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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 Posttraumatic Stress Disorder After Orthopaedic Trauma” (2004;86:1115-21), 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 posttraumatic stress disorder (as measured with the Revised Civilian Mississippi Scale for Posttraumatic Stress Disorder) was startlingly high. Because the presence of a serious psychiatric disorder in more than one-half of a traumatized 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 cannot be diagnosed until at least one month after the traumatic episode. The authors noted that some respondents had been injured 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 response to the event must involve intense fear, helplessness, or horror (Criterion A2 of the DSM [Diagnostic and Statistical Manual of Mental Disorders]-IV). These responses do not appear to have been assessed.

3. According to the DSM-IV, symptoms must be present for one month (Criterion 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 considered by many to be the hallmark of the disorder. Again, it does not appear to have been assessed.

Thus, it is clear that, while the investigators measured symptoms that … 

Corresponding author: Adam J. Starr, MD Department of Orthopaedic Surgery University of Texas Southwestern Medical Center 5323 Harry Hines Boulevard Dallas, TX 75390-8883 adam.starr{at}utsouthwestern.edu