Posttraumatic stress disorder in OEF/OIF veterans with and without traumatic brain injury

The Co-Occurrence of Post-Traumatic Stress Disorder and Depression in Individuals with and without Traumatic Brain Injury: A Comprehensive Investigation

Post-traumatic stress disorder (PTSD) is a prevalent psychiatric disorder that often occurs following war trauma. Despite its high prevalence, there is still a lack of comprehensive understanding regarding the mechanisms underlying its progression and treatment resistance. Recent research has shed light on the biological basis of PTSD, with neuroimaging studies revealing altered brain connectivity patterns in affected individuals. In war contexts, traumatic brain injury (TBI) is a common occurrence and is associated with a high prevalence of PTSD. This study aimed to compare the severity of PTSD and depression in patients with and without a history of TBI to shed light on the impact of comorbid TBI on the presentation of PTSD symptoms. To achieve this goal, a cross-sectional study was conducted involving a sample of 60 outpatients who were diagnosed with both PTSD and Depressive Disorder. The inclusion criteria required participants to meet the diagnostic criteria for both disorders using validated tools. The severities of PTSD and depressive symptoms were assessed using scales that have been widely used and validated in previous research. By utilizing these standardized assessment tools, this study aimed to ensure the reliability and validity of the obtained data. The results of this study revealed that patients with comorbid PTSD and TBI exhibited a significantly higher severity of PTSD symptoms compared to those with PTSD only. Specifically, the comorbid group demonstrated higher ratings of symptom intensity across all symptom clusters. These findings are consistent with previous research that has highlighted the impact of comorbid TBI on the intensity and persistence of PTSD symptoms. When controlling for PTSD severity, no significant differences were observed in the severity of depressive symptoms between the two groups. This suggests that the increased depressive symptoms observed in the comorbid group may be primarily driven by the presence of more intense PTSD symptoms rather than TBI per se. The findings highlight the need for an accurate diagnosis of TBI in individuals with PTSD to guide appropriate treatment interventions. Further research is warranted to delve into the underlying mechanisms that contribute to the interaction between TBI and PTSD and to develop targeted interventions for individuals with comorbid PTSD and TBI.

Disturbances in fear extinction learning after mild traumatic brain injury in mice are accompanied by alterations in dendritic plasticity in the medial prefrontal cortex and basolateral nucleus of the amygdala

Mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD) have emerged as the signature injuries of the U.S. veterans who served in Iraq and Afghanistan, and frequently co-occur in both military and civilian and populations. To better understand how fear learning and underlying neural systems might be altered after mTBI we examined the acquisition of cued fear conditioning and its extinction along with brain morphology and dendritic plasticity in a mouse model of mTBI. To induce mTBI in adult male C57BL/6J mice, a lateral fluid percussive injury (LFP 1.7) was produced using a fluid pulse of 1.7 atmosphere force to the right parietal lobe. Behavior in LFP 1.7 mice was compared to behavior in mice from two separate control groups: mice subjected to craniotomy without LFP injury (Sham) and mice that did not undergo surgery (Unoperated). Following behavioral testing, neural endpoints (dendritic structural plasticity and neuronal volume) were assessed in the basolateral nucleus of the amygdala (BLA), which plays a critical sensory role in fear learning, and medial prefrontal cortex (mPFC), responsible for executive functions and inhibition of fear behaviors. No gross motor abnormalities or increased anxiety-like behaviors were observed in LFP or Sham mice after surgery compared to Unoperated mice. We found that all mice acquired fear behavior, assessed as conditioned freezing to auditory cue in a single session of 6 trials, and acquisition was similar across treatment groups. Using a linear mixed effects analysis, we showed that fear behavior decreased overall over 6 days of extinction training with no effect of treatment group across extinction days. However, a significant interaction was demonstrated between the treatment groups during within-session freezing behavior (5 trials per day) during extinction training. Specifically, freezing behavior increased across within-session extinction trials in LFP 1.7 mice, whereas freezing behavior in control groups did not change on extinction test days, reflecting a dissociation between within-trial and between-trial fear extinction. Additionally, LFP mice demonstrated bilateral increases in dendritic spine density in the BLA and decreases in dendritic complexity in the PFC. The translational implications are that individuals with TBI undergoing fear extinction therapy may demonstrate within-session aberrant learning that could be targeted for more effective treatment interventions.

