A comparison of insufficient effort rates, neuropsychological functioning, and neuropsychiatric symptom reporting in military veterans and civilians with chronic traumatic brain injury

Association Between Self-Reported Disability and Lifetime History of Traumatic Brain Injury With Loss of Consciousness Among Veterans and Nonveterans in North Carolina

BACKGROUND

Compared with civilians, service members and veterans who have a history of traumatic brain injury (TBI) are more likely to experience poorer physical and mental health. To investigate this further, this article examines the association between self-reported history of TBI with loss of consciousness and living with 1 or more current disabilities (ie, serious difficulty with hearing, vision, cognition, or mobility; any difficulty with self-care or independent living) for both veterans and nonveterans.

METHODS

A cross-sectional study using data from the North Carolina Behavioral Risk Factor Surveillance System for 4733 veterans and nonveterans aged 18 years and older.

RESULTS

Approximately 34.7% of veterans residing in North Carolina reported having a lifetime history of TBI compared with 23.6% of nonveterans. Veterans reporting a lifetime history of TBI had a 1.4 times greater risk of also reporting living with a current disability (adjusted prevalence ratio = 1.4; 95% confidence interval, 1.2-1.8) compared with nonveterans. The most common types of disabilities reported were mobility, cognitive, and hearing.

CONCLUSIONS

Compared with nonveterans, veterans who reported a lifetime history of TBI had an increased risk of reporting a current disability. Future studies, such as longitudinal studies, may further explore this to inform the development of interventions.

Diffusion tensor imaging findings and neuropsychological performance in adults with TBI across the spectrum of severity in the chronic-phase

PRIMARY OBJECTIVE

To examine associations between neuroimaging indicators of cerebral tract integrity and neurocognitive functioning in traumatic brain injury (TBI).

RESEARCH DESIGN

Between-Groups design with two TBI groups and controls.

METHOD AND PROCEDURES

Forty-four participants with TBI and 27 matched controls completed diffusion tensor imaging and neuropsychological measures of processing speed, attention, memory, and executive function. Multivariate analyses were conducted to examine group differences in white matter integrity (fractional anisotropy) for 11 regions of interest and cognitive performance among adult males with chronic phase, mild, moderate, or severe TBI. Correlational analyses investigated associations between white matter integrity, brain injury severity, and cognitive status.

MAIN OUTCOMES AND RESULTS

Participants with moderate or severe TBI exhibited reduced white matter integrity in 8 of 11 ROIs and worse performance on most cognitive measures, relative to control participants. Persons with mild TBI did not differ from controls on white matter integrity values and differed on one measure of processing speed. Significant correlations were found between injury severity ratings and 10 ROIs, most notably between ROIs and measures of processing speed or memory.

CONCLUSIONS

These findings provide nuanced information regarding white matter connectivity as it relates to neurocognitive abilities across the TBI severity spectrum.

Preliminary validation of the Dutch version of the Posttraumatic stress disorder checklist for DSM-5 (PCL-5) after traumatic brain injury in a civilian population

The Posttraumatic stress disorder checklist (PCL) is the most widely used questionnaire to screen for symptoms of posttraumatic stress disorder (PTSD), based on the Diagnostic and Statistical manual of Mental disorders (DSM-IV) criteria. In the latest edition of the DSM (DSM-5), the criteria for PTSD were revised leading to the development of the PCL-5. So far, there is no validated Dutch version of the PCL-5. The aim of this study is to determine psychometric characteristics of the Dutch translation and linguistic validation of the PCL-5 and to evaluate internal consistency, criterion and structural validity. In a population of 495 civilian, traumatic brain injury patients, the PCL-5, the Generalized anxiety disorder questionnaire and the Depression scale of the Patient health questionnaire were administered. The PCL-5 was translated in Dutch following a strict procedure of linguistic validation and cognitive debriefing. Results show an excellent internal consistency and high criterion validity. Confirmatory factor analysis demonstrated a good fit for the four-factor DSM-5 model, but a superior fit for the six-factor Anhedonia model and the seven-factor Hybrid model, similar to the English version of the PCL-5. Preliminary validation of the Dutch translation of the PCL-5 was proven to be psychometrically sound and can be used for clinical and academic purposes, specifically for TBI patients. Future research should examine concurrent and discriminant validity for the Dutch translation in broader populations at risk for PTSD, and include a structured interview to evaluate diagnostic utility.

