To the Editor:

It was a pleasure to receive Dr. Silver’s letter regarding our paper. She raises several good points, and we’ll do our best to address them.

First, Dr. Silver points out that, according the DSM-IV, PTSD cannot be diagnosed until at least one month post-trauma, and she suggests, that patients who were less than 4 weeks post trauma should have been excluded. We considered excluding patients seen at less than 4 weeks, but decided against it. In our sample, patients further out from injury had more symptoms of PTSD. Exclusion of patients less than 4 weeks post-trauma made the apparent prevalence of the illness even higher. If we excluded those assessed less than 30 days after injury, the rate of PTSD would jump 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 2 weeks after injury with symptoms of PTSD may not meet rigid criteria for the illness, but the symptoms are still present. Our goal was to record those symptoms, and bring them to the attention of other orthopaedic surgeons. For that reason we wanted to be as inclusive as possible.

Next, Dr. Silver raises concerns about our failure to assess other criteria listed in the DSM-IV, and states, “In fact, because all DSM-IV criteria were not assessed (e.g., degree of functional impairment; duration of symptoms), respondents should NOT have been assumed to have PTSD”. The question of impairment is very important. In fact, a search for causes of impairment after orthopaedic trauma was one thing that led us to do this study.

If one asks orthopaedic trauma patients, “Are you impaired?” the answer for many is a resounding “Yes!” We assumed, perhaps incorrectly, that the fact that the patients were seeking treatment at an orthopaedic clinic meant their injury had caused a “clinically significant impairment”. It seems probable that some patients’ impairment is due to their physical injury. But for others, impairment may arise from psychological distress. In fact, it may be difficult to tell whether impaired function is caused by physical injury, or by psychological distress, or by some combination of the two. Psychological distress is strongly associated with poor functional outcome scores among high-energy lower extremity trauma patients (1). Could the same be true for less severely injured orthopaedic trauma patients? And, how common are PTSD symptoms among orthopaedic trauma patients? As best we can tell, nobody knows the answer to those questions.

Our goal with this study was to try to estimate the prevalence of PTSD in our patient population. In the future we hope to see if functional impairment can be reduced by treating psychological distress.

As we noted, “…diagnosis of posttraumatic stress disorder based on a questionnaire is not the same as a clinical diagnosis made by a mental health professional. A more rigorous diagnosis may reveal different results.” Dr. Silver, a mental health professional, may be right when she says we should be more circumspect with our terminology. However, if we assume that our patients answered the questions honestly, it is hard to ignore their responses. Perhaps, in the interest of diagnostic rigor, it would be more accurate to say that patients in our sample do not meet all criteria to make the diagnosis of post-traumatic stress disorder; they just have lots of post-traumatic stress symptoms.

Given that we failed to adopt the one-month criterion for symptom duration, and that we assumed that attendance at an orthopaedic trauma clinic constituted evidence of a “clinically significant impairment”, Dr. Silver’s criticism of our assignment of the diagnosis is probably deserved.

Dr. Silver also raises the question of the impact of the September 11 terrorist attacks on our patient sample, and cites research carried out by her and her colleagues (1), a web-based survey of 933 people residing outside New York, NY. The sample of people assessed by Silver et al. included only one patient personally injured in the attacks. Thirty-eight percent of the respondents had no direct first-hand exposure to the attacks as they occurred, and another 60% reported watching them occur live on TV. Only 2% of the sample had direct firsthand exposure to the attacks. Surprisingly, at 2 months, 17% of the respondents reported September 11 related post-traumatic stress symptoms; 5.8% did so at 6 months.

It may be that the September 11 attacks inflated the results of our study. Or, it may be that direct personal injury, such as that sustained by our patients, is more likely to cause post-traumatic stress symptoms than indirect exposure to an event such as the September 11 attacks.