Oxidative Dysregulation in Early Life Stress and Posttraumatic Stress Disorder: A Comprehensive Review

Traumatic stress may chronically affect master homeostatic systems at the crossroads of peripheral and central susceptibility pathways and lead to the biological embedment of trauma-related allostatic trajectories through neurobiological alterations even decades later. Lately, there has been an exponential knowledge growth concerning the effect of traumatic stress on oxidative components and redox-state homeostasis. This extensive review encompasses a detailed description of the oxidative cascade components along with their physiological and pathophysiological functions and a systematic presentation of both preclinical and clinical, genetic and epigenetic human findings on trauma-related oxidative stress (OXS), followed by a substantial synthesis of the involved oxidative cascades into specific and functional, trauma-related pathways. The bulk of the evidence suggests an imbalance of pro-/anti-oxidative mechanisms under conditions of traumatic stress, respectively leading to a systemic oxidative dysregulation accompanied by toxic oxidation byproducts. Yet, there is substantial heterogeneity in findings probably relative to confounding, trauma-related parameters, as well as to the equivocal directionality of not only the involved oxidative mechanisms but other homeostatic ones. Accordingly, we also discuss the trauma-related OXS findings within the broader spectrum of systemic interactions with other major influencing systems, such as inflammation, the hypothalamic-pituitary-adrenal axis, and the circadian system. We intend to demonstrate the inherent complexity of all the systems involved, but also put forth associated caveats in the implementation and interpretation of OXS findings in trauma-related research and promote their comprehension within a broader context.

"Operator syndrome": A unique constellation of medical and behavioral health-care needs of military special operation forces

OBJECTIVE

U.S. military special operation forces represent the most elite units of the U.S. Armed Forces. Their selection is highly competitive, and over the course of their service careers, they experience intensive operational training and combat deployment cycles. Yet, little is known about the health-care needs of this unique population.

METHOD

Professional consultations with over 50 special operation forces operators (and many spouses or girlfriends) over the past 6 years created a naturalistic, observational base of knowledge that allowed our team to identify a unique pattern of interrelated medical and behavioral health-care needs.

RESULTS

We identified a consistent pattern of health-care difficulties within the special operation forces community that we and other special operation forces health-care providers have termed "Operator Syndrome." This includes interrelated health and functional impairments including traumatic brain injury effects; endocrine dysfunction; sleep disturbance; obstructive sleep apnea; chronic joint/back pain, orthopedic problems, and headaches; substance abuse; depression and suicide; anger; worry, rumination, and stress reactivity; marital, family, and community dysfunction; problems with sexual health and intimacy; being "on guard" or hypervigilant; memory, concentration, and cognitive impairments; vestibular and vision impairments; challenges of the transition from military to civilian life; and common existential issues.

CONCLUSIONS

"Operator Syndrome" may be understood as the natural consequences of an extraordinarily high allostatic load; the accumulation of physiological, neural, and neuroendocrine responses resulting from the prolonged chronic stress; and physical demands of a career with the military special forces. Clinical research and comprehensive, intensive immersion programs are needed to meet the unique needs of this community.

The impact of PTSD and mTBI on the relationship between subjective and objective cognitive deficits in combat-exposed veterans

OBJECTIVE

Cognitive complaints, such as attentional or memory concerns, are commonly reported by veterans diagnosed with posttraumatic stress disorder (PTSD) or a history of mild traumatic brain injury (mTBI). The degree to which those complaints actually map onto measurable cognitive deficits is unclear and is likely complicated by the severity of trauma-related sequelae. In the present study we sought to characterize the degree to which PTSD symptoms and mTBI accounted for the relationship of subjective cognitive complaints to objective cognitive performance, with the goal of facilitating the accurate assessment of trauma-exposed veterans complaining of cognitive decline.

METHOD

A sample of 203 U.S. military veterans previously deployed to Iraq and/or Afghanistan were assessed for PTSD severity, history of blast and impact mTBI, objective cognitive function, and subjective cognitive complaints. Separate mediation analyses were conducted to explore the degree that PTSD severity, blast mTBI severity, and impact mTBI severity influenced the association between subjective cognitive complaints and objective cognitive performance. Models reflecting significant mediation were followed by post hoc moderated mediation analyses.

RESULTS

Subjective cognitive complaints and objective cognitive performance were significantly associated (β = -6.49, SE = 2.85, p = .03), but this relationship was mediated by PTSD severity (β= -2.95, SE = 2.86, p = .30). PTSD mediation was not moderated by either blast or impact mTBI.