Post-Traumatic Stress Disorder after Civilian Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Prevalence Rates

Post-traumatic stress disorder (PTSD) is a commonly diagnosed psychiatric disorder following traumatic brain injury (TBI). Much research on PTSD and TBI has focused on military conflict settings. Less is known about PTSD in civilian TBI. We conducted a systematic review and meta-analysis on the prevalence of PTSD after mild and moderate/severe TBI in civilian populations. We further aimed to explore the influence of methodological quality and assessment methods. A systematic literature search was performed on studies reporting on PTSD in civilian TBI, excluding studies on military populations. The risk of bias was assessed using the MORE (Methodological evaluation of Observational REsearch) checklist. Meta-analysis was conducted for overall prevalence rates for PTSD with sensitivity analyses for the severity of TBI. Fifty-two studies were included, of which 31 were graded as low risk of bias. Prevalence rates of PTSD in low risk of bias studies varied widely (2.6-36%) with a pooled prevalence rate of 15.6%. Pooled prevalence rates of PTSD for mild TBI (13.5%, 95% confidence interval [CI]: 11.7-15.3; I2 = 2%) did not differ from moderate/severe TBI (11.8, 95% CI: 7.5-16.1; I2 = 63%). Similar rates were reported in studies using different approaches and times of assessment. Although most studies that compared participants with TBI with trauma patients and healthy controls found no difference in prevalence rates of PTSD, a meta-analysis across studies revealed a higher prevalence of PTSD in patients with TBI (odds ratio [OR]: 1.73, 95% CI: 1.21-2.47). This review highlights variability between studies and emphasizes the need for higher-quality studies. Further research is warranted to determine risk factors for the development of PTSD after TBI.

Evidence Review-Social Determinants of Health for Veterans

BACKGROUND

Veterans Health Administration (VHA) is committed to providing high-quality care and addressing health disparities for vulnerable Veterans. To meet these goals, VA policymakers need guidance on how to address social determinants in operations planning and day-to-day clinical care for Veterans.

METHOD

MEDLINE (OVID), CINAHL, PsycINFO, and Sociological Abstracts were searched from inception to January 2017. Additional articles were suggested by peer reviewers and/or found through search of work associated with US and VA cohorts. Eligible articles compared Veterans vs non-Veterans, and/or Veterans engaged with those not engaged in VA healthcare. Our evidence maps summarized study characteristics, social determinant(s) addressed, and whether health behaviors, health services utilization, and/or health outcomes were examined. Qualitative syntheses and quality assessment were performed for articles on rurality, trauma exposure, and sexual orientation.

RESULTS

We screened 7242 citations and found 131 eligible articles-99 compared Veterans vs non-Veterans, and 40 included engaged vs non-engaged Veterans. Most articles were cross-sectional and addressed socioeconomic factors (e.g., education and income). Fewer articles addressed rurality (N = 20), trauma exposure (N = 17), or sexual orientation (N = 2); none examined gender identity. We found no differences in rural residence between Veterans and non-Veterans, nor between engaged and non-engaged Veterans (moderate strength evidence). There was insufficient evidence for role of rurality in health behaviors, health services utilization, or health outcomes. Trauma exposures, including from events preceding military service, were more prevalent for Veterans vs non-Veterans and for engaged vs non-engaged Veterans (low-strength evidence); exposures were associated with smoking (low-strength evidence).

DISCUSSION

Little published literature exists on some emerging social determinants. We found no differences in rural residence between our groups of interest, but trauma exposure was higher in Veterans (vs non-Veterans) and engaged (vs non-engaged). We recommend consistent measures for social determinants, clear conceptual frameworks, and analytic strategies that account for the complex relationships between social determinants and health.

White Matter Associations With Performance Validity Testing in Veterans With Mild Traumatic Brain Injury: The Utility of Biomarkers in Complicated Assessment

OBJECTIVE

Failure on performance validity tests (PVTs) is common in Veterans with histories of mild traumatic brain injury (mTBI), leading to questionable validity of clinical presentations.

PARTICIPANTS

Using diffusion tensor imaging, we investigated white matter (WM) integrity and cognition in 79 Veterans with history of mTBI who passed PVTs (n = 43; traumatic brain injury [TBI]-passed), history of mTBI who failed at least 1 PVT (n = 13; TBI-failed), and military controls (n = 23; MCs) with no history of TBI.

