Validating the usefulness of the NSI validity-10 with the MMPI-2-RF.

Purpose/Aim of the Study: The Neurobehavioral Symptom Inventory (NSI) is a 22-item self-report measure created to quantify the somatosensory, cognitive, and affective symptoms of Post-concussive Syndrome. Developers of the NSI used a subset of 10 items, the Validty-10, to measure symptom overreporting. We compared the Validity-10 versus the remaining NSI items (i.e., the Remaining-12) for how accurately they detect symptom exaggeration on the Minnesota Multiphasic Personality Inventory Second Edition - Restructured Form (MMPI-2-RF).Materials and Methods: We used a sample of 45 veterans evaluated in a Polytrauma/TBI Clinic of a Midwest VA Healthcare System who completed the NSI and MMPI-2-RF.Results: The Vaidity-10, Remaining-12, and Total Score all strongly correlated with mean of the MMPI-2-RF validity scales (r = .65, .67, and .70, respectively), illustrating equivalency among the various NSI scores. Groups were created based on significant T score elevation on any MMPI-2-RF validity scale (i.e. F-r > 119, or Fp-r, F-s, FBS, or RBS > 99). ROC analyses demonstrated that areas under the curve were equivalent for NSI Total Score (.84), Validity-10 (.81), and Remaining-12 (.81) in detecting overreporting.Conclusions: These findings do not support the notion that the Validity-10 has unique utility as an embedded symptom validity scale and highlights the likelihood that NSI Total Score can also serve this function.

Measuring change in anhedonia using the "Happy Faces" task pre- to post-repetitive transcranial magnetic stimulation (rTMS) treatment to left dorsolateral prefrontal cortex in Major Depressive Disorder (MDD): relation to empathic happiness.

We investigated whether repetitive transcranial magnetic stimulation (rTMS) to the left dorsolateral prefrontal cortex (DLPFC) would reduce anhedonia in a sample of 19 depressed adults (Mage = 45.21, SD = 11.21, 63% women) randomized to either active or sham rTMS. To track anhedonia, patients completed the Snaith-Hamilton Pleasure Scale (SHAPS)1 and a novel behavioral task called "Happy Faces," which required patients to interpret neutral versus various intensities of positively valenced human facial expressions. Patients had to indicate dichotomously whether any degree of positive emotion was expressed. We expected that more anhedonic patients would struggle most with low intensity happy faces; often incorrectly calling them neutral. Patients also completed a self-report measure of "empathic happiness"-i.e., vicarious joy. Measures were completed pre- to post-treatment. Results indicate rTMS to DLPFC related to improvement in interpretation of subtle forms of happiness in active rTMS patients relative to sham. Furthermore, empathic happiness and anhedonia score were significantly antagonistic across all patients.

Emerging evidence for speeded alphabet printing as a measure of processing speed and working memory.

Alphabet Printing (in the forward and backward order) is a brief and highly portable test with promise as a screening measure of processing speed and simple working memory, constructs which are only minimally assessed in many of the most commonly-used cognitive screening instruments. The aim of this project was to examine the construct validity of timed Alphabet Printing in a sample of 254 Veterans with cognitive complaints and a history of possible head injury. Criterion measures included more established tests of processing speed and simple working memory, including the Trail Making Test and the Digit Span subtest from the fourth edition of the Wechsler Adult Intelligence Scales. Alphabet Printing scores moderately correlated with the criterion measures of attention, working memory, and processing speed, and demonstrated acceptable classification accuracy in discriminating between individuals with and without evidence of cognitive impairment on Trails B. These findings provide additional support for the possible utility of including Alphabet Printing during cognitive screenings or as part of a larger neuropsychological test battery.

Suspiciously slow: timed digit span as an embedded performance validity measure in a sample of veterans with mTBI.