Dr. Silver also notes, “Many of the items on the Revised Civilian Mississippi Scale for PTSD assess trauma symptoms that are NOT specific to the orthopaedic trauma or injury”. Our patient sample was composed entirely of people who had sustained an orthopaedic injury who were seen in follow-up in an orthopaedic trauma clinic. The cover sheet for our questionnaire carried the title, “Study of Stress after Orthopaedic Trauma”, and stated, “You are being asked to complete this questionnaire because you have sustained an injury. Our goal with this study is to see how injury affects orthopaedic patients emotionally or psychologically”. Questions 1, 4, 10, 11, 12 and 13 from the Revised Civilian Mississippi Scale for PTSD were altered by us to include references to “the injury”, “my injury”, or “since I was injured”, instead of “the event”, as originally written by Norris and Perilla, the questionnaire’s developers (2). Questions 19, 21, 22, 24, 25, 26, 27, 28, 29 and 30 were used verbatim from Norris and Perilla. Our thought was that the cover sheet and the questions made it clear that the goal of the questionnaire was to assess how injury affected patients psychologically or emotionally. There is a possibility that symptoms arising from the September 11 attacks may have inflated our results. Since we did not address the attacks directly, we have no way to be certain if this is the case.

Finally, Dr. Silver suggests that a more traditional analytic strategy might have assisted us in identifying at risk individuals who might benefit from psychological referral. Previously, we had performed a multiple independent variable logistic regression with backward elimination, initially including those variables which were statistically significant (p <.05) at a univariate level. The intent was to ascertain if combinations of significant variables were good predictors. Using this technique, ISS remained in the model, while summed EAIS and elapsed time since injury were dropped. Motivated by her suggestion, we increased the complexity of the model to include other variables and numerous first-order interactions. We found that age and ISS remained in an additive model whereby the predicted probability of PTSD increased with higher ISS and with lower age. However, the area under the associated ROC curve was .57, a value in the same range as reported for single variables in the paper. So, we think logistic regression adds little useful information to the analysis of the data.

As for identifying “at risk” individuals, we think we have. Orthopaedic trauma patients are at risk for PTSD, or at least for PTSD symptoms. And, at least in our sample, patients who said the emotional problems caused by their injury were more difficult than the physical problems were at increased risk. We think this simple question may serve as a screening tool in identifying patients who may benefit from further screening or treatment.

Sincerely,

Adam Starr, William Frawley, Charles Reinert

1. McCarthy ML, MacKenzie EJ, Edwin D, Bosse MJ, Castillo RC, Starr A. Psychological distress associated with severe lower limb injury. J Bone Joint Surg Am, 2003; 85: 1689 - 1697.

2. Norris FH, Perilla JL. The revised Civilian Mississippi Scale for PTSD: reliability, validity, and cross-language stability. J Trauma Stress.1996; 9:285 -98.

To the Editor:

I appreciate Dr. Bellamy’s interest in our study, and agree with him that information about the compensation status of our patients would have been useful. Unfortunately, we did not collect that information.

Other data I wish we had, but don’t, is information about education level, social-support network, level of self-efficacy (the patient’s confidence in being able to resume life activities), and smoking history. These variables, along with involvement in disability compensation, were identified as predictors of a poorer score for the Sickness Impact Profile in the LEAP study (1). Further examination of LEAP study patients indicated that factors associated with psychological distress include history of a drinking problem, neuroticism, a poor sense of self-efficacy, and poor social support (2).

My guess is that some of these same variables may also be predictive of PTSD among the general orthopaedic trauma population. However, since we did not collect that data I cannot be certain.

Sincerely, Adam J. Starr, MD

References:

1. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF et al. Reconstruction or amputation of lower limb threatening injuries: an analysis of two-year outcomes in level-I trauma centers. NEJM. 2002 347: 1924-31.

2. McCarthy ML, MacKenzie EJ, Edwin D, Bosse MJ, Castillo RC, Starr A. Psychological distress associated with severe lower limb injury. J Bone Joint Surg Am, 2003; 85: 1689 - 1697.

