Primary Objective To gain a better understanding of the complex relationship between combat deployment-related mild traumatic brain injury (mTBI) and persistent post-concussive symptoms (PPCSs), taking into consideration a wide range of potentially mediating and confounding factors. Research Design Cross-sectional. Methods and Procedures Subjects were 613 U. S. military Veterans and Service Members who served during operations Enduring Freedom, Iraqi Freedom, or New Dawn (OEF/OIF/OND) and completed a structured interview of mental disorders and a battery of questionnaires. Hierarchical binary logistic regression analyses were used to test the hypotheses. Main Outcomes and Results After accounting for mental disorders, lifetime mTBIs outside of OEF/OIF/OND deployment, medical conditions, and injury/demographic characteristics, deployment-related mTBI continued to be associated with several PPCSs (headaches, sleep disturbance, and difficulty making decisions). Deployment-related mTBI was also associated with two symptoms not normally associated with mTBI (nausea/upset stomach and numbness/tingling). Conclusions After adjusting for a wide range of factors, OEF/OIF/OND deployment-related mTBI was still associated with PPCSs on average 10 years after the injury. These findings suggest that mTBI sustained during OEF/OIF/OND deployment may have enduring negative health effects. More studies are needed that prospectively and longitudinally track health and mental health outcomes after TBI.

AIMS:Compared to the general U.S. population, military veterans and those living in rural areas disproportionately smoke cigarettes at higher rates, leading to increased health consequences. In the current study, prevalence and severity of cigarette smoking in Iraq and Afghanistan era veterans was assessed across rural and urban areas and comorbid mental health disorders.METHOD:Iraq/Afghanistan era veterans who participated in the Post-Deployment Mental Health study from 2005 to 2017 (N = 3229) were cross-sectionally assessed for the probability of being a current cigarette smoker based on locality status and psychiatric comorbidity. Multivariate logistic and linear regressions, adjusted for demographic characteristics, were used to model the odds of being a current smoker and the severity of nicotine dependence, respectively.RESULTS:Veterans residing in rural regions, veterans with psychiatric comorbidities, and the interaction of locality and psychiatric disorders were significantly associated with smoking rates. Those veterans living in extremely rural areas and, independently, those living with psychiatric comorbidities were also more severely dependent on nicotine compared to urban veterans and veterans without psychiatric conditions.CONCLUSIONS:Rural veterans and veterans with psychiatric comorbidities are at increased risk of smoking and are more severely dependent on nicotine than urban veterans. These findings underscore the need to reduce barriers for treatment both for smoking cessation and mental healthcare for veterans residing in the most rural areas.

Around half of Iraq and Afghanistan war veterans with traumatic brain injury (TBI) have co-occurring post traumatic stress disorder (PTSD). Research on the differences between male and female veterans with co-occurring PTSD/TBI is sparse. This study evaluated behavioral health differences between sexes with these conditions. Veterans (N = 1577) completed a structured psychiatric interview, TBI interview, and self-report interviews assessing sleep quality, alcohol use, substance use, pain, depression symptoms, PTSD symptoms, and combat exposure. Groups depended on the presence/absence of a lifetime PTSD diagnosis and history of TBI. Among veterans with PTSD and TBI, males and females were equally likely to meet criteria for current PTSD, and in the PTSD only group, male veterans were more likely to have current PTSD. Male veterans with PTSD were also more likely to meet criteria for lifetime alcohol and substance use disorders (AUD and SUD), and mild TBI. Although TIM severity did not differ between sexes in the TBI only group, female veterans were more likely to have a moderate/severe TBI among veterans with co-occurring PTSD. Female veterans without PTSD and TBI were more likely to have major depressive disorder (MDD). Significant sex differences were found for AUD, MDD, current PTSD, and TBI severity.

