Psychometric properties of the late positive potential in combat-exposed veterans.

Trauma exposure is prevalent, associated with multiple forms of psychopathology, and thought to alter the neurobiological substrates of threat processing. The late positive potential (LPP) is an event-related potential (ERP) that may be a clinically useful probe of the neurobiology of threat processing. Despite evidence that combat-exposed veterans exhibit aberrant threat modulation of the LPP, no studies to date have tested the psychometric properties of the LPP in combat trauma-exposed, symptomatic veterans. The primary aim of the current study was to evaluate the reliability (internal consistency, retest reliability) and convergent validity of LPP modulation by threatening faces and scenes in two common tasks among combat-exposed veterans. Participants included 82 combat-exposed veterans who completed face-matching and emotion regulation tasks during EEG recording at baseline and twelve weeks. Internal consistencies of the early LPP time windows (<1000 ms) were acceptable in both tasks, whereas they were poor in late time windows (>1000 ms). Twelve-week retest reliabilities were fair for the early window LPPs to threatening scenes and fear faces, as well as in the late time window for fear faces. Reliabilities were better for individual condition compared to difference scores. Finally, LPPs modulated by threatening scenes and faces were unrelated. Together, these results suggest that the LPPs to threatening scenes and faces reflect distinct forms of threat processing in combat-exposed veterans, and their reliabilities for the early window indicate potential clinical utility in this population.

Concordance of Embedded Performance and Symptom Validity Tests and Associations with Mild Traumatic Brain Injury and Posttraumatic Stress Disorder among Post-9/11 Veterans.

OBJECTIVE: The present study explored both embedded symptom (SVT) and performance (PVT) validity test scores within a post-9/11 veteran sample to elucidate the degree to which there is concordance between validity indicators, as well as how frequently one SVT and four PVT indicators were failed in screened mild traumatic brain injury (mTBI) and diagnosed posttraumatic stress disorder (PTSD). METHOD: A total of 114 post-9/11 veterans were evaluated utilizing the Neurobehavioral Symptom Inventory (NSI) Validity-10, four embedded PVTs, mTBI screening, and a diagnostic interview for PTSD. RESULTS: While we found concordance between embedded PVTs and the NSI Validity-10 at select cutoffs (i.e., ≥13, ≥19), symptom and performance validity indicators were clinically dissociable in that only SVT significantly predicted diagnosed PTSD and screened mTBI. CONCLUSIONS: Dissociation between symptom and performance validity may be clinically useful when interpreting neuropsychological evaluation findings in post-9/11 veterans with a history of mTBI or PTSD.

Nonlinear relations between post-traumatic stress symptoms and electrocortical reactivity during emotional face processing in combat-exposed veterans.

Combat-related post-traumatic stress symptoms (PTSS) are prevalent among recently deployed veterans, making identification of biomarkers of PTSS in this population a public health priority. Given the link between threat processing neurobiology and PTSS, the threat-related late positive potential (LPP), an ERP reflective of attentional processing sensitive to emotion and its regulation, may have utility as a cost-effective biomarker. Existing PTSS/threat-related LPP findings are mixed, possibly due to variability in PTSS across samples, but this has never been explicitly tested. To address this gap, LPP amplitudes to angry, fearful, and happy emotional face stimuli were recorded among 81 combat-exposed veterans at a VA hospital. A quadratic relationship between self-reported PTSS and LPP amplitude modulation by angry faces emerged such that greater PTSS was related to a decreased LPP response to angry faces among veterans with subthreshold PTSD and an enhanced LPP response to angry faces among veterans with probable PTSD. These results suggest that prior mixed findings may be due to variability in PTSS severity. In addition, exploratory moderation analysis revealed that PTSS was positively associated with late LPP modulation for veterans reporting low cognitive reappraisal use and negatively associated with late LPP modulation for veterans reporting high cognitive reappraisal use. All results were specific to the 1,000-3,000 ms LPP time window. Thus, the functional nature of LPP modulation by direct threat cues may depend upon PTSS severity and/or related variables (e.g., cognitive reappraisal utilization).