CONCLUSION

The present results delineate the prominent impact of PTSD symptoms, relative to blast and impact mTBI, on cognition following combat. These findings highlight the importance of assessing for trauma-related psychopathology in those seeking neuropsychological assessment or rehabilitative care for cognitive complaints. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Alcohol misuse and traumatic brain injury: a review of the potential roles of dopaminergic dysfunction and physiological underarousal post-injury

Although many researchers have demonstrated an increase in alcohol use following traumatic brain injury (TBI), there is also a body of research indicating that alcohol misuse predisposes one to injury and precedes TBI. Accordingly, various mechanisms have been proposed (e.g., self-medication, dampened levels of arousal, dopaminergic dysfunction, etc.) and variable results have emerged. This paper reviews the empirical evidence, for and against, TBI as a risk factor for alcohol misuse. In particular, this paper focuses on the brain-behavior relationships involved and examines the roles of physiological underarousal and dopaminergic dysfunction in the development of alcohol misuse after injury. Alcohol misuse impedes community reintegration among TBI survivors and creates additional rehabilitative challenges. Thus, in order to inform and improve treatment outcomes among this vulnerable population, a deeper understanding of the neural mechanisms implicated is needed.

Untangling PTSD and TBI: Challenges and Strategies in Clinical Care and Research

PURPOSE OF REVIEW

Traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) can result from similar injuries and can result in similar symptoms, such as problems with sleep, concentration, memory, and mood. Although PTSD and persistent sequelae due to a TBI (PST) have generally been viewed as pragmatically confounded but conceptually separable entities, we examine emerging evidence emphasizing the breadth of overlap in both clinical presentation and underlying pathophysiology between PST and PTSD.

RECENT FINDINGS

New evidence underscores the poor specificity of symptoms to etiology and emphasizes the potential, after both physical brain injury and traumatic stress, for changes in each of the three interacting systems that coordinate the body's response to the experience or expectation of major injury-the immune, endocrine, and neuromodulatory neurotransmitter systems. A view of PTSD and PST sharing common pathophysiologic elements related to the CNS response to acute injury or threat carries important implications for research and clinical care.

Vision Rehabilitation After Traumatic Brain Injury

Visual dysfunctions and symptoms are commonly experienced after even mild traumatic brain injury (TBI) despite excellent visual acuity. All individuals who have experienced a TBI/concussion should be screened for vision symptoms and visual dysfunction. A TBI-specific eye examination is necessary to identify the visual sequelae of TBI and address any vision/ocular issues that may be contributing to other post-TBI complaints. A vision rehabilitation plan that includes vision therapy can improve visual dysfunction secondary to TBI. Combining office-based and home-based vision therapy training will maximize visual potential and functional results.

Does Traumatic Brain Injury Attenuate the Exposure Therapy Process?

Research indicates that exposure therapy is efficacious for combat-related posttraumatic stress disorder (PTSD) comorbid with traumatic brain injury (TBI) as is shown by reduced PTSD treatment outcome scores. What is unknown, however, is whether the process of fear extinction is attenuated in veterans with TBI history. Increased PTSD symptomatology and possible cognitive deficits associated with TBI sequelae may indicate additional or longer exposure sessions to achieve habituation and extinction comparable to individuals without TBI history. As such, a more extensive course of treatment may be necessary to achieve comparable PTSD treatment outcome scores for individuals with TBI history. Using a sample of veterans with combat-related PTSD, some of whom were comorbid for TBI, this study compared process variables considered relevant to successful treatment outcome in exposure therapy. Individuals with and without TBI demonstrated similar rates of fear activation, length and number of exposure sessions, within-session habituation, between-session habituation, and extinction rate; results remained consistent when controlling for differential PTSD symptomatology. Furthermore, results indicated that self-perception of executive dysfunction did not impact the exposure process. Results suggest that individuals with PTSD and TBI history engage successfully and no differently in the exposure therapy process as compared to individuals with PTSD alone. Findings further support exposure therapy as a first-line treatment for combat-related PTSD regardless of TBI history.

Neural differences underlying face processing in veterans with TBI and co-occurring TBI and PTSD

BACKGROUND

Traumatic brain injury (TBI) is common in military personnel and associated with high rates of posttraumatic stress disorder (PTSD). TBI impacts widely-distributed neural patterns, some of which influence affective processing. Better understanding how TBI and PTSD/TBI alters affective neural activity may improve our understanding of comorbidity mechanisms, but to date the neural correlates of emotional processing in these groups has been relatively understudied.