RESULTS

The TBI-failed group demonstrated significantly lower cognitive scores relative to MCs and the TBI-passed group; however, no such differences were observed between MCs and the TBI-passed group. On a global measure of WM integrity (ie, WM burden), the TBI-failed group showed more overall WM abnormalities than the other groups. However, no differences were observed between the MCs and TBI-passed group on WM burden. Interestingly, regional WM analyses revealed abnormalities in the anterior internal capsule and cingulum of both TBI subgroups relative to MCs. Moreover, compared with the TBI-passed group, the TBI-failed group demonstrated significantly decreased WM integrity in the corpus callosum.

CONCLUSIONS

Findings revealed that, within our sample, WM abnormalities are evident in those who fail PVTs. This study adds to the burgeoning PVT literature by suggesting that poor PVT performance does not negate the possibility of underlying WM abnormalities in military personnel with history of mTBI.

The Clinical Utility of the Conners' Continuous Performance Test-II in Traumatic Brain Injury

OBJECTIVE

The Conners' Continuous Performance Test Second Edition (CPT-II) is a measure commonly used in persons with suspected attentional deficits. Our study examined the utility of the CPT-II as a measure of attention in adults with traumatic brain injury (TBI) of varying severity.

METHOD

As part of a larger investigation, several measures of cognitive functioning, including the CPT-II, were administered to 30 healthy control participants (HCP), 30 mild TBI participants (M-TBI), and 30 moderate to severe TBI participants (MS-TBI). Multivariate and correlational analyses compared group performances and examined convergent and divergent relationships between the CPT-II and various measures, including other tests of attention and neuropsychological function.

RESULTS

Group differences were found for four of six CPT-II variables, with the MS-TBI group exhibiting greater impairment, relative to M-TBI and HCP. In addition, the CPT-II commission and detectability variables were found to correlate significantly with TBI severity. The CPT-II variables also demonstrated correlations of varying magnitude between commonly used neuropsychological measures.

CONCLUSIONS

These findings support the utility of the CPT-II for assessing attentional abilities in persons with TBI of varying severity, particularly those with moderate to severe status. Moreover, the current study also demonstrates relationships that are consistent with convergent validity but inconsistent findings with regard to divergent validity. As a result, the CPT-II measures components of attention that is unique to other commonly used neuropsychological measures of attentive functioning. Further research examining CPT-II performance in TBI populations is recommended.

Reconsidering the Word Memory Test as a Memory Measure in Traumatic Brain Injury

OBJECTIVE

This study examined relationships among traumatic brain injury (TBI) severity, the Word Memory Test (WMT), and California Verbal Learning Test-Second Edition (CVLT-II).

METHOD

Participants (N = 104) passed WMT validity indices and were categorized by TBI severity on the basis of medical records. Outcome measures included norm-referenced scores on the CVLT-II and WMT.

RESULTS

Participants grouped by TBI severity significantly differed on the CVLT-II but not WMT. Post-traumatic amnesia (PTA) significantly correlated with the CVLT-II but not WMT. In a non-medicolegal sample subset (N = 61), TBI severity groups significantly differed on CVLT-II and WMT FR; PTA significantly correlated with the CVLT-II and WMT FR. CVLT-II impairment groups differed on all WMT variables. Participants grouped by neuroimaging findings differed on CVLT-II but not WMT. WMT FR predicted two-level TBI severity using logistic regression but did not contribute in a model including the CVLT-II.

CONCLUSION

Overall, WMT memory subtests appeared less sensitive to TBI severity than the CVLT-II.

Detecting feigned postconcussional and posttraumatic stress symptoms with the structured inventory of malingered symptomatology (SIMS)

The Structured Inventory of Malingered Symptomatology (SIMS) is a standalone symptom validity test (SVT) designed as a screening measure to detect a variety of exaggerated psychological symptoms. A number of studies have explored the accuracy of the SIMS in litigious and clinical populations, yet few have examined the validity of the SIMS in detecting feigned symptoms of postconcussional disorder (PCD) and posttraumatic stress disorder (PTSD). The present study examined the sensitivity of the SIMS in detecting undergraduate simulators (N = 78) feigning symptoms of PCD, PTSD, and the comorbid presentation of both PCD and PTSD symptomatologies. Overall, the SIMS Total score produced the highest sensitivities for the PCD symptoms and PCD+PTSD symptoms groups (.89 and .85, respectively), and to a lesser extent, the PTSD symptoms group (.69). The Affective Disorders (AF) subscale was most sensitive to the PTSD symptoms group compared to the PCD and PCD+PTSD symptoms groups. Additional sensitivity values are presented and examined at multiple scale cutoff scores. These findings support the use of the SIMS as a SVT screening measure for PCD and PTSD symptom exaggeration in neuropsychological assessment.