Cognitive reappraisal moderates the relationship between PTSD symptoms and alcohol use over time in post-9/11 U.S. military veterans.

BACKGROUND: Rates of comorbid alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD) are increasing among post-9/11 veterans, and emotion regulation problems have been identified as a feature of both disorders. However, no studies to date have explored how individual differences in emotion regulation may moderate the relationship between PTSD symptoms and alcohol use. We evaluated how two core emotion regulation strategies - one adaptive (i.e., cognitive reappraisal) and one maladaptive (i.e., expressive suppression) are related to PTSD symptoms and alcohol use over one-year. METHODS: A total of 71 post-9/11 veterans (12 female, 59 male) completed a baseline screening and at least two follow-up assessments over the course of 12 months which included measures of emotion regulation, PTSD symptoms, and alcohol use. A mixed growth model was utilized to determine if changes in PTSD symptoms covaried with alcohol use over time and whether this relation was moderated by frequency of use of emotion regulation strategies. RESULTS: In general, higher PTSD symptoms were significantly associated with greater alcohol use, but cognitive reappraisal moderated this relationship. Specifically, at low cognitive reappraisal, greater PTSD symptoms were associated with greater alcohol use. At high cognitive reappraisal, there was no significant association between PTSD symptoms and alcohol use. CONCLUSIONS: Findings from the present study suggest that baseline individual differences in cognitive reappraisal influence the relation between PTSD symptoms and alcohol use. For post-9/11 veterans, high levels of cognitive reappraisal may serve as a protective factor against ongoing alcohol use.

Impact of PTSD on post-concussive symptoms, neuropsychological functioning, and pain in post-9/11 veterans with mild traumatic brain injury.

Prior work suggested that post-traumatic stress disorder (PTSD) worsens post-concussive symptoms (PCS), neuropsychological functioning, and pain-related outcomes in post-9/11 veterans. However, the impact of PTSD in the context of mild traumatic brain injury (mTBI) is not entirely clear. We evaluated possible differences among veterans with deployment-related mTBI with and without PTSD, and a comparison group. We hypothesized that veterans with comorbid mTBI and PTSD would report more PCS, perform worse on neuropsychological tasks, and report greater pain intensity and maladaptive pain coping relative to those without PTSD. Ninety (15 female, 75 male) post-9/11 veterans completed measures of psychiatric functioning, PCS, deployment-related mTBI, pain intensity, pain coping, and a brief neuropsychological evaluation. Veterans with comorbid mTBI and PTSD reported significantly higher PCS across domains, and greater pain intensity and maladaptive coping. They also performed more poorly on measures of recall, but not on measures of attention, encoding, or executive functioning. Findings suggest that PTSD results in greater PCS in the context of mTBI, and is associated with greater pain catastrophizing, worse recall, greater pain intensity, and greater illness-focused coping than in mTBI alone. PCS symptoms, recall, and pain coping may be of clinical importance for post-9/11 veterans with the "polytrauma triad."

Individual differences in combat experiences and error-related brain activity in OEF/OIF/OND veterans.

Increased error-related negativity (ERN) has been implicated in the pathophysiology of multiple forms of psychopathology. Although there is increasing evidence that the ERN can be shaped by environment and experience, no studies to date have examined this question in a clinical sample. In the current study, we examined the influence of combat exposure on the ERN using electroencephalogram (EEG) in a sample of military veterans with a high prevalence of psychopathology. Participants included sixty-seven U.S. military veterans from Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND). The degree of combat exposure was assessed using the Deployment Risk and Resilience Inventory-2 (DRRI-2) and Combat Exposure Scale (CES). A well-validated flanker task was used to elicit the ERN during continuous EEG recording. Results revealed that veterans who reported experiencing greater combat exposure exhibited a more enhanced ERN, even when adjusting for broad anxiety and posttraumatic stress disorder (PTSD) symptoms. The association between combat exposure and ERN was not moderated by PTSD symptom severity. The current study demonstrates that greater combat exposure is associated with a more enhanced ERN among OEF/OIF/OND veterans. This enhanced ERN may be one mechanism that places veterans at greater risk for developing psychiatric disorders following exposure to combat. Future longitudinal studies are needed to directly test whether the ERN mediates the relation between level of combat exposure and the development of internalizing disorders.