This study evaluated whether a history of traumatic brain injury (TBI) was associated with increased risk for recent suicidal ideation (SI) after accounting for demographics, depression, posttraumatic stress disorder (PTSD), and sleep quality. In terms of increased risk, we hypothesized that a history of lifetime TBI would be associated with increased recent SI when compared with no history of TBI; multiple injuries were also evaluated. The sample included Iraq and Afghanistan war-era veterans (n = 838) who served in the United States military since 9/2001 and completed a structured TBI interview. Approximately 50% reported a lifetime history of at least 1 TBI, and 17.9% met criteria for current major depressive disorder (MDD). SI over the past week per the Beck Scale for Suicide Ideation was the primary outcome. Demographics, current MDD and posttraumatic stress disorder (PTSD) per Structured Clinical Interview of DSM-IV Axis I Disorders, sleep quality per Pittsburgh Sleep Quality Index, and TBI history per structured interview were included in all statistical models. Current depression and poor sleep quality were consistently associated with recent SI. A history of any TBI history across the life span was not associated with increased recent SI (OR = 1.35, 95% CI [0.83, 2.19]). However, a history of multiple TBIs compared with no history of TBI was associated with increased recent SI (OR = 1.76, 95% CI [1.01, 3.06]). Results support the assertion than an accumulation of injuries amplifies risk. Severity of injury and deployment injuries were not significant factors. Among those with a history of 1 TBI, sleep, and depression, which may also be injury sequelae, may be salient treatment targets. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Behavioral Dyscontrol Scale—II (BDS-II) is a unique test of frontal lobe function. Although the test was created for use in geriatric populations, it can add useful data to assessments of non-elderly patients. The original scoring system for the BDS was characterized by a low ceiling, limiting its use with higher functioning populations. The BDS-II scoring system was created to address this issue; however, new normative data were not published. This study used a non-elderly Veteran sample to compare the psychometric properties of the BDS and BDS-II scoring systems. The BDS-II showed improved psychometric properties (reductions in skewness and kurtosis) and was significantly more reliable than the BDS. Normative data using both the total sample, as well as the subsample of healthy individuals, are provided for clinical use.

Prior research on executive ability and suicidal ideation (SI) has frequently failed to account for either symptom or performance validity. Similarly, studies have not adequately examined both objective performance on executive tests and subjective report of executive deficits in relationship to SI. The purpose of this study was to address these gaps in research by accounting for performance validity, symptom validity, and considering self-reported executive complaints with objective performance. We hypothesized that (a) increases in self-reported SI on the Personality Assessment Inventory (PAI; Morey, 1991) Suicidal Ideation subscale would be related to poorer performance on objective and subjective tests of executive function and (b) level of self-reported depressive symptoms would moderate the relationship between SI and measures of executive function, such that individuals with higher levels of both depressive symptoms and executive dysfunction would be more likely to experience higher levels of SI. No measure of executive function was related to SI when accounting for demographic variables and depressive symptoms. Wisconsin Card Sort Test categories completed was the only measure of executive function to interact significantly with depressive symptoms to predict SI (beta = .43). Of particular note, self-reported executive dysfunction was highly correlated with Beck Depression Inventory - II (Beck, Steer, & Brown, 1996) scores (r = .78). Clinical implications and future directions for research are discussed.

The goals of this study were to describe clinical practice patterns associated with the Veterans Health Administration's (VHA's) Comprehensive Traumatic Brain Injury Evaluation (CTBIE) and determine whether practice patterns vary by patient, provider, or facility characteristics. Veterans (N = 614) who had initial healthcare visits between 2008 and 2011 and who had previously completed the VHA's traumatic brain injury (TBI) screen and subsequent CTBIE were drawn from a national database. Participants were primarily male (95%) with a mean age of 29.8 yr (standard deviation = 8). Chart reviews were conducted on a random sample of charts with completed CTBIEs from 21 sites. Using a cross-sectional design, patient- and facility-specific variables were investigated as potential predictors of practice variation. During the study period, 79% of patients in this national sample were screened within 1 d of their initial healthcare visit and 65% were evaluated via CTBIE within 30 d of screening. Provider and participant characteristics were generally not associated with timeliness. The CTBIE was completed by individuals versus teams at comparable rates. Much of what occurred during the evaluation, beyond TBI-specific procedures, were medical assessments, such as review of medications and other substances.