To the Editor:

I read with interest the study by Starr,et.al. I am unaware of any mention of litigation status or compensation issues among the study subjects. Given the well known propensity of litigants to be stressed by the litigation process which adds to the impact of the physical injury, this would appear to be essential information.

When compensation issues exist, full emotional and physical recovery is often compromised. Litigants usually are aware that the amount of any judgement depends on evidence that permanent injury has been sustained, and some guilt regarding their possible complicity in their symptoms (or magnification thereof) is common. There is additionally the stress of perhaps being doubted by defense attorneys, family members, friends, and coworkers as to the severity of the impairments, and possible life-altering financial settlement which may be rewarded.

All of the above add up to significant confounding factors in the attempted smooth physical rehabilitation and emotional adjustment of the trauma victim. It would appear that mention of compensation status is an essential part of any ananlysis of emotional state following trauma.

To the Editor:

Posttraumatic Stress Disorder (PTSD) is a serious psychological condition that has received increasing attention over the past decade, and Starr and colleagues (1) should be commended for their attempt to alert orthopaedic surgeons to the fact that psychological consequences of a severe orthopaedic injury are possible and important. Nonetheless, the percentage of respondents who “met the criteria” for PTSD (as measured by the Revised Civilian Mississippi Scale for PTSD) was startlingly high. Because the presence of a serious psychiatric disorder in more than one- half a traumatized sample is exceedingly rare, it led to a further examination of the methods and analytic strategy used in this report. There are a number of issues that deserve mention.

1. PTSD cannot be diagnosed until at least one month post-trauma. The authors note that some respondents had been injured as little as 2 days prior to assessment. Individuals under 4 weeks post trauma should have been excluded from the sample.

2. For a PTSD diagnosis, the person's response to the event must involve intense fear, helplessness, or horror – Criterion A2 of the DSM- IV. This does not appear to have been assessed.

3. Per the DSM-IV, symptoms must be present for one month’s duration (Criterion E). This does not appear to have been measured in the present investigation.

4. Criterion F – that the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning – is considered by many to be the hallmark of the disorder, and does not appear to have been assessed.

Thus, it is clear that while the investigators measured symptoms that were consistent with criteria B, C and D of the DSM-IV, the absence of the full assessment of PTSD requires investigators to be extremely circumspect about their terminology. In fact, because all DSM-IV criteria were not assessed (e.g., degree of functional impairment; duration of symptoms), respondents should NOT have been assumed to have PTSD.

Moreover, an important historical event occurred very close to the assessment of PTSD among the respondents in this study. The September 11, 2001 terrorist attacks had a substantial impact on the psychological state of individuals across the country – not simply those individuals who lived in a directly affected community.(2) Moreover, these attacks had a clear, demonstrable impact over six months post-attacks, with substantial numbers of individuals from a nationally representative sample showing posttraumatic stress symptoms and elevated levels of distress.(2) The fact that the assessment of PTSD was conducted within weeks of the attacks at one site, and within months after the attacks at the second site, may have inflated the results obtained. In fact, many of the items on the Revised Civilian Mississippi Scale for PTSD assess trauma symptoms that are NOT specific to the orthopedic trauma or injury (e.g., items #1, 4, 10, 11, 12, 13, 19, 21, 22, 24, 25, 26, 27, 28, 29, 30).

Finally, a more traditional way to analyze these data to examine demographic and injury-related predictors of the presence or absence of posttraumatic stress symptoms would have been to use logistic regression. The non-traditional analytic strategy employed may have masked factors that, in combination, could have assisted the orthopaedic surgeon in identifying at-risk individuals who might benefit from psychological referral.

1 Starr AJ, Smith WR, Frawley WH, Borer DS, Morgan SJ, Reinert CM, Medoza-Welch M. Symptoms of Posttraumatic Stress Disorder after orthopaedic trauma. J Bone Joint Surg. 2004;86:1115-1121.

2 Silver RC, Holman EA, McIntosh DN, Poulin M, Gil-Rivas V. Nationwide longitudinal study of psychological responses to September 11. JAMA. 2002;288:1235-1244.