OBJECTIVE: To explore the utility of Timed Digit Span (TDS) as an embedded performance validity test (PVT) in a sample of veterans with mild traumatic brain injury (mTBI). We hypothesize that TDS will predict PVT failure on an established stand-alone measure (Trial 1 of the Test of Memory Malingering; TOMM). METHODS: TDS was compared to Digit Span accuracy (DS), using TOMM as a criterion measure, in a sample of 99 veterans with mTBI. Correlation and regression were used to characterize associations between PVTs. Logistic regression was utilized to examine the relationship between embedded PVTs and the odds of TOMM failure. Classification accuracy of TDS was examined using receiver operating characteristic (ROC) curves. Predictive power of TDS to estimate TOMM failure was calculated for the current sample and for hypothetical populations with common base rates (BRs). OUTCOMES: TDS significantly predicted failure on the TOMM and added greater incremental predictive value to the model compared to DS accuracy. Estimates of the predictive power of TDS were calculated using observed and hypothetical BRs. Sensitivity to stand-alone PVT, failure was 38% when specificity was set at 90%. CONCLUSION: TDS offers a promising embedded PVT method, given its strong convergence with an established stand-alone PVT.

Streamlining screening of emotional function in Veterans with traumatic brain injury.

OBJECTIVES: This study examined how depression, anxiety, and sleep items from the Neurobehavioral Symptom Inventory (NSI) predict results from longer inventories. METHOD: This was a retrospective review from 484, predominantly male (96.1%) Veterans, mean age 29.7 years, who underwent brief neuropsychological screening during a comprehensive, multidisciplinary evaluation for mild traumatic brain injury (TBI). Participants completed the NSI, insomnia severity index (ISI), and hospital anxiety and depression scale (HADS). RESULTS: OVERALL,: 97.1% who endorsed "severe"/"very severe" anxiety on the NSI had significant anxiety on the HADS; 85% reporting "severe"/"very severe" depression on the NSI, had significant depression on the HADS; and 97.7% reporting "severe"/"very severe" sleep problems on the NSI, had significant sleep difficulties on the ISI. CONCLUSION: Close correspondence between "severe"/"very severe" symptoms on the NSI and lengthier checklists suggests additional checklists may be eliminated and individuals can be referred for mental health treatment. NSI reports of "mild"/"moderate" require further screening.

Population Base Rates and Disease Course of Common Psychiatric and Neurodegenerative Disorders.

Knowledge of population base rates of neurological and psychiatric disorders is fundamental for diagnostic decision making. Consideration of relevant probabilistic information can improve diagnostic efficiency and accuracy. However, such data continue to be misused or underutilized, which can lead to misdiagnoses and negative patient outcomes. The aim of the current review is to create an easily accessible and comprehensive reference of existing age of onset as well as prevalence and incidence data for common neurodegenerative and psychiatric disorders in adults. Relevant epidemiological data were compiled from well-respected and frequently-cited textbooks and scholarly studies. Reviews were collected from PubMed, and publicly-available sources were gathered from Google Scholar. Results are organized and presented in several tables and a figure, which can be used as a diagnostic guide for students and clinicians across healthcare disciplines.

Self-Reported Health and Safety Awareness Improves Prediction of Level of Care Needs in Veterans Discharged From a Postacute Unit.

OBJECTIVES: To evaluate the differential value of a self-reported health and safety awareness measure relative to other medical, psychosocial, and cognitive factors in predicting level of care (LOC) needs after hospital discharge. DESIGN: Retrospective medical record review. SETTING: Community living center postacute care (CLC-PAC) unit at a Veterans Affairs hospital. PARTICIPANTS: A total of 175 veterans admitted to the Veterans Affairs hospital or directly to the CLC-PAC from home. METHODS: Cognitive status was assessed with the Mini-Mental State Examination, Digit Span Backward subtest, Trail Making Test (Part B), and Hopkins Verbal Learning Test-Revised. Self-report of health and safety awareness was measured with the Independent Living Scales Health and Safety (ILS-HS) subscale. Additional demographic and admission-related variables were coded, along with medical comorbidity, with the Charlson Comorbidity Index and depression using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision Depression Checklist. MAIN OUTCOME MEASUREMENTS: Increased level of care was collected from social work and occupational therapy notes and defined as increased assistance with activities of daily living or nursing home placement comparing prehospitalization with CLC-PAC discharge. RESULTS: A total of 19% (n = 34) of residents required increased LOC on CLC-PAC discharge. The ILS-HS was a significant predictor of increased LOC above and beyond age and Mini Mental Status Examination score; for each standard deviation decrease in ILS-HS, there was an increased likelihood of greater LOC (odds ratio 0. 54, 95% confidence interval 0.35-0.83). Other neuropsychological tests (memory, executive functioning) did not significantly improve the model. CONCLUSIONS: The inclusion of the ILS-HS to a standard cognitive screen (Mini Mental Status Examination) can improve prediction of increased LOC. Although select aspects of memory and executive functioning independently contribute to increased LOC prediction, the ILS-HS likely measures a unique aspect of cognitive functioning that may be specific to discharge planning needs in CLC-PAC residents. LEVEL OF EVIDENCE: II.