Objective: Neuropsychiatric complaints often accompany mild traumatic brain injury (mTBI), a common condition in post-deployed Veterans. Self-report, multi-scale personality inventories may elucidate the pattern of psychiatric distress in this cohort. This study investigated valid Personality Assessment Inventory (PAI) profiles in post-deployed Veterans. Method: Measures of psychopathology and mTBI were examined in a sample of 144 post-deployed Veterans divided into groups: healthy controls (n = 40), mTBI only (n = 31), any mental health diagnosis only (MH; n = 25), comorbid mTBI and Posttraumatic Stress Disorder (mTBI/PTSD; n = 23), and comorbid mTBI, PTSD, and other psychological diagnoses (mTBI/PTSD/MDD+; n = 25). Results: There were no significant differences between the mTBI and the control group on mean PAI subscale elevation, or number of subscale elevations above 60T or 70T. The other three groups had significantly higher overall mean scores, and more elevations above 60 and 70T compared to both controls and mTBI only. The mTBI/PTSD/MDD+ group showed the highest and most elevations. After entering demographics, PTSD, and number of other psychological diagnoses into hierarchical regressions using the entire sample, mTBI history did not predict mean PAI subscale score or number of elevations above 60T or 70T. PTSD was the only significant predictor. There were no interaction effects between mTBI and presence of PTSD, or between mTBI and total number of diagnoses. Conclusions: This study suggests that mTBI alone is not uniquely related to psychiatric distress in Veterans, but that PTSD accounts for self-reported symptom distress.

The Behavioral Dyscontrol Scale-II (BDS-II) was developed as an improved scoring method to the original BDS, which was designed to evaluate the capacity for independent regulation of behavior and attention. The purpose of this study was to evaluate the factor structure and construct validity of the BDS-II, which had not been adequately re-examined since the development of the new scoring system. In a sample of 164 Veterans with a mean age of 35 years, exploratory factor analysis was used to evaluate BDS-II latent factor structure. Correlations and regressions were used to explore validity against 22 psychometrically sound neurocognitive measures across seven neurocognitive domains of sensation, motor output, processing speed, attention, visual-spatial reasoning, memory, and executive functions. Factor analysis found a two-factor solution for this sample which explained 41% of the variance in the model. Validity analyses found significant correlations among the BDS-II scores and all other cognitive domains except sensation and language (which was not evaluated). Hierarchical regressions revealed that PASAT performance was strongly associated with all three BDS-II scores; dominant hand Finger Tapping Test was also associated with the Total score and Factor 1, and CPT-II Commissions was also associated with Factor 2. These results suggest the BDS-II is both a general test of cerebral functioning, and a more specific test of working memory, motor output, and impulsivity. The BDS-II may therefore show utility with younger populations for measuring frontal lobe abilities and might be very sensitive to neurological injury.

Embedded validity measures support comprehensive assessment of performance validity. The purpose of this study was to evaluate the accuracy of individual embedded measures and to reduce them to the most efficient combination. The sample included 212 postdeployment veterans (average age=35 years, average education=14 years). Thirty embedded measures were initially identified as predictors of Green's Word Memory Test (WMT) and were derived from the California Verbal Learning Test-Second Edition (CVLT-II), Conners' Continuous Performance Test-Second Edition (CPT-II), Trail Making Test, Stroop, Wisconsin Card Sorting Test-64, the Wechsler Adult Intelligence Scale-Third Edition Letter-Number Sequencing, Rey Complex Figure Test (RCFT), Brief Visuospatial Memory Test-Revised, and the Finger Tapping Test. Eight nonoverlapping measures with the highest area-under-the-curve (AUC) values were retained for entry into a logistic regression analysis. Embedded measure accuracy was also compared to cutoffs found in the existing literature. Twenty-one percent of the sample failed the WMT. Previously developed cutoffs for individual measures showed poor sensitivity (SN) in the current sample except for the CPT-II (Total Errors, SN=.41). The CVLT-II (Trials 1-5 Total) showed the best overall accuracy (AUC=.80). After redundant measures were statistically eliminated, the model included the RCFT (Recognition True Positives), CPT-II (Total Errors), and CVLT-II (Trials 1-5 Total) and increased overall accuracy compared with the CVLT-II alone (AUC=.87). The combination of just 3 measures from the CPT-II, CVLT-II, and RCFT was the most accurate/efficient in predicting WMT performance.