Barriers and strategies for coordinating care among veterans with traumatic brain injury: a mixed methods study of VA polytrauma care team members.

BACKGROUND: Veterans who experience traumatic brain injury (TBI) may have long-term needs placing a premium on well-coordinated care. This study aimed to (1) identify barriers to care coordination for Veterans with TBI; and (2) describe strategies used by VA polytrauma care team members to coordinate care for Veterans with TBI. METHODS: We utilised a mixed method design, including an online survey of VA polytrauma care team members (N = 236) and subsequent semi-structured interviews (N = 25). Analysis of the survey data was descriptive; interview data was analysed using constant comparative techniques. RESULTS: The most common system-related barriers 25 for access to military records (64%) and insufficient time (58%). The most common patient-related barriers were missed appointments/no shows (87%) and the mental health issues (74%). Strategies reported on the survey to promote coordination reflected the centrality of teamwork and communication, and included promoting multidisciplinary team collaboration (32%) and holding 30 regular meetings (23%). Interview findings were consistent, emphasising the effective functioning of multidisciplinary clinics. CONCLUSION: Polytrauma care team members encounter barriers to care coordination for Veterans with TBI, and have developed strategies in response. Information sharing, provider workload, communication, and patient engagement will be critical to address in future efforts to enhance care coordination in this context.

Differential impact of post-deployment stress and PTSD on neural reactivity to emotional stimuli in Iraq and Afghanistan veterans.

For many veterans returning from combat in Iraq and Afghanistan, the transition from military to civilian life is complicated by an array of postdeployment stressors. In addition to significant stress associated with reintegration after deployment, many returning veterans also contend with the added burden conferred by PTSD symptoms. While the relationship between PTSD symptoms and the neurobiological substrates of emotion dysregulation has begun to be studied, even less is known about the effects of postdeployment stress on neural function. In order to assess the relationship among a neural measure of attention to emotion (i.e. the late positive potential; LPP), PTSD symptoms and postdeployment stressors, EEG was recorded and examined in a linear mixed model of 81 OEF/OIF/OND veterans. Results revealed a main effect for postdeployment stressors such that increased postdeployment stress was associated with a relatively enhanced LPP across all emotion types. There was also a main effect for PTSD symptoms such that greater symptoms were related to a relatively blunted LPP across all emotion types. Findings may have important implications for understanding how both current stress and PTSD symptoms affect motivated attention as measured by the LPP. Moreover, this work highlights the need to consider the effects of current stress, in addition to PTSD symptoms, on the functioning of returning veterans.

Neural response to errors is associated with problematic alcohol use over time in combat-exposed returning veterans: An event-related potential study.

BACKGROUND: Currently, we do not have biomarkers to help identify individuals at-risk for chronic, problematic alcohol use, especially among veteran populations, who have notoriously high rates of alcohol use. One biomarker that may predict individuals at risk for chronic, problematic alcohol use is error-related brain activity. We examined longitudinal associations between the error-related negativity (ERN), an event-related potential observed following the commission of errors, and problematic alcohol use among U.S. military veterans returning from recent conflicts in Iraq and Afghanistan. METHODS: Forty-six military veterans, aged 18-55 years, completed a well-validated flanker task known to elicit the ERN at baseline. Problematic alcohol use and other clinically relevant variables were assessed at baseline, 3-, 6-, 9-, 12-, 15-, 18-, 21-months, and 2 years. RESULTS: Results indicated that the ERN magnitude was associated with problematic alcohol use over time, even after controlling for relevant clinical variables. Specifically, veterans with a smaller ERN magnitude evidenced a decline in problematic alcohol use over time, while veterans with a larger ERN magnitude had no change in their problematic alcohol use across the follow-up. In addition, exploratory analyses found that treatment engagement during the study did not moderate these relationships. CONCLUSIONS: Our findings provide preliminary evidence that ERN can be used as a predictor of problematic alcohol use over time. Therefore, neural response to errors could help to identify individuals at risk for continued problematic alcohol use for intervention efforts and suggests that error processing may be an important therapeutic target within Alcohol Use Disorder intervention efforts.

