Somatic Symptom Severity, Not Injury Severity, Predicts Probable Posttraumatic Stress Disorder and Major Depressive Disorder in Wounded Service Members

Management of Psychological Complications Following Mild Traumatic Brain Injury

PURPOSE OF REVIEW

It has been clear for decades that psychological factors often contribute to mild traumatic brain injury (mTBI) outcome, but an emerging literature has begun to clarify which specific factors are important, when, for whom, and how they impact recovery. This review aims to summarize the contemporary evidence on psychological determinants of recovery from mTBI and its implications for clinical management.

RECENT FINDINGS

Comorbid mental health disorders and specific illness beliefs and coping behaviors (e.g., fear avoidance) are associated with worse recovery from mTBI. Proactive assessment and intervention for psychological complications can improve clinical outcomes. Evidence-based treatments for primary mental health disorders are likely also effective for treating mental health disorders after mTBI, and can reduce overall post-concussion symptoms. Broad-spectrum cognitive-behavioral therapy may modestly improve post-concussion symptoms, but tailoring delivery to individual psychological risk factors and/or symptoms may improve its efficacy. Addressing psychological factors in treatments delivered primarily by non-psychologists is a promising and cost-effective approach for enhancing clinical management of mTBI. Recent literature emphasizes a bio-psycho-socio-ecological framework for understanding mTBI recovery and a precision rehabilitation approach to maximize recovery. Integrating psychological principles into rehabilitation and tailoring interventions to specific risk factors may improve clinical management of mTBI.

Association of Traumatic Brain Injury Severity and Self-Reported Neuropsychiatric Symptoms in Wounded Military Service Members

The impact of traumatic brain injury (TBI) severity and loss of consciousness (LOC) on the development of neuropsychiatric symptoms was studied in injured service members (SMs; n = 1278) evacuated from combat settings between 2003 and 2012. TBI diagnoses of mild TBI (mTBI) or moderate-to-severe TBI (MS-TBI) along with LOC status were identified using International Classification of Diseases, Ninth Revision (ICD-9) codes and the Defense and Veterans Brain Injury Center Standard Surveillance Case Definition for TBI. Self-reported psychiatric symptoms were evaluated for post-traumatic stress disorder (PTSD) with the PTSD Checklist, Civilian Version for PTSD, the Patient Health Questionnaire-9 for major depressive disorder (MDD), and the Patient Health Questionnaire-15 for somatic symptom disorder (SSD) in two time periods post-injury: Assessment Period 1 (AP1, 0.0-2.5 months) and Assessment Period 2 (AP2, 3-12 months). mTBI, but not MS-TBI, was associated with increased neuropsychiatric symptoms: PTSD in AP1 and AP2; MDD in AP1; and SSD in AP2. A subgroup analysis of mTBI with and without LOC revealed that mTBI with LOC, but not mTBI without LOC, was associated with increased symptoms as compared to non-TBI: PTSD in AP1 and AP2; MDD in AP1; and SSD in AP1 and AP2. Moreover, mTBI with LOC was associated with increased MDD symptoms in AP2, and SSD symptoms in AP1 and AP2, compared to mTBI without LOC. These findings reinforce the need for the accurate characterization of TBI severity and a multi-disciplinary approach to address the devastating impacts of TBI in injured SMs.

Natural recovery from posttraumatic stress in injured military service members: A commentary on Soumoff et al. (2021)

Soumoff et al. (2021) reported on a sample of 2,217 injured military service members and found that somatic symptom severity was more predictive of the development of probable posttraumatic stress disorder (PTSD) symptoms than injury severity. PTSD has been described as one of the invisible wounds of war, suggesting that many military service members with PTSD may suffer in silence because some symptoms-such as psychological and somatic symptoms-are often not observable by others. In contrast, friends, family, fellow service members, and health care providers often ask military service members with visible, physical wounds what happened, prompting a discussion of their injury and the events that contributed to it. I posit that the findings reported by Soumoff et al. may be an example of the differences that can occur in the course of natural recovery in military service members suffering from visible versus invisible wounds of war and further hypothesize that the repeated conversations that often occur after physical injuries in military service members may foster natural recovery from the co-occurring invisible, psychological wounds of war.

Hospitalization for physical injury may contribute to recovery of invisible war wounds: Response to Peterson's (2021) commentary on Soumoff et al. (2021)

Peterson's (2021) commentary on our recently published manuscript (Soumoff et al., 2021) suggests that our findings are an example of visible, physical injuries of war facilitating communication with others, which, in turn, fosters recovery from invisible war wounds. We agree that in the proper context, the retelling of one's traumatic story can be important for recovery from and, perhaps, even the prevention of posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Participants in our study cohort differed from most others who experienced combat trauma in that while they were hospitalized, they experienced nearly daily visits from a behavioral health provider to address traumatic stress-related symptoms. It is likely that individuals who sustained more severe physical injury (i.e., higher Injury Severity Score [ISS] ratings) had longer hospital stays, received more support, and had more opportunities to retell their stories than those with less severe injuries, leading to decreases in PTSD and MDD symptoms. To note support of this supposition, in Table 5 of Soumoff et al. (2021), although not significant, the adjusted odds ratios (aORs) for PTSD and MDD were below 1 for service members with high (i.e., above 16) ISS ratings. The physical injury-related hospitalizations participants in our sample experienced fostered activities described by Peterson (2021) that likely contributed to the prevention and resolution of PTSD and MDD symptoms, benefits not received by most individuals who suffer only invisible wounds of war.