"Top-Down" Mu-Opioid System Function in Humans: Mu-Opioid Receptors in Ventrolateral Prefrontal Cortex Mediate the Relationship Between Hedonic Tone and Executive Function in Major Depressive Disorder.

Cognitive dysfunction and anhedonia, the reduced ability to experience pleasure, are commonly comorbid symptoms that are persistent following successful resolution of negative affect in major depressive disorder (MDD). Little is known about whether they share common etiology. In the present study, the relationship between ventrolateral prefrontal cortex (VLPFC) activity, cognitive dysfunction (i.e., executive dysfunction), and positive emotionality was investigated in conjunction with mu-opioid neurotransmission in a sample of 39 MDD patients. Results suggest that increased endogenous mu-opioid tone in the VLPFC mediates the relationship between increased trait positive emotionality and more efficient executive functioning.

Executive Functioning at Baseline Prospectively Predicts Depression Treatment Response.

OBJECTIVE: Existing cognitive and clinical predictors of treatment response to date are not of sufficient strength to meaningfully impact treatment decision making and are not readily employed in clinical settings. This study investigated whether clinical and cognitive markers used in a tertiary care clinic could predict response to usual treatment over a period of 4 to 6 months in a sample of 75 depressed adults. METHODS: Patients (N = 384) were sequentially tested in 2 half-day clinics as part of a quality improvement project at an outpatient tertiary care center between August 2003 and September 2007; additional subjects evaluated in the clinic between 2007 and 2009 were also included. Diagnosis was according to DSM-IV-TR criteria and completed by residents and attending faculty. Test scores obtained at intake visits on a computerized neuropsychological screening battery were the Parametric Go/No-Go task and Facial Emotion Perception Task. Treatment outcome was assessed using 9-item Patient Health Questionnaire (PHQ-9) self-ratings at follow-up (n = 75). Usual treatment included psychotropic medication and psychotherapy. Decline in PHQ-9 scores was predicted on the basis of baseline PHQ-9 score and education, with neuropsychological variables entered in the second step. RESULTS: PHQ-9 scores declined by 46% at follow-up (56% responders). Using 2-step multiple regression, baseline PHQ-9 score (P ≤ .05) and education (P ≤ .01) were significant step 1 predictors of percent change in PHQ-9 follow-up scores. In step 2 of the model, faster processing speed with interference resolution (go reaction time) independently explained a significant amount of variance over and above variables in step 1 (12% of variance, P < .01), while other cognitive and affective skills did not. This 2-step model accounted for 28% of the variance in treatment change in PHQ-9 scores. Processing speed with interference resolution also accounted for 12% variance in treatment and follow-up attrition. CONCLUSIONS: Use of executive functioning assessments in clinics may help identify individuals with cognitive weaknesses at risk for not responding to standard treatments.

PPVT-I administration rules significantly shorten PPVT-III/IV administration.

This study evaluated whether using the Peabody Picture Vocabulary Test-First Edition (PPVT-I) basal and ceiling criteria would result in similar estimates of receptive vocabulary while permitting administration of fewer test items when using the third and fourth editions of the PPVT. Data were retrospectively collected from 119 adult inpatients who completed a neuropsychological screen that included the PPVT-III or PPVT-IV, which were re-scored using PPVT-I criteria. PPVT-III/IV raw scores were not significantly different from PPVT-I raw scores. Although the difference between the PPVT-III/IV and PPVT-I standard scores was statistically significant, the difference was less than 8 points in 95% of cases. On average, 15 fewer items would be administered using the PPVT-I rules, leading to shorter administration time.

Neuropsychological test validity in Veterans presenting with subjective complaints of 'very severe' cognitive symptoms following mild traumatic brain injury.

