Research Article: Post-traumatic stress disorder and self-reported outcomes after traumatic brain injury in victims of assault

Date Published: February 7, 2019

Publisher: Public Library of Science

Author(s): Dominic Bown, Antonio Belli, Kasim Qureshi, David Davies, Emma Toman, Rachel Upthegrove, Soraya Seedat.


Assault is the third most common cause of traumatic brain injury (TBI), after falls and road traffic collisions. TBI can lead to multiple long-term physical, cognitive and emotional sequelae, including post-traumatic stress disorder (PTSD). Intentional violence may further compound the psychological trauma of the event, in a way that conventional outcome measures, like the Glasgow Outcome Scale (GOS), fail to capture. This study aims to examine the influence of assault on self-reported outcomes, including quality of life and symptoms of PTSD.

Questionnaire were completed by 256 patients attending a TBI clinic, including Quality of Life after Brain Injury (QOLIBRI) and PTSD checklist (PCL-C). Medical records provided demographics, clinical data and aetiology of injury. Subjective outcomes were compared between assault and other causes.

Of 202 patients analysed, 21% sustained TBI from assault. There was no difference in severity of injuries between assault and non-assault groups. No relationship was found between self-reported outcomes and TBI severity or GOS. The assault group scored worse in all self-reported questionnaires, with statistically significant differences for measures of PTSD and post-concussion symptoms. However, using threshold scores, the prevalence of PTSD in assaulted patients was not higher than non-assault. After adjusting for age, ethnicity and the presence of extra-cranial trauma, assault did not have a significant effect on questionnaire scores. Exploratory analysis showed that assault and road traffic accidents were associated with significantly worse outcomes compared to falls.

Quality of life is significantly related to functional and psychological outcomes after TBI. Assaulted patients suffer from worse self-reported outcomes than other patients, but these differences were insignificant when adjusted for demographic factors. Intentionality behind the traumatic event is likely more important than cause alone. Differences in quality of life and other self-reported outcomes are not reflected by the Glasgow Outcome Scale. This information is useful in arranging earlier and targeted review and support.

Partial Text

Traumatic brain injury (TBI) is a traumatically induced disruption of brain function, manifesting as loss of consciousness or memory, alteration in mental and/or focal neurological deficits. TBI is a leading cause of death and disability in both developing and developed countries [1]. The incidence of TBI varies between 150–300 cases per 100,000 population per year [1], and is associated with younger age and male gender [2]. The three most common causes of TBI are falls, road traffic collisions (RTC) and assault, with assaults accounting for around 18% of all cases in western populations, and around 40% of cases for younger patients [2]. TBI due to assault is also strongly associated with being male, substance misuse, low income, and minority ethnicity [2–4]. While TBI mortality has reduced by 30–40% in recent years [5], more victims are surviving with multiple chronic sequelae. Patients may develop post-concussion syndrome (PCS), characterised by physical symptoms, including headaches; cognitive problems, such as difficulty concentrating; and emotional issues, like irritability [6].

This study aims to examine the influence of assault, compared to other aetiologies, on HRQoL, symptoms of post-traumatic stress and other subjective outcomes in victims of TBI.

This is a cross-sectional study of 256 TBI patients attending the multidisciplinary TBI clinic for follow-up review at University Hospital Birmingham NHS Foundation Trust (UHBFT). The study consists of secondary analysis of an anonymised database of all patients who attended between August 2013 and February 2016. UHBFT is a major level-1 trauma centre that provides adult neurotrauma services to the Birmingham urban area and surrounding rural counties, with a catchment population of approximately 4 million. Patients are referred to the TBI clinic from hospitals within the catchment area.

In this cohort, patients who suffered from TBI following assault were younger and less likely to be Caucasian, as expected from previous literature. Assaulted patients showed a possible trend towards worse subjective outcomes in all six questionnaires, with a significant difference in the IES, measuring symptoms of post-traumatic stress, and the first subsection of the RPQ, measuring early symptoms of post-concussion. However, there did not appear to be a significantly greater prevalence of PTSD in the assault group. Self-reported outcomes were independent of TBI severity (GCS) and of objective outcome scores (GOS). Younger patients and non-Caucasian patients scored less favourably, confounding results.

Self-reported outcomes appear independent of TBI severity, and are more sensitive to patients’ needs than objective outcome scores. Assessment of cognitive and psychological function at follow-up is as important as assessing physical function, in order to ensure improvements to HRQoL. Assaulted patients were at a higher risk of developing symptoms of post-concussion and PTSD than all other patients, but this may not correspond with a higher prevalence of PTSD. Assault and RTC were associated with worse outcomes than falls or other causes.




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