By Arielle Lehman, MD
Synopsis: This cohort study of U.S. veterans found that mild traumatic brain injuries occurring alongside psychological trauma are associated with long-term post-concussive symptoms and disability. The authors postulate that the traumatic context contributes to the development of post-traumatic stress disorder, which may in turn potentiate long-term sequelae.
Source: Van Etten EJ, Knight AR, Colaizzi TA, et al. Peritraumatic context and long-term outcomes of concussion. JAMA Netw Open. 2025;8(1):e2455622.
Mild traumatic brain injuries (mTBIs) are prevalent among U.S. veterans, but their long-term effects on physical health, mental well-being, and overall functioning remain uncertain. Existing literature has incompletely evaluated relationships between comorbidity, post-traumatic stress disorder (PTSD) symptoms, and long-term outcomes, with conflicting results. Although emerging evidence suggests that biological and psychological responses during trauma may contribute to PTSD development, the interplay between these factors remains underexplored. Addressing these limitations, this study represents the first to consider the influence of psychological trauma occurring alongside mTBI as a factor mediating outcomes.
Specifically, in this single-center, retrospective study of 567 veterans receiving care from 2009-2024 at a Veterans Affairs hospital, the authors examined differences in PTSD severity, post-concussive symptoms, and disability between veterans with mTBIs coincident with psychological trauma (peritraumatic mTBIs) and those sustained in other contexts (nonperitraumatic mTBIs). The Boston Assessment of Traumatic Brain Injury-Lifetime (BAT-L) was used to retrospectively evaluate head injuries across each participant’s lifespan and classify the mTBIs, with the aid of the Posttraumatic Diagnostic Scale (PDS-5). PTSD severity was assessed with the Clinician-Administered PTSD Scale-4th edition (CAPS-IV) and further stratified into three time points: symptoms from the past month, the worst post-deployment symptoms, and pre-deployment symptoms. Additional questionnaires evaluated traumatic life exposures, post-concussive symptoms, and disability levels.
Ultimately, there were 183 veterans with no TBI, 189 veterans with nonperitraumatic mTBI, and 195 veterans with peritraumatic mTBI included in the analysis (mean age 33.72 years, 89.4% male). Considering differences across groups, the no TBI group had the highest proportion of women (16.9% compared to 7.4% and 7.7%, respectively; P = 0.003), while the peritraumatic mTBI group had the highest rate of trauma exposure (22.93 peritraumatic mTBI, 17.38 nonperitraumatic mTBI, 13.97 no TBI; P < 0.001). PTSD severity (F = 8.45, P < 0.001), post-concussive symptoms (F = 11.09, P < 0.001), and disability scores (F = 11.13, P < 0.001) also were significantly higher in the peritraumatic mTBI group, whereas no significant differences were observed between the nonperitraumatic mTBI and no TBI groups. These findings remained consistent even after controlling for combat exposure, total lifetime trauma, and mTBI severity.
Findings also revealed that veterans with peritraumatic mTBI exhibited higher post-concussive symptoms across all Neurobehavioral Symptom Inventory (NSI) subfactors, including vestibular, somatic, cognitive, and affective. However, after controlling for PTSD severity, only the affective subfactor was no longer significantly different between groups.
Commentary
This study offers important insights into the relationships among mTBI, psychological trauma, PTSD, post-concussive symptoms, and disability. The findings indicate that mTBI is associated with worse long-term outcomes when sustained during a traumatic event. Even after controlling for PTSD severity, post-concussive symptoms and disability levels remained significantly higher in the peritraumatic mTBI group compared to the nonperitraumatic mTBI and no TBI groups. This suggests that the negative effects arise from the timing and context of the injury, rather than merely the coexistence of both conditions. Furthermore, the results imply that sustaining an mTBI during a traumatic event may increase susceptibility to developing PTSD.
To explain their findings, the authors proposed the peritraumatic scaffolding effect, a new theoretical framework suggesting that acute psychological and physiological responses at the moment of injury create a scaffold that influences long-term recovery. According to this model, disruptions in information processing from the mTBI may alter physiological and psychological responses, increasing the likelihood of developing PTSD and other persistent post-concussive symptoms.
Clinically, observed findings underscore the importance of screening for peritraumatic factors when evaluating individuals with mTBIs. Veterans who experience peritraumatic mTBI may be more susceptible to developing psychiatric comorbidities and prolonged post-concussive symptoms, making early intervention strategies, including psychiatric and psychological support, especially crucial. Ultimately, targeted approaches addressing both neurological and psychological factors in individuals with peritraumatic mTBI may be valuable in mitigating long-term complications and improving overall outcomes. Further research is necessary to determine the applicability of these findings to civilian populations.
Beyond limitations in generalizability, several other study constraints warrant discussion. First, the retrospective nature of the study introduces the potential for recall bias. Individuals with PTSD may possess a heightened or altered memory of the traumatic event, leading them to perceive or report the injury context as more severe than it may objectively have been. Second, residual confounding still may exist despite statistical adjustments. Unmeasured factors, such as genetic predisposition, preexisting psychiatric conditions, or social support, also could contribute to the observed differences between groups. Additionally, although they controlled for the number of traumatic life exposures, this may be too reductive to capture the dimensions of these experiences. An area for further exploration is whether stratifying mTBIs into those with and without post-traumatic amnesia reveals differences in outcomes, particularly if amnesia plays a protective role in preventing behavioral sequelae, including PTSD.
Arielle Lehman, MD, is a Neurologist at New York Presbyterian/Weill Cornell.
This cohort study of U.S. veterans found that mild traumatic brain injuries occurring alongside psychological trauma are associated with long-term post-concussive symptoms and disability. The authors postulate that the traumatic context contributes to the development of post-traumatic stress disorder, which may in turn potentiate long-term sequelae.
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