METHODS

Military controls, military personnel with a history of TBI, and military personnel with both TBI and PTSD (N = 53) completed an emotional face processing task during fMRI. Whole-brain activation and functional connectivity during task conditions were compared between groups.

RESULTS

Few whole-brain group differences emerged in planned pairwise contrasts, though the TBI group showed some areas of hypoactivation relative to other groups during processing of faces versus shapes. The PTSD/TBI group compared to the control and TBI groups demonstrated greater connectivity between the amygdala and insula seed regions and a number of prefrontal and posterior cingulate regions.

LIMITATIONS

Generalizability to other patient groups, including those with only PTSD, has not yet been established.

CONCLUSION

TBI alone was associated with hypoactivation during a condition processing faces versus shapes, but PTSD with TBI was associated altered functional connectivity between amygdala and insula regions and cingulate and prefrontal areas. Altered connectivity patterns across groups suggests that individuals with PTSD/TBI may need to increase frontal connectivity with the insulae in order to achieve similar task-based activity.

The influence of traumatic brain injury on treatment outcomes of Concurrent Treatment for PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) in veterans

BACKGROUND

The co-occurrence of posttraumatic stress disorder (PTSD), substance use disorders (SUD), and traumatic brain injury (TBI) in veterans of Operations Enduring/Iraqi Freedom and New Dawn has received much attention in the literature. Although hypotheses have been presented and disseminated that TBI history will negatively influence treatment response, little data exist to support these claims. The present study investigates the influence of TBI history on response to COPE (Concurrent Treatment of PTSD and SUD Using Prolonged Exposure), a 12-session, integrated psychotherapy designed to address co-occurring PTSD and SUD.

METHOD

Participants were 51 veterans with current PTSD and SUD enrolled in a clinical trial examining COPE. Assessments of PTSD symptoms, substance use, and depression were collected at baseline and each treatment session. A TBI measure was used to dichotomize veterans into groups with and without a history of TBI (ns=30 and 21, respectively).

RESULTS

Participants with and without TBI history demonstrated significant improvements in PTSD and depression symptoms during the course of treatment. However, participants with TBI history experienced less improvement relative to participants without TBI history.

CONCLUSIONS

The present findings suggest that, although patients with a TBI history respond to treatment, their response to treatment was less so than that observed in patients without a TBI history. As such, identification, symptom monitoring, and treatment practices may require alteration and further special consideration in individuals with PTSD, SUD and TBI.

Completion of a Veteran-Focused Civic Service Program Improves Health and Psychosocial Outcomes in Iraq and Afghanistan Veterans With a History of Traumatic Brain Injury

INTRODUCTION

Volunteering as a health promotion intervention is positively related to improved health and well-being in civilians and older adults. Yet, the impacts of participating in a community-based volunteering program on returning military veterans have not been studied, nor have the outcomes for veterans who have experienced a traumatic brain injury (TBI).

MATERIALS AND METHODS

This observational, pre-post survey examines health, psychological, and social outcomes from a cohort of post-9/11/01 veterans with (N = 67) and without a reported TBI history (N = 273) who completed a 6-month, 20-hour per week veteran-focused civic service program. This study was approved by the Saint Louis University Institutional Review Board.

RESULTS

Veterans with a TBI history who completed the 6-month civic service program conducted by a veteran-focused national nonprofit organization showed significant pre-post improvement (p < 0.05) in overall health, decreased post-traumatic stress disorder (PTSD) symptoms, increased perceived self-efficacy, decreased feelings of isolation and loneliness, and increased perceived availability of social support. These significant findings were not due to participants seeking external help for emotional problems. Out of four aspects of PTSD symptomatology assessed, "feeling numb or detached from others, activities, or surroundings" most accounted for the decrease in PTSD scores. Given this and taken together with the significant decrease in social isolation and loneliness and the social nature of the program, we posit that decreased social isolation and loneliness is the primary driver of the improved psychological and social outcomes documented here. Finally, pre-post change scores did not differ significantly between veterans with and without a TBI, indicating that TBI history did not hinder the ability to benefit from this program.