OBJECTIVE: This study explored the utility of combining data from measures of performance validity and symptom validity among Veterans undergoing neuropsychological evaluation for mild traumatic brain injury (mTBI). BACKGROUND: Persistent cognitive impairments following mTBI are often reported by returning combat veterans. However, objectively-measured cognitive deficits are not common among individuals with mTBI, raising the question of whether negative impression management influences self-ratings. METHODS: Self-report ratings were obtained for memory, concentration, decision-making, and processing speed/organization using a 5-point scale ranging from 'none' to 'very severe'. Veterans also completed brief neuropsychological testing which included measures of performance validity. RESULTS: Study 1 examined data from 122 participants and demonstrated that veterans reporting a 'very severe' cognitive deficit were over three times as likely to demonstrate poor effort on a validity test than those without a very severe rating. Study 2 replicated these findings in an independent sample of 127 veterans and also demonstrated that both severity of self-report ratings and performance on an embedded measure of effort were predictive of poor effort on a stand-alone performance validity test. CONCLUSION: Veterans with suspected mTBI who report 'very severe' cognitive impairment have a greater likelihood of putting forth sub-optimal effort on objective testing.

Incidental Learning: A Brief, Valid Measure of Memory Based on the WAIS-IV Vocabulary and Similarities Subtests.

OBJECTIVE: We assessed the validity of a brief incidental learning measure based on the Similarities and Vocabulary subtests of the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV). BACKGROUND: Most neuropsychological assessments for memory require intentional learning, but incidental learning occurs without explicit instruction. Incidental memory tests such as the WAIS-III Symbol Digit Coding subtest have existed for many years, but few memory studies have used a semantically processed incidental learning model. METHODS: We conducted a retrospective analysis of 37 veterans with traumatic brain injury, referred for outpatient neuropsychological testing at a Veterans Affairs hospital. As part of their evaluation, the participants completed the incidental learning tasks. We compared their incidental learning performance to their performance on traditional memory measures. RESULTS: Incidental learning scores correlated strongly with scores on the California Verbal Learning Test-Second Edition (CVLT-II) and Brief Visuospatial Memory Test-Revised (BVMT-R). After we conducted a partial correlation that controlled for the effects of age, incidental learning correlated significantly with the CVLT-II Immediate Free Recall, CVLT-II Short-Delay Recall, CVLT-II Long-Delay Recall, and CVLT-II Yes/No Recognition Hits, and with the BVMT-R Delayed Recall and BVMT-R Recognition Discrimination Index. CONCLUSIONS: Our incidental learning procedures derived from subtests of the WAIS-IV Edition are an efficient and valid way of measuring memory. These tasks add minimally to testing time and capitalize on the semantic encoding that is inherent in completing the Similarities and Vocabulary subtests.

Delirium Detection and Impact of Comorbid Health Conditions in a Post-Acute Rehabilitation Hospital Setting.

Misdiagnosis and under-detection of delirium may occur in many medical settings. This is important to address as delirium clearly increases risk of morbidity and mortality in such settings. This study assessed whether Veterans who screened positive on a delirium severity measure (Memorial Delirium Assessment Scale; MDAS) differed from those with and without corresponding medical documentation of delirium in terms of cognitive functioning, psychiatric/medical history, and medication use. A medical record review of 266 inpatients at a VA post-acute rehabilitation unit found that 10.9% were identified as delirious according to the MDAS and/or medical records. Of the Veterans who screened positive on the MDAS (N = 19), 68.4% went undetected by medical screening. Undetected cases had a higher number of comorbid medical conditions as measured by the Age-Adjusted Charlson Index (AACI) scores (median = 9, SD = 3.15; U = 5.5, p = .003) than medically documented cases. For Veterans with a score of 7 or greater on the AACI, the general relative risk for delirium was 4.46. Delirium is frequently under-detected in a post-acute rehabilitation unit, particularly for Veterans with high comorbid illness. The relative risk of delirium is up to 4.46 for those with high medical burden, suggesting the need for more comprehensive delirium screening in these patients.

Decreased Fronto-Limbic Activation and Disrupted Semantic-Cued List Learning in Major Depressive Disorder.