The Behavioral Dyscontrol Scale-II (BDS-II) is a unique test of frontal lobe function. Although the test was created for use in geriatric populations, it can add useful data to assessments of non-elderly patients. The original scoring system for the BDS was characterized by a low ceiling, limiting its use with higher functioning populations. The BDS-II scoring system was created to address this issue; however, new normative data were not published. This study used a non-elderly Veteran sample to compare the psychometric properties of the BDS and BDS-II scoring systems. The BDS-II showed improved psychometric properties (reductions in skewness and kurtosis) and was significantly more reliable than the BDS. Normative data using both the total sample, as well as the subsample of healthy individuals, are provided for clinical use.

OBJECTIVE: The objective of the study was to investigate the prevalence of cognitive anosognosia in mild TBI as well as normal healthy individuals BACKGROUND: Traumatic brain injury (TBI) has been characterized as a “hidden epidemic.” About 45% of individuals with moderate to severe TBI demonstrate reduced or complete lack of awareness of deficits, which interferes with functional ability and often leads to significant mood dysfunction, medication non-compliance. Terms such as anosognosia, loss of insight, unawareness of illness, or impaired self awareness have been used interchangeably. Mild TBI is the most prevalent form of TBI, accounting for about 75% of the estimated 1.7 million annually. Despite being the most prevalent form of TBI, there have been no studies on cognitive anosognosia in this population. DESIGN/METHODS: The study is a retrospective analysis of existing research data gathered as part of two multisite protocols administered by the Mid-Atlantic Mental Illness, Research, Education, and Clinical Center (MIRECC). A sample of 96 postdeployment OEF/OIF/OND Veterans, was identified containing 56 participants with mild TBI history and 40 healthy control participants. Items were identified from the Frontal System Behavioral Scale (FrSBe), that could be used as self-report ratings for specific cognitive domains (attention, dual task, sequencing, cognitive flexibility, retrieval). Cognitive anosagnosia was defined as meeting the two following criteria, 1) denying problems in a cognitive domain, as reported on the FrSBe, and 2)displaying poor performance in that same cognitive domain on an objective cognitive test. RESULTS: The following number of participants denied having problems in a cognitive domain, but displayed problems in that domain on objective testing: attention=10, dual task=7, sequencing = 4, cognitive flexibility=13, and retrieval=4. Of all individuals displaying problems on objective cognitive testing, the following percentages denied experiencing those problems: attention=67%, dual task=88%, sequencing=67%, cognitive flexibility=76% and retrieval=40%. CONCLUSIONS: These results suggest that cognitive anosognosia may be present in patients with mild TBI Disclosure: Dr. Ahmed has nothing to disclose. Dr. Hurley has nothing to disclose. Dr. Taber has nothing to disclose. Dr. Rowland has nothing to disclose. Dr. Yoash-Gantz has nothing to disclose. Dr. Kramer has nothing to disclose.

This study investigates prior reports of high neuropsychological symptom validity test (SVT) failure rates in post-deployed Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) active and veteran military personnel, using a large, multi-site sample (N 214) drawn from three levels of the Department of Defense/Department of Veterans Affairs (VA) Polytrauma System of Care. The sample failure rate and its relationship to research versus dual research/clinical context of evaluation were examined, in addition to secondary variables explored in prior studies. Results yielded an overall failure rate of 25, lower than prior reports describing OEF/OIF active-duty and veteran military personnel. Findings also supported the hypothesis that SVT failure rates would differ by context (dual research). Participants with traumatic brain injury (TBI) failed more frequently than those without TBI in the dual context but not in the research context. Secondary analyses revealed that failure rates increased in the presence of depression, posttraumatic stress disorder, and male sex but were unrelated to active versus veteran military status, service connection (SC) or percentage of SC, age, education, or ethnicity. Further research is required to elucidate the underpinnings of these findings in light of the limited literature and variability between OEF/OIF-related SVT studies, as well as the substantial diagnostic and treatment implications for VA.