CONCLUSION

Completion of this civic service program positively impacted veterans with TBI, especially on psychological and social outcomes important to recovery and life satisfaction after TBI. Civic service may provide an innovative approach to promoting wellness in returning veterans with a TBI. Results of this study provide preliminary evidence that civic service decreases social isolation and loneliness in veterans with a reported TBI history. Given our findings, volunteering may prevent against social isolation and be promotional of perceived social support in veterans with TBI.

Veterans transitioning from isolation to integration: a look at veteran/service dog partnerships

BACKGROUND

This study explored the dynamics of veteran/service dog partnerships by gathering the perspectives of veterans with a history of post-traumatic stress disorder and/or traumatic brain injury.

METHODS

Exploratory qualitative methods (focus groups and individual interviews) were used to investigate veteran/service dog relationships related to community involvement, family and friend relationships, self-care, work, and leisure. Nine male veterans, Paws, and Stripes program graduates participated. Data were audio recorded and transcribed by two research team members who used qualitative analytic software to manage and code the data. The full research team discussed themes and reached consensus on the themes that emerged from analysis.

RESULTS

Five themes emerged about the perceived benefit of veteran/service dog relationship: Secluded but Seeking Society (moving from isolation to reconnection); Opening Opportunities (navigating daily life); Bridging the Gap (facilitating social opportunities); and Reclaiming Life (transforming sense of worth and purpose). An overarching theme, Calming Catalyst, connected the other four themes.

CONCLUSIONS

Veterans in this study reported that their goal was to reclaim and develop key aspects of their lives and they perceived service dogs as a support in their transition from isolation to reintegration. This study found that service dogs supported the veterans to meet their goal. Implications for rehabilitation There are a significant number of veterans with post-traumatic stress disorder and/or traumatic brain injury who are facing life challenges including self-care, securing work, participating in leisure activities, and integrating into the community. Service dogs are an emerging intervention used to assist veterans with reintegration into civilian life. There is a need for professionals to be aware of potential benefits of service dog/veteran partnerships. Based on our findings, veterans could benefit from being paired with a service dog to facilitate their successful return to community life.

Does Co-Occurring Traumatic Brain Injury Affect VHA Outpatient Health Service Utilization and Associated Costs Among Veterans With Posttraumatic Stress Disorder? An Examination Based on VHA Administrative Data

OBJECTIVE

To examine whether a traumatic brain injury (TBI) diagnosis was associated with increased outpatient service utilization and associated costs among Iraq and Afghanistan (Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]/Operation New Dawn [OND]) War veterans with posttraumatic stress disorder (PTSD) who used Veterans Health Affairs (VHA) care in a 1-year period.

SETTING

N/A.

PARTICIPANTS

OEF/OIF/OND veterans with a diagnosis of PTSD and/or TBI who utilized VHA services during fiscal year 2012 (N = 164 644).

DESIGN

Observational study using VHA administrative data.

MAIN MEASURES

Outpatient VHA utilization (total and by category of care) and associated costs (total and by VA Health Economic Resource Center cost category).

RESULTS

Veterans in the comorbid PTSD/TBI group had significantly more total outpatient appointment than veterans with PTSD but no TBI. This pattern held for all categories of care except orthopedics. The comorbid TBI/PTSD group ($5769) incurred greater median outpatient healthcare costs than the PTSD ($3168) or TBI-alone ($2815) group.

CONCLUSIONS

Co-occurring TBI increases the already high level of healthcare utilization by veterans with PTSD, suggesting that OEF/OIF/OND veterans with comorbid PTSD/TBI have complex and wide-ranging healthcare needs.

Symptoms Associated with Vestibular Impairment in Veterans with Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a chronic and disabling, anxiety disorder resulting from exposure to life threatening events such as a serious accident, abuse or combat (DSM IV definition). Among veterans with PTSD, a common complaint is dizziness, disorientation and/or postural imbalance in environments such as grocery stores and shopping malls. The etiology of these symptoms in PTSD is poorly understood and some attribute them to anxiety or traumatic brain injury. There is a possibility that an impaired vestibular system may contribute to these symptoms since, symptoms of an impaired vestibular system include dizziness, disorientation and postural imbalance. To our knowledge, this is the first report to describe the nature of vestibular related symptoms in veterans with and without PTSD. We measured PTSD symptoms using the Posttraumatic Stress Disorder Checklist (PCL-C) and compared it to responses on vestibular function scales including the Dizziness Handicap Inventory (DHI), the Vertigo Symptom Scale Short Form (VSS-SF), the Chambless Mobility Inventory (CMI), and the Neurobehavioral Scale Inventory (NSI) in order to identify vestibular-related symptoms. Our findings indicate that veterans with worse PTSD symptoms report increased vestibular related symptoms. Additionally veterans with PTSD reported 3 times more dizziness related handicap than veterans without PTSD. Veterans with increased avoidance reported more vertigo and dizziness related handicap than those with PTSD and reduced avoidance. We describe possible contributing factors to increased reports of vestibular symptoms in PTSD, namely, anxiety, a vestibular component as well as an interactive effect of anxiety and vestibular impairment. We also present some preliminary analyses regarding the contribution of TBI. This data suggests possible evidence for vestibular symptom reporting in veterans with PTSD, which may be explained by possible underlying vestibular impairment, worthy of further exploration.