OBJECTIVES: Individuals with major depressive disorder (MDD) demonstrate poorer learning and memory skills relative to never-depressed comparisons (NDC). Previous studies report decreased volume and disrupted function of frontal lobes and hippocampi in MDD during memory challenge. However, it has been difficult to dissociate contributions of short-term memory and executive functioning to memory difficulties from those that might be attributable to long-term memory deficits. METHODS: Adult males (MDD, n=19; NDC, n=22) and females (MDD, n=23; NDC, n=19) performed the Semantic List Learning Task (SLLT) during functional magnetic resonance imaging. The SLLT Encoding condition consists of 15 lists, each containing 14 words. After each list, a Distractor condition occurs, followed by cued Silent Rehearsal instructions. Post-scan recall and recognition were collected. Groups were compared using block (Encoding-Silent Rehearsal) and event-related (Words Recalled) models. RESULTS: MDD displayed lower recall relative to NDC. NDC displayed greater activation in several temporal, frontal, and parietal regions, for both Encoding-Silent Rehearsal and the Words Recalled analyses. Groups also differed in activation patterns in regions of the Papez circuit in planned analyses. The majority of activation differences were not related to performance, presence of medications, presence of comorbid anxiety disorder, or decreased gray matter volume in MDD. CONCLUSIONS: Adults with MDD exhibit memory difficulties during a task designed to reduce the contribution of individual variability from short-term memory and executive functioning processes, parallel with decreased activation in memory and executive functioning circuits. Ecologically valid long-term memory tasks are imperative for uncovering neural correlates of memory performance deficits in adults with MDD.

Patterns of frontoparietal activation as a marker for unsuccessful visuospatial processing in healthy aging.

Visuospatial abilities are sensitive to age-related decline, although the neural basis for this decline (and its everyday behavioral correlates) is as yet poorly understood. fMRI was employed to examine age-related differences in patterns of functional activation that underlie changes in visuospatial processing. All participants completed a brief neuropsychological battery and also a figure ground task (FGT) assessing visuospatial processing while fMRI was recorded. Participants included 16 healthy older adults (OA; aged 69-82 years) and 16 healthy younger adults (YA; aged 20-35 years). We examined age-related differences in behavioral performance on the FGT in relation to patterns of fMRI activation. OA demonstrated reduced performance on the FGT task and showed increased activation of supramarginal parietal cortex as well as increased activation of frontal and temporal regions compared to their younger counterparts. Performance on the FGT related to increased supramarginal gyrus activity and increased medial prefrontal activity in OAs, but not YAs. Our results are consistent with an anterior-posterior compensation model. Successful FGT performance requires the perception and integration of multiple stimuli and thus it is plausible that healthy aging may be accompanied by changes in visuospatial processing that mimic a subtle form of dorsal simultanagnosia. Overall, decreased visuospatial processing in OA relates to an altered frontoparietal neurobiological signature that may contribute to the general phenomenon of increasingly fragmented execution of behavior associated with normal aging.

Cognitive reserve and executive function: Effect on judgment of health and safety.

Individuals with the same neurological conditions do not necessarily manifest the same behavioral presentation, which suggests differences in resilience and vulnerability among individuals, a concept known as cognitive reserve. This study sought to explore the relationship among cognitive reserve, executive functioning, and health and safety judgment among a sample of older adult inpatients in an extended medical care unit at a Veterans Health Administration hospital. We hypothesized that cognitive reserve, as determined by an estimate of premorbid intellectual ability, would act as a protective factor against poor judgment in older adults with executive dysfunction. Participants included 200 Veterans who completed a comprehensive neuropsychological assessment, including measures of health and safety judgment, executive functioning, global cognitive functioning, and premorbid intellectual ability. After controlling for global cognitive functioning, executive functioning abilities did not have an effect on judgment abilities among those with high estimated intellectual ability. However, executive functioning had a significant effect on judgment abilities among those with low estimated intellectual ability. Our results suggest that intact executive functioning is critical for making appropriate health and safety decisions for patients with lower measured intellectual abilities and provide further support for the cognitive reserve model. Clinical implications are also discussed.

Reliability and factor structure of the Hospital Anxiety and Depression Scale in a polytrauma clinic.

The Hospital Anxiety and Depression Scale (HADS) is a brief self-report measure of anxiety and depression symptoms. This study examined the internal consistency and factor structure of the HADS among Veterans in a polytrauma/traumatic brain injury clinic. The sample consisted of 312 Veterans. A confirmatory factor analysis of the depression and anxiety subscales showed, not surprisingly, that the two factors were highly correlated (r = 0.7). Goodness of fit statistics for the two-factor model were acceptable (root mean square error of approximation = 0.06, comparative fit index = 0.94). The HADS demonstrated very good reliability overall (alpha = 0.89) and for the individual subscales (alpha = 0.84). This study supports the use of the HADS as a screen for depression and anxiety in the assessment of mild traumatic brain injury in a Veteran population.

