.05 of the accident was one of the 17 symptoms No 11:52) 30 :77):77)617 :81) of PTSD. There were no differences in prev- Yes 10 :48):48)9:23) 9 :23)179 :23) alence at 1 year in thosesymptoms often PTSD at 1 year NS associated with concussion included in the No 14:67) 3232 :86):86)594 :83) HAD scale and the PSS scale, with the Yes 7:33)7 :33)5:14) 5 :14)116 :17) exception of difficulty in concentrating. Travel anxiety at 3 months NS There were no documented cases of No 15:71) 33 :85):85)621 :78) PTSD and only two cases of travel anxiety among the 23 subjects with major head Yes 6:29)6 :29)6:15) 6 :15) 173173 :22):22) injury who suffered prolonged uncon- Travel anxiety at 1 year NS sciousness and were therefore excluded No 15 :68):68) 3232 :86):86) 596596 :84):84) from our postal study). However, we found Yes 7:32)7 :32)5:14) 5 :14)115 :16) clear evidence that PTSD is at least as com- HAD case at 3 months 550.050.05 mon in those who suffer brief unconscious- No 13 :62):62) 3535 :90):90)638 :81) ness as in those who were not unconscious. Yes 8:38)8 :38)4:10) 4 :10)146 :19) Several explanations have been sug- HAD case at 1 year NS gested in relation to subjects with clear evi- No 16:76) 26 :70):70) 567567 :80):80) dence of post-traumatic amnesia. The Yes 5:24)5 :24) 1111 :30):30) 139139 :20):20) intrusive memories may relate to events before or after the period of amnesia, there PTSD, post-traumatic stress disorder; HAD, Hospital Anxiety and Depression scale.

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unconscious) was common among those at risk of legal proceedings. This was most CLINICAL IMPLICATIONS obvious in the case of complete amnesia reported by a driver who had been respon- && Patient report of brief unconsciousness is unreliable. sible for the death of a child and for whom there was extensive neurological and psy- && Clinicalrecordingof post-traumatic amnesia shouldbe routine in all attenders with chiatric documentation of clear conscious- possible head injury. ness throughout. && Brief unconsciousness is associated with increased risk of post-traumatic stress disorder.disorder.