Clinical information seeking in traumatic brain injury: a survey of Veterans Health Administration polytrauma care team members.

BACKGROUND: The polytraumatic nature of traumatic brain injury (TBI) makes diagnosis and treatment difficult. OBJECTIVES: To (1) characterise information needs among Veterans Health Administration (VHA) polytrauma care team members engaged in the diagnosis and treatment of TBI; (2) identify sources used for TBI related information; and (3) identify barriers to accessing TBI related information. METHODS: Cross-sectional online survey of 236 VHA polytrauma care team members. RESULTS: Most respondents (95.8%) keep at least somewhat current regarding TBI, but 31.5% need more knowledge on diagnosing TBI and 51.3% need more knowledge on treating TBI. Respondents use VHA affiliated sources for information, including local colleagues (81.7%), VHA offsite conferences/meetings (78.3%) and onsite VHA educational offerings (73.6%); however, limited time due to administrative responsibilities (50.9%), limited financial resources (50.4%) and patient care (50.4%) were prominent barriers. DISCUSSION: Medical librarians are in a unique position to develop information services, resources and other electronic tools that reflect the clinical context in which polytrauma care team members practice, and the different tasks they perform. CONCLUSION: Polytrauma care team members could benefit from additional information regarding the diagnosis and treatment of TBI. Addressing their information needs and supporting their information seeking requires a mulit-pronged approach to time and financial constraints.

Neural indices of emotional reactivity and regulation predict course of PTSD symptoms in combat-exposed veterans.

After diagnosis, veterans with posttraumatic stress disorder (PTSD) display significant variability in the natural course of illness (Bonanno et al., 2012)). Cross-sectional work reveals that abnormal neural response during emotion reactivity-measured using the late positive potential (LPP)-correlates with PTSD symptom severity; however, whether the LPP during emotional reactivity and regulation predicts symptoms over time is unknown. The current study examined the LPP during emotion reactivity and regulation as predictors of PTSD symptoms over one year in OEF/OIF/OND combat-exposed veterans. At baseline, participants completed an Emotion Regulation Task (ERT) during electroencephalogram recording. The Clinician Administered PTSD Scale (CAPS) was completed at baseline (N=86), 6-months (N=54) and 1-year (N=49) later. During ERT, participants viewed negative pictures; partway through they were instructed to "reappraise" (i.e., reduce negative affect/regulate) or "look" (i.e., passively react). Change in LPP during emotional reactivity (ΔLPP-E) and reappraisal (ΔLPP-R) were calculated and used in multilevel mixed modeling to predict CAPS over time. Findings demonstrated that deficiency in reappraisal (ΔLPP-R) predicted more overall symptoms over time, while greater neural responses to emotion (ΔLPP-E) and greater change in neural response as a function of reappraisal (ΔLPP-R) predicted a decline in avoidance symptoms over time. Together, results support the utility of neural markers of emotional reactivity and regulation as predictors of PTSD symptoms-and change in symptoms-across one year.

PTSD symptoms are associated with visual retrieval performance in OEF/OIF/OND veterans.

Posttraumatic stress disorder (PTSD) is associated with poorer performance on neuropsychological tests in veterans. However, prior studies have generally compared individuals with PTSD to control groups, often excluding individuals with moderate symptoms. The present study evaluated neuropsychological performance among OEF/OIF/OND veterans as a function of overall PTSD severity, while also exploring potential associations between cognitive performance and PTSD symptom clusters. Using a brief neuropsychological battery, clinical interviews, and self-report instruments, we evaluated neuropsychological and psychiatric functioning in 90 OEF/OIF/OND veterans. When controlling for the effects of premorbid intellectual functioning and combat exposure, higher PTSD severity predicted worse visual retrieval performance, but not attention, verbal retrieval, visual learning, or executive functioning performance. A trend was observed where higher PTSD symptoms predicted worse verbal learning performance. All PTSD symptom clusters were associated with visual retrieval performance within the full sample. Avoidance and numbing symptoms were associated with verbal learning in the full sample. Findings suggest that among OEF/OIF/OND veterans with a range of PTSD symptoms, the assessment of visual memory may have implications for clinical practice.