White Matter Microstructural Compromise Is Associated With Cognition But Not Posttraumatic Stress Disorder Symptoms in Military Veterans With Traumatic Brain Injury

OBJECTIVE

To investigate white matter microstructure compromise in Veterans with a history of traumatic brain injury (TBI) and its possible contribution to posttraumatic stress disorder (PTSD) symptomatology and neuropsychological functioning via diffusion tensor imaging.

PARTICIPANTS AND METHODS

Thirty-eight Veterans with mild (n = 33) and moderate (n = 5) TBI and 17 military control participants without TBI completed neuropsychological testing and psychiatric screening and underwent magnetic resonance imaging an average of 4 years following their TBI event(s). Fractional anisotropy (FA) and diffusivity measures were extracted from 9 white matter tracts.

RESULTS

Compared with military control participants, TBI participants reported higher levels of PTSD symptoms and performed worse on measures of memory and psychomotor-processing speed. Traumatic brain injury was associated with lower FA in the genu of the corpus callosum and left cingulum bundle. Fractional anisotropy negatively correlated with processing speed and/or executive functions in 7 of the 8 tracts. Regional FA did not correlate with memory or PTSD symptom ratings.

CONCLUSION

Results suggest that current PTSD symptoms are independent of TBI-related white matter alterations, as measured by diffusion tensor imaging. In addition, white matter microstructural compromise may contribute to reduced processing speed in our sample of participants with history of neurotrauma. Findings of the current study add insight into the factors associated with complicated recovery from mild to moderate TBI.

Potential pleiotropic beneficial effects of adjuvant melatonergic treatment in posttraumatic stress disorder

Loss of circadian rhythmicity fundamentally affects the neuroendocrine, immune, and autonomic system, similar to chronic stress and may play a central role in the development of stress-related disorders. Recent articles have focused on the role of sleep and circadian disruption in the pathophysiology of posttraumatic stress disorder (PTSD), suggesting that chronodisruption plays a causal role in PTSD development. Direct and indirect human and animal PTSD research suggests circadian system-linked neuroendocrine, immune, metabolic and autonomic dysregulation, linking circadian misalignment to PTSD pathophysiology. Recent experimental findings also support a specific role of the fundamental synchronizing pineal hormone melatonin in mechanisms of sleep, cognition and memory, metabolism, pain, neuroimmunomodulation, stress endocrinology and physiology, circadian gene expression, oxidative stress and epigenetics, all processes affected in PTSD. In the current paper, we review available literature underpinning a potentially beneficiary role of an add-on melatonergic treatment in PTSD pathophysiology and PTSD-related symptoms. The literature is presented as a narrative review, providing an overview on the most important and clinically relevant publications. We conclude that adjuvant melatonergic treatment could provide a potentially promising treatment strategy in the management of PTSD and especially PTSD-related syndromes and comorbidities. Rigorous preclinical and clinical studies are needed to validate this hypothesis.

Life after Adolescent and Adult Moderate and Severe Traumatic Brain Injury: Self-Reported Executive, Emotional, and Behavioural Function 2-5 Years after Injury