Psychological symptoms following LIMITATIONS traumatic amnesia/unconsciousness && No research assessment of head injury or post-traumatic amnesia at hospital Our findings can be compared with those in attendance.attendance. other reports. The conclusions are clearly at variance with our own previous conclu- && Self-report follow-up only. sions from a series in which there were no && Response rate at follow-up was 75% of participants at 3 months and 67% at1year. cases of PTSD among the few subjects who were briefly unconscious. This should be seen as a chance finding in a much smaller series. Blanchard and colleagues Hickling et aletal, 1998) recruited subjects a number of weeks after accidents and relied on cogni- RICHARD A. MAYOU,FRCPsych,MAYOU, FRCPsych, Department of Psychiatry,University of Oxford; JOHN BLACK, FFAEM, Accident and Emergency Department, John Radcliffe Hospital,Oxford; BRIDGET BRYANT,MSc, Department tive testing and self-report of unconscious- of Psychiatry,University of Oxford ness. They found similar rates of PTSD among those who believed they had been CorrespCorrespondence:ondence: Professor R. A.Mayou,University of Oxford,Department of Psychiatry,WarnefordPsychiatry,Warneford unconscious and those who had not. Bryant Hospital,Oxford OX3 7JX,UK.Tel: 01865 226477; fax: 01865 793101 and Harvey Bryant & Harvey, 1998; Har- vey & Bryant, 1998) studied admitted $First received15November1999,finalrevision 30 May 2000, accepted 9 June 2000) patients not all of whom had suffered road accidents) who were assessed as having suffered transient brain injury, and found that understanding of the complexity of psycho- Ehlers, A., Mayou, R. A. & Bryant, B. 1998) logicallogicalcomplications.complications. Psychological predictors of chronic posttraumatic stress 14% satisfied criteria for acute stress dis- disorder after motor vehicle accidents. Journal of order, and 24% sastisfied criteria for PTSD They also contribute to the evidence Abnormal Psychology,, 107107, 508^519.,508^519. base for medico-legal reporting on the sig- among subjects whose amnesia lasted up to Foa, E. B., Riggs, D. S., Dancu, C.V., et aletal 19 93) 24 hours. Post-concussive symptoms were nificance of evidence of possible minor Reliability and validity of a brief instrument for assessing more frequent in subjects who suffered brain injury, unconsciousness and amnesia posttraumatic stress disorder. Journal of Traumatic Stress,, PTSD Bryant & Harvey, 1999). Bryant etet in relation to the aetiology of long-term 66,459^473.,459^473. alal 2000) have recently reported PTSD fol- psychological consequences. Harvey, A. G. & Bryant, R. A. 1998) Acute stress lowing severe traumatic brain injury. disorder following mild traumatic brain injury. Journal ofofJournal Nervous and Mental Disease,, 186186,,333^337. 333^337. We have demonstrated the particular ACKNOWLEDGEMENTS problems of assessment of minor impair- Hickling, E. J., Gillen, R., Blanchard, E. B., et aletal 19 9 8) Traumatic brain injury and posttraumatic stress TheresearchwassupportedbyagrantfromtheThe research was supported by a grant from the ment of consciousness and of brief periods disorder: a preliminary investigation of of amnesia and raised issues which require Wellcome Trust.We are grateful to Mrs Gail Stock- neuropsychological test results in PTSD secondary to further, more specific research. However, it ford, who was responsible for the organisation of motor vehicle accidents. Brain InjuryInjuryBrain ,, 12,,265^274. 265^274. data collection. is apparent that a significant subgroup of Kushner, D. 1998) Mild traumatic brain injury: toward road traffic accident victims suffer minor understanding manifestations and treatment. Archives ofofArchives Internal Medicine,, 158158, 1617^1624.,1617^1624. traumatic brain injury and that the risk of REFERENCES subsequent psychiatric complications ± in- McMillan, T. M. 1997) Minor head injury. Current American Psychiatric Association 1994) Diagnostic Opinion in Neurology,, 1010, 479^483. cluding travel anxiety and PTSD ± is at least and Statistical Manual of Mental Disorders $4th edn) as great as for those who do not suffer brain $DSM^IV).Washington,$DSM ^IV).Washington, DC: APA. Mayou, R., Bryant, B. & Duthie, R. 1993) Psychiatric injury. Many symptoms are not specific for consequences of road traffic accidents. British Medical Bryant, R. A. & Harvey, A. G. 1998) RelationshipRelationship JournalJournal,, 307307,,647^651. 647^651. any particular psychiatric disorder. Symp- between acute stress disorder and posttraumatic stress toms associated with chronic concussion disorder following mild traumatic brain injury. American Murray, J. 1997) Trauma and dissociation. DPhil thesis, Journal of Psychiatry,, 155,625^629. University of Oxford. were not more common in the subjects with The spectrum of emotional distress traumatic brain injury but were associated __ && __ 1999) 19 9 9) Postconcussive symptoms and Parker,R.Parker, R. S. 1996) posttraumatic stress disorder after mild traumatic brain and personality changes after minor head injury incurred with the other psychiatric complications. injuryinjury.Journal of Nervous and Mental Disease,,187187,302^305.,302^305. in a motor vehicle accident. Brain Injury,, 1010, 287^302. The findings indicate the need for __ , Marosszeky, J. E., Crooks, H., et aletal 2000) Zigmond, A. S. & Snaith, R. P. 1983) The hospital routine recording of post-traumatic amnesia Posttraumatic stress disorder after severe traumatic anxiety and depression scale. Acta Psychiatrica and have clinical implications for the brain injury. American Journal of Psychiatry,, 157,629^631.,629^631. Scandinavica,, 6767,,361^370. 361^370.

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