An electrocortical investigation of emotional face processing in military-related posttraumatic stress disorder.

PTSD is a disorder of emotion dysregulation. Although much work has intended to elucidate the neural underpinnings of the disorder, much remains unknown about the neurobiological substrates of emotion dysregulation in PTSD. In order to assess the relationship between a neural measure of attention to emotion (i.e. the late positive potential; LPP) and PTSD symptoms, EEG was recorded and examined as a potential predictor of military-related PTSD symptoms in a sample of 73 OEF/OIF/OND veterans. Results revealed that higher PTSD symptoms were related to an attenuated LPP response to angry facial expressions. This finding was not observed for happy or fearful faces. The current study provides initial evidence that, in a relatively young, mostly male sample of OEF/OIF/OND veterans, hyporeactivity to angry faces at the neural level may provide phenotypic data to characterize individual differences in PTSD symptom severity. This work may assist in future studies that seek to examine useful psychophysiologic targets for treatment and early interventions.

Affective and cognitive correlates of PTSD: Electrocortical processing of threat and perseverative errors on the WCST in combat-related PTSD.

PTSD is characterized by both affective and cognitive dysfunction. Affectively, PTSD is associated with both heightened emotional reactivity and disengagement. Cognitively, perseverative thinking is a core feature of the disorder. In order to assess the interactive effects of affective and cognitive correlates of PTSD symptoms, 47 OEF/OIF/OND veterans completed an emotional faces matching task while EEG (i.e., late positive potential; LPP) was recorded, and separately completed the Wisconsin Card Sorting Test (WCST) to assess perseverative errors. There was no relationship between PTSD symptoms and either perseverative errors or EEG reactivity to faces. However, an interaction was found such that high perseverative errors on the WCST and a relatively enhanced LPP to angry faces was associated with greater PTSD symptoms, while low errors on the WCST and a relatively blunted LPP to angry faces also related to greater PTSD symptoms. These findings suggest that emotion-cognition interactions are important for understanding PTSD, and that distinct emotion-cognition constellations interact with symptoms.

Impact of alcohol use disorder comorbidity on defensive reactivity to errors in veterans with posttraumatic stress disorder.

Converging lines of evidence suggest that individuals with comorbid posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) may be characterized by heightened defensive reactivity, which serves to maintain drinking behaviors and anxiety/hyperarousal symptoms. However, it is important to note that very few studies have directly tested whether individuals with PTSD and AUD exhibit greater defensive reactivity compared with individuals with PTSD without AUD. Therefore, the aim of the current study was to test this emerging hypothesis by examining individual differences in error-related negativity (ERN), an event-related component that is larger among anxious individuals and is thought to reflect defensive reactivity to errors. Participants were 66 military veterans who completed a well-validated flanker task known to robustly elicit the ERN. Veterans were comprised of 3 groups: controls (i.e., no PTSD or AUD), PTSD-AUD (i.e., current PTSD but no AUD), and PTSD + AUD (i.e., current comorbid PTSD and AUD). Results indicated that individuals with PTSD and controls generally did not differ in ERN amplitude. However, among individuals with PTSD, those with comorbid AUD had significantly larger ERNs than those without AUD. These findings suggest that PTSD + AUD is a neurobiologically unique subtype of PTSD, and the comorbidity of AUD may enhance defensive reactivity to errors in individuals with PTSD. (PsycINFO Database Record

