J Head Trauma Rehabil Vol. 29, No. 2, pp. E11–E18 Copyright c  2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychotic Symptoms as Manifestations of the Posttraumatic Confusional State: Prevalence, Risk Factors, and Association With Outcome Mark Sherer, PhD; Stuart A. Yablon, MD; Todd G. Nick, PhD Objectives: To (1) determine factors associated with psychotic-type symptoms in persons with moderate or severe traumatic brain injury (TBI) during early recovery and (2) investigate the prognostic significance of early psychotic- type symptoms for patient outcome. Setting: Acute neurorehabilitation inpatient unit. Participants: A total of 168 persons with moderate or severe TBI were admitted for inpatient rehabilitation. Of these, 107 had psychotic-type symptoms on at least 1 examination. One-year productivity outcome was available for 87 of the 107 participants. Design: Prospective, inception cohort, observational study. Main Measures: Confusion Assessment Protocol, pro- ductivity outcome at 1 year postinjury. Results: Presence of sleep disturbance, a shorter interval from admission to assessment, and greater cognitive impairment were associated with a greater incidence of psychotic-type symptoms. Younger age, more years of education, and lower frequency and severity of psychotic-type symptoms were associated with a greater likelihood of favorable productivity outcome. Conclusions: We identified risk factors for the occur- rence of psychotic-type symptoms and extended previous findings regarding the significance of these symptoms for outcome after TBI. These findings suggest that improved sleep in early TBI recovery may decrease the occurrence of psychotic-type symptoms. Key words: confusion, delirium, outcome, traumatic brain injury I N responsive patients, early recovery from moderate or severe traumatic brain injury (TBI) is characterized by disorientation, pervasive cognitive impairments, and other neurobehavioral deficits. 1 While this period of recovery has been referred to as posttraumatic amnesia, Stuss and colleagues 2 noted some phenomenological similarity to delirium and suggested renaming this phase as the posttraumatic confusional state (PTCS). They offered evidence that the key neurobehavioral impairment for Author Affiliations: TIRR Memorial Hermann, Baylor College of Medicine, University of Houston Medical School, Houston, Texas (Dr Sherer); Division of Physical Medicine and Rehabilitation, University of Alberta, Edmonton, Canada (Dr Yablon); and Department of Pediatrics and Biostatistics, University of Arkansas for Medical Sciences, Little Rock (Dr Nick). This research was supported by US Department of Education National Insti- tute on Disability and Rehabilitation Research Grants H133A070043 and H133A020514. The authors declare no conflicts of interest. Corresponding Author: Mark Sherer, PhD, TIRR Memorial Hermann, 1333 Moursund, Houston, TX 77030 (Mark.Sherer@memorialhermann. org). DOI: 10.1097/HTR.0b013e318287f894 patients in PTCS is a global disturbance of attentional functions. In our program of research on the PTCS, we have de- veloped a procedure for assessing PTCS, the Confusion Assessment Protocol (CAP), 3 and have proposed diag- nostic criteria for PTCS. 3 We have identified 7 key symp- toms of PTCS: cognitive impairment, disorientation, fluctuation, restlessness, decreased daytime arousal, nighttime sleep disturbance, and psychotic-type symp- toms, and we have demonstrated the frequencies of these symptoms in confused and nonconfused patients in early recovery from moderate or severe TBI. 4 Our work has shown that confusion severity is predictive of early and late outcome after TBI and, in preliminary results, that presence or absence of key symptoms of confusion in the early period postinjury predicts employment out- come at 1-year postinjury. 4 Finally, we have reported on the typical patterns of recovery from PTCS. 5 Of par- ticular note from this line of investigation, we found a surprisingly high incidence of psychotic-type symptoms (hallucinations, delusions) in confused patients in early recovery from moderate or severe TBI with more than 40% of patients showing these symptoms on at least 1 ex- amination during inpatient brain injury rehabilitation. 4 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. E11