Posttraumatic stress following spinal cord injury: a systematic review of risk and vulnerability factors

Objectives: To summarise quantitatively the available evidence relating to pretraumatic, peritraumatic and posttraumatic characteristics that may increase or decrease the risk of developing posttraumatic stress disorder (PTSD) following spinal cord injury (SCI). Study design: Systematic review. Methods: Seventeen studies were identified from the PubMed, PsycInfo, Embase, Scopus, CINAHL, Web of Science and PILOTS databases. Effect size estimates (r) with associated 95% confidence intervals (CIs), P-values and fail-safe Ns were calculated. Results: Individual studies reported medium-to-large associations between factors that occurred before (psychiatric history r = 0.48 (95% CI, 0.23-0.79) P = 0.01) or at the time of injury (tetraplegia r = -0.36 (95% CI, -0.50 to -0.19) P < 0.01). Postinjury factors had the strongest pooled effects: depressed mood (r(w) = 0.64, (95% CI, 0.54-0.72)), negative appraisals (r(w) = 0.63 (95% CI, 0.52-0.72)), distress (r(w) = 0.57 (95% CI, 0.50-0.62)), anxiety (r(w) = 0.56 (95% CI, 0.49-0.61)) and pain severity (r(w) = 0.35 (95% CI, 0.27-0.43)) were consistently related to worsening PTSD symptoms (P < 0.01). Level of injury significantly correlated with current PTSD severity for veteran populations (Q(B) (1)= 18.25, P < 0.001), although this was based on limited data. Conclusion: Combinations of peri-and post-injury factors appear to be influential in the development of PTSD among persons with SCI. Further studies are needed to extrapolate these findings to the broader spinal cord-injured population. More longitudinal research, driven by multicausal models of causation such as the diathesis-stress model, is also needed to determine the temporality of PTSD risk factors.