Health symptoms after war zone deployment-related mild traumatic brain injury: contributions of mental disorders and lifetime brain injuries.

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.

Embedded Performance Validity Measures with Postdeployment Veterans: Cross-Validation and Efficiency with Multiple Measures.

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.

Personality Assessment Inventory profiles of veterans: Differential effects of mild traumatic brain injury and psychopathology.

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.

Factor structure and construct validity of the Behavioral Dyscontrol Scale-II.

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.

The Behavioral Dyscontrol Scale-II with non-elderly veterans.

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.

Performance on the Green Word Memory Test following Operation Enduring Freedom/Operation Iraqi Freedom-era military service: Test failure is related to evaluation context.

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.

Relationship between processing speed and executive functioning performance among OEF/OIF veterans: implications for postdeployment rehabilitation.

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.