An electrocortical investigation of voluntary emotion regulation in combat-related posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) - a debilitating disorder characterized by severe deficits in emotion regulation - is prevalent among U.S. military veterans. Research into the pathophysiology of PTSD has focused primarily on emotional reactivity, showing evidence of heightened neural response during negative affect provocation. By comparison, studies of brain functioning during the voluntary regulation of negative affect are limited. In the current study, combat-exposed U.S. military veterans with (n=25) and without (n=25) PTSD performed an emotion regulation task during electroencephalographic (EEG) recording. The late positive potential (LPP) was used as a measure of sustained attention toward, and processing of, negative and neutral pictures, and was scored prior to and after instructions to either maintain or down-regulate emotional response using the strategy of cognitive reappraisal. Results showed that groups did not differ in picture-elicited LPP amplitude either prior to or during cognitive reappraisal; reappraisal reduced the LPP in both groups over time. Time-dependent increases in LPP amplitude as a function of emotional reactivity maintenance were evident in the non-PTSD group only. This latter finding may signal PTSD-related deficits in sustained engagement with emotion-processing over the course of several seconds.

Burnout and coping strategies of polytrauma team members caring for veterans with traumatic brain injury.

OBJECTIVE: The aims of this national study were to (1) examine the extent of job burnout among VA Polytrauma team members engaged in the diagnosis and treatment of traumatic brain injury (TBI); and (2) identify their coping strategies for dealing with job-related stress. DESIGN: A cross-sectional sample of 233 VA Polytrauma team members completed the Maslach Burnout Inventory (MBI) and identified strategies for coping with work stress as part of an online survey. RESULTS: VA Polytrauma team members experience moderate levels of emotional exhaustion, but low levels of depersonalization and high levels of personal accomplishment. Moreover, 24% of participants reported high levels of emotional exhaustion, which may be a precursor to job burnout. Participants who reported caring for veterans with TBI ≥50% of their time experienced higher levels of emotional exhaustion than those who spent <50% of their time (p ≤ 0.001). Five major thematic categories related to coping strategies emerged from the data: (1) connecting with others, (2) promoting a healthy lifestyle, (3) pursuing outside interests, (4) managing work environment and (5) maintaining positive thinking. CONCLUSION: Polytrauma team members caring for Veterans with TBI may be at risk for job burnout.

Healthcare utilization and costs of Veterans screened and assessed for traumatic brain injury.

Approximately 15% of casualties in the Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) conflicts received mild traumatic brain injury (TBI). To identify Veterans who may benefit from treatment, the Department of Veterans Affairs (VA) implemented a national clinical reminder in 2007 to screen for TBI. Veterans who screen positive are referred for a comprehensive TBI evaluation. We conducted a national retrospective study of OIF/OEF Veterans receiving care at VA facilities between 2007 and 2008. We examined the association of the TBI screen with healthcare costs over a 12 mo period following the initial evaluation. Of the Veterans, 164,438 met inclusion criteria: 31,627 screened positive, 118,545 screened negative, and 14,266 received no TBI screening. Total healthcare costs of Veterans who screened positive, screened negative, or had no TBI screening were $9,610, $5,184, and $3,399, respectively (p < 0.001). Understanding these healthcare utilization and cost patterns will assist policymakers to address the ongoing and future healthcare needs of these returning Veterans.

Hypnotically facilitated exposure response prevention therapy for an OIF veteran with OCD.

The highly stressful conditions of a war zone may exacerbate or trigger a wide variety of symptoms including Obsessive Compulsive Disorder (OCD) once a service member returns home. Service members and new veterans of the Iraq and Afghanistan wars present to treatment with multiple psychosocial concerns and co-morbid psychiatric conditions. Evidence-based treatments including exposure based therapies are commonly recommended for use with returning veterans. Although studies support the efficacy of Exposure Response Prevention (ERP) therapy for treating OCD, eligibility for these studies limits participation to subjects who self-report a well-defined, circumscribed complaint. This approach is not typical of clinic clients who, more often than not, report multiple psychological issues. The following individual case study demonstrates how integrating hypnosis facilitated the cognitive-behavioral ERP therapy and treatment for a patient suffering from OCD.