Limited usefulness of the Rey Fifteen-Item Test in detection of invalid performance in veterans suspected of mild traumatic brain injury.

OBJECTIVE: This study explored using the FIT as a measure of performance validity among veterans undergoing neuropsychological evaluation for mild traumatic brain injury (mTBI). BACKGROUND: The Rey Fifteen-Item Memory Test (FIT) is a performance validity measure criticized for poor sensitivity. METHODS: Two hundred and fifty-seven veterans completed the FIT and Wechsler Adult Intelligence Scale, Fourth Edition, Digit Span (DS); 109 of whom completed the Test of Memory Malingering (TOMM). FIT cut-offs of <9, <8 and stricter cut-offs were examined using DS and/or TOMM as criterion performance validity measures. RESULTS: Only four participants scored below the standard cut score of 9 on the FIT. Among the 13 veterans failing both criterion tests, only two scored below 9 on the FIT. Regardless of which FIT cut-off was used, the FIT had poor diagnostic accuracy. CONCLUSION: Despite its popularity, the FIT is not supported as an appropriate measure of performance validity in veterans undergoing evaluation for possible mTBI. Therefore, inferences regarding neuropsychological data reliability with adequate statistical certainty require use of other measures of performance validity with greater sensitivity.

Age and gender modulate the neural circuitry supporting facial emotion processing in adults with major depressive disorder.

OBJECTIVES: Emotion processing, supported by frontolimbic circuitry known to be sensitive to the effects of aging, is a relatively understudied cognitive-emotional domain in geriatric depression. Some evidence suggests that the neurophysiological disruption observed in emotion processing among adults with major depressive disorder (MDD) may be modulated by both gender and age. Therefore, the present study investigated the effects of gender and age on the neural circuitry supporting emotion processing in MDD. DESIGN: Cross-sectional comparison of fMRI signal during performance of an emotion processing task. SETTING: Outpatient university setting. PARTICIPANTS: One hundred adults recruited by MDD status, gender, and age. MEASUREMENTS: Participants underwent fMRI while completing the Facial Emotion Perception Test. They viewed photographs of faces and categorized the emotion perceived. Contrast for fMRI was of face perception minus animal identification blocks. RESULTS: Effects of depression were observed in precuneus and effects of age in a number of frontolimbic regions. Three-way interactions were present between MDD status, gender, and age in regions pertinent to emotion processing, including frontal, limbic, and basal ganglia. Young women with MDD and older men with MDD exhibited hyperactivation in these regions compared with their respective same-gender healthy comparison (HC) counterparts. In contrast, older women and younger men with MDD exhibited hypoactivation compared to their respective same-gender HC counterparts. CONCLUSIONS: This the first study to report gender- and age-specific differences in emotion processing circuitry in MDD. Gender-differential mechanisms may underlie cognitive-emotional disruption in older adults with MDD. The present findings have implications for improved probes into the heterogeneity of the MDD syndrome.

Affect and psychiatric symptoms in a veteran polytrauma clinic.

Although the relationship between negative affect and psychiatric symptoms has been well-demonstrated in research, less is known about positive affect relative to negative affect, and its relationship to psychiatric symptoms, especially among veterans. This study examined how levels of positive and negative affect are associated with symptoms of depression, anxiety, and posttraumatic stress disorder (PTSD). Data were collected in a veteran polytrauma clinic; analyses were conducted using data from 94 veterans (87 males) with and without a mild traumatic brain injury (mTBI) diagnosis. Results demonstrate that positive and negative affect were separate dimensions and that both were independently related to each symptom measure. After removing the contribution of negative affect from symptom reports, strong relationships remained between positive affect and psychiatric symptoms. Furthermore, the magnitude of the associations for positive affect and for negative affect with symptoms of depression, anxiety, and PTSD were not impacted by a mTBI diagnosis. Altogether, findings suggest that both positive and negative affect should be uniquely considered when conceptualizing, assessing, and treating returning service members; in addition, positive affect may be an appropriate target of assessment and interventions of persons who have experienced polytrauma.