Copyright: © 2013 Liu Y, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Association of Variant rs4790904 in Protein Kinase C Alpha with Posttraumatic Stress Disorder in a U.S. Caucasian and African-American Veteran Sample

The cycle of military deployment can he a stressful experience that is associated with a number of adverse impacts. This chapter details psychological stressors and their sequelae during the cycles of deployment, beginning with pre-deployment stressors, followed by stressors that occur in the military theater of deployment, and finally focusing on post-deployment mental-health issues. During the pre-deployment phase, the service member often is attempting to handle multiple competing social, vocational, and emotional demands. Family responsibilities and pressures often mount during this time. To prepare for stressors that may be faced in the military theater, service members may undergo resiliency training. While in the war theater, service members may face a host of stressful experiences, including military combat. The psychological impact of these stressors, while apparent at times during deployment, may not be fully felt until the service member has returned from deployment. After deployment, service members may seek and receive treatment for a number of mental-health conditions, including posttraumatic stress disorder (PTSD), depression, substance abuse, and adjustment following, traumatic brain injury (TBI). This chapter outlines the various ways that these conditions are being addressed among post-deployed service members in the USA

Objective: This study examined the association of lifetime traumatic stress with psychiatric diagnostic status and symptom severity in veterans serving in the US military after 9/11/01.Method: Data from 356 US military veterans were analyzed. Measures included a standardized clinical interview measure of psychiatric disorders, and paper-and-pencil assessments of trauma history, demographic variables, intellectual functioning, posttraumatic stress disorder (PTSD) symptoms, depression, alcohol misuse, and global distress.Results: Ninety-four percent of respondents reported at least one traumatic stressor meeting DSM-IV criterion A for PTSD (i.e., life threatening event to which the person responded with fear, helplessness or horror), with a mean of four criterion A traumas. Seventy-one percent reported serving in a war-zone, with 50% reporting occurrence of an event meeting criterion A. The rate of current psychiatric disorder in this sample was: 30% PTSD, 20% major depressive disorder, 6% substance abuse or dependence and 10% for the presence of other Axis I psychiatric disorders. After accounting for demographic covariates and combat exposure, childhood physical assault and accident/disasters were most consistently associated with increased likelihood of PTSD. However, PTSD with no comorbid major depressive disorder or substance use disorder was predicted only by combat exposure and adult physical assault. Medical/unexpected-death trauma and adult physical assault were most consistently associated with more severe symptomatology.Conclusions: Particular categories of trauma were differentially associated with the risk of psychiatric diagnosis and current symptom severity. These findings underscore the importance of conducting thorough assessment of multiple trauma exposures when evaluating recently post-deployed veterans. Published by Elsevier Ltd.

CME Educational Objectives 1. Evaluate measures of processing speed and executive functioning in OEF/OIF combat veterans with posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), and comorbid TBI/PTSD. 2. Assess the role that comorbid TBI/PTSD may play in the speed of verbal processing. 3. Justify potential reasons slowed speed of verbal processing may impact therapies for PTSD.

Background: Comorbid mild traumatic brain injury (mTBI) with posttraumatic stress disorder (PTSD) is a common clinical presentation among troops returning from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). This study examined processing speed and executive functioning in a sample of OEF/OIF veterans who had sustained mTBI, a subset of whom also had comorbid PTSD. Methods: Fifty-three OEF/OIF veterans with a history of mTBI completed Wechsler Adult Intelligence Scale-III Symbol Search and Digit Symbol-Coding subscales, Stroop Word, color and color-word trials, and Trail Making Test, Parts A and B as part of a comprehensive neuropsychological test battery. Results: Excluding from analysis those who scored poorly on effort testing, multiple regression showed that measures of processing speed accounted for 43% of the variance in performance on the Trail Making Test, Part B and 50% of the variance in performance on the Stroop task. Significant differences in processing speed and executive functioning were found on the basis of presence of comorbid PTSD. Stroop Color (F = 9.27, df = 52, P < .004) and Stroop Color Word (F = 7.19, df = 52, P < .01) scores differed significantly between the groups. Those having comorbid PTSD (+TBI/+PTSD) scored significantly poorer than the mTBI-only group (+TBI/-PTSD). Implications for treatment of the comorbid conditions are discussed.