Survivors of moderate-severe Traumatic Brain Injury (TBI) are at risk for long-term cognitive, emotional, and behavioural problems. This prospective cohort study investigated self-reported executive, emotional, and behavioural problems in the late chronic phase of moderate and severe TBI, if demographic characteristics (i.e., age, years of education), injury characteristics (Glasgow Coma Scale score, MRI findings such as traumatic axonal injury (TAI), or duration of posttraumatic amnesia), symptoms of depression, or neuropsychological variables in the first year after injury predicted long-term self-reported function. Self-reported executive, emotional, and behavioural functioning were assessed among individuals with moderate and severe TBI (N = 67, age range 15–65 years at time of injury) 2–5 years after TBI, compared to a healthy matched control group (N = 72). Results revealed significantly more attentional, emotional regulation, and psychological difficulties in the TBI group than controls. Demographic and early clinical variables were associated with poorer cognitive and emotional outcome. Fewer years of education and depressive symptoms predicted greater executive dysfunction. Younger age at injury predicted more aggressive and rule-breaking behaviour. TAI and depressive symptoms predicted Internalizing problems and greater executive dysfunction. In conclusion, age, education, TAI, and depression appear to elevate risk for poor long-term outcome, emphasising the need for long-term follow-up of patients presenting with risk factors.

Sleep disturbances, TBI and PTSD: Implications for treatment and recovery

Post-Traumatic Stress Disorder (PTSD), traumatic brain injury (TBI), and sleep problems significantly affect recovery and functional status in military personnel and Veterans returning from combat. Despite recent attention, sleep is understudied in the Veteran population. Few treatments and rehabilitation protocols target sleep, although poor sleep remains at clinical levels and continues to adversely impact functioning even after the resolution of PTSD or mild TBI symptoms. Recent developments in non-pharmacologic sleep treatments have proven efficacious as stand-alone interventions and have potential to improve treatment outcomes by augmenting traditional behavioral and cognitive therapies. This review discusses the extensive scope of work in the area of sleep as it relates to TBI and PTSD, including pathophysiology and neurobiology of sleep; existing and emerging treatment options; as well as methodological issues in sleep measurements for TBI and PTSD. Understanding sleep problems and their role in the development and maintenance of PTSD and TBI symptoms may lead to improvement in overall treatment outcomes while offering a non-stigmatizing entry in mental health services and make current treatments more comprehensive by helping to address a broader spectrum of difficulties.

Caregivers of veterans with "invisible" injuries: what we know and implications for social work practice

Today, as a result of the longest volunteer-fought conflict in U.S. history, there are many wounded coming home not only with posttraumatic stress disorder (PTSD), but also with traumatic brain injury (TBI), which together have been called the "signature" or "invisible" injuries of the Iraq and Afghanistan wars. Caregivers are an important part of their recovery, yet little is known about them, as previous research on caregivers mostly focused on geriatric populations. According to one estimate 275,000 to 1 million people are currently caring or have cared for loved ones who have returned from Iraq and Afghanistan. These caregivers are unique in that they are younger, some with children, and they are caring for a unique under-studied population for longer periods of time. This article summarizes literature on caregivers of veterans who suffer from PTSD, TBI, or both; provides a theoretical framework; and discusses implications for social workers in assisting caregivers and their families.

Temperamental correlates of trauma symptoms in firemen, policemen and soldiers

OBJECTIVES

The main goal of the research was to assess temperamental determinants of trauma symptoms in firemen, policemen and soldiers. The temperament traits which were considered were those postulated by the Regulative Theory of Temperament (briskness, perseveration, sensory sensitivity, emotional reactivity, endurance and activity).

MATERIAL AND METHODS

A cross-sectional study was run on non-clinical samples. The participants were 417 men, White-Caucasian only: 284 firemen (aged 21-55), 58 policemen (aged 22-45), and 75 soldiers (aged 21-42). Temperament was assessed using the Formal Characteristics of Behavior - Temperament Inventory. Intensity of trauma symptoms was assessed with the PTSD-Factorial Version Inventory, a quantitative measure of trauma-related symptoms. The respondents were examined in their place of work. The study included only men reporting at least 1 traumatic event during the year before the trauma diagnosis.

RESULTS

Emotional reactivity had a significant positive effect on the intensity of trauma symptoms only in the group of firemen. Emotional reactivity accounted for 16% of the variance of trauma intensity symptoms in this occupational group. Negative significant effect on trauma symptoms was found for briskness only in the soldiers group (briskness explained 20% trauma intensity variance in this group).

CONCLUSIONS

Emotional reactivity was conducive to the increased trauma symptoms intensity in firemen, whereas briskness tended to reduce symptoms intensity only in the group of soldiers.

Traumatic brain injury and posttraumatic stress disorder

Given the upsurge of research in posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), much of which has focused on military samples who served in Iraq and Afghanistan, the purpose of this article is to review the literature published after September 11th, 2001 that addresses the epidemiology, pathophysiology, evaluation, and treatment of PTSD in the context of TBI.