The contributions of self-reported injury characteristics and psychiatric symptoms to cognitive functioning in OEF/OIF veterans with mild traumatic brain injury

Factors perpetuating functional cognitive symptoms after mild traumatic brain injury

INTRODUCTION

Self-reported memory difficulties (forgetting familiar names, misplacing objects) often persist long after a mild traumatic brain injury (mTBI), despite normal neuropsychological test performance. This clinical presentation may be a manifestation of a functional cognitive disorder (FCD). Several mechanisms underlying FCD have been proposed, including metacognitive impairment, memory perfectionism, and misdirected attention, as well as depression or anxiety-related explanations. This study aims to explore these candidate perpetuating factors in mTBI, to advance our understanding of why memory symptoms frequently persist following mTBI.

METHODS

A cross-sectional study of 67 adults (n = 39 with mTBI mean = 25 months ago and n = 28 healthy controls). Participants completed standardized questionnaires (including the Functional Memory Disorder Inventory), a metacognitive task (to quantify discrepancies between their trial-by-trial accuracy and confidence), and a brief neuropsychological test battery. We assessed candidate mechanisms in two ways: (1) between-groups, comparing participants with mTBI to healthy controls, and (2) within-group, examining their associations with functional memory symptom severity (FMDI) in the mTBI group.

RESULTS

Participants with mTBI performed similarly to controls on objective measures of memory ability but reported experiencing much more frequent memory lapses in daily life. Contrary to expectations, metacognitive efficiency did not differentiate the mTBI and control groups and was not associated with functional memory symptoms. Memory perfectionism was strongly associated with greater functional memory symptoms among participants with mTBI but did not differ between groups when accounting for age. Depression and checking behaviors produced consistent results across between-groups and within-group analyses: these factors were greater in the mTBI group compared to the control group and were associated with greater functional memory symptoms within the mTBI group.

CONCLUSIONS

This study highlights promising (e.g., depression, checking behaviors) and unlikely (e.g., metacognitive impairment) mechanisms underlying functional memory symptoms after mTBI, to guide future research and treatment.

Psychiatric symptoms influence social support in VA Million Veteran Program enrollees screening positive for traumatic brain injury

OBJECTIVE

To examine measures of social support and associations with neurobehavioral, psychiatric, and cognitive symptoms in Veterans who underwent the Veterans Health Administration's Traumatic Brain Injury (TBI) Screening and Evaluation Program.

SETTING

Nationally representative sample of U.S. Veterans enrolled in the Veterans Affairs Million Veteran Program.

PARTICIPANTS

Veterans (N = 9,837) were classified into the following three diagnostic groups based on results from the TBI Screening and Evaluation Program: (1) negative TBI screen (Screen-; n = 6,523), (2) positive TBI screen but no TBI diagnosis (Screen+/TBI-; n = 1,308), or (3) positive TBI screen and TBI diagnosis (Screen+/TBI+; n = 2,006).

DESIGN

Epidemiological cross-sectional study.

MAIN MEASURES

Medical Outcomes Study Social Support Survey Instrument (MOS-SSSI), with subscales representing emotional, tangible, and affectionate support and positive social interaction; Neurobehavioral Symptom Inventory (NSI); PTSD Checklist (PCL); Patient Health Questionnaire-4 (PHQ-4); and Medical Outcomes Study Cognitive Functioning-Revised Scale (MOS-Cog-R).

RESULTS

ANCOVAs showed significant associations between diagnostic group and all aspects of social support. Pairwise comparisons revealed that Veterans in the two Screen+ groups (Screen+/TBI+ and Screen+/TBI-) reported comparable levels of social support, but that both Screen+ groups reported significantly lower levels of social support compared to the Screen- group. Among the Screen+ groups, adjusted linear regression models controlling for age, sex, and race/ethnicity showed significant associations between social support indices and all symptom measures, such that lower levels of social support were associated with more severe neurobehavioral and psychiatric symptoms and worse cognitive functioning. Finally, mediation analyses showed that psychiatric symptoms mediated the association between TBI screen group and social support.

CONCLUSIONS

Our results are clinically informative and suggest (1) that the relationship between TBI screen status and social support is influenced by psychiatric symptoms and (2) that implementing distress reduction techniques before social support interventions may be most beneficial for Veterans screening positive for TBI.

Neuropsychological Performance and Functional Capacity Following Mild Traumatic Brain Injury in Veterans

OBJECTIVE

To examine the relationship between neuropsychological functioning and performance-based functional capacity in veterans with a history of mild traumatic brain injury (mTBI), as well as the moderating effects of age and psychiatric symptoms on this relationship.

SETTING

Three Veterans Affairs medical centers.

PARTICIPANTS

One hundred nineteen Iraq/Afghanistan veterans with a history of mTBI and self-reported cognitive difficulties.

DESIGN

Cross-sectional, secondary data analysis of baseline measures in a randomized controlled trial.

MAIN MEASURES

The main outcome measure, functional capacity, was assessed using the objective and performance-based University of California San Diego Performance-based Skills Assessment-Brief. A global deficit score (GDS) was created as a composite score for performance on a battery of neuropsychological measures assessing domains of attention, processing speed, executive functioning, and verbal memory performance. Posttraumatic stress disorder (PTSD) symptom severity was assessed using the PTSD Checklist-Military Version, and depressive symptom severity was assessed using the Beck Depression Inventory, Second Edition.

RESULTS

Bivariate analyses indicated that worse neuropsychological performance (ie, higher GDS) and greater PTSD symptom severity were associated with worse communication abilities and worse overall functional capacity. Multiple linear regressions demonstrated that GDS and PTSD symptom severity explained 9% of the variance in communication and 10% of the variance in overall functional capacity; however, GDS emerged as the only significant predictor in both regressions. Age, PTSD, and depressive symptom severity did not moderate the relationship between GDS and overall functional capacity. Performance in the verbal learning and memory domain emerged as the strongest neuropsychological predictor of communication and overall functional capacity.

CONCLUSIONS

Worse neuropsychological functioning was moderately associated with worse performance-based functional capacity, even when accounting for PTSD symptom severity. Verbal learning and memory was the primary neuropsychological domain driving the relationship with functional capacity; improvement in verbal learning and memory may translate into improved functional capacity.

Subjective cognitive and psychiatric well-being in U.S. Military Veterans screened for deployment-related traumatic brain injury: A Million Veteran Program Study

The purpose of this study was to examine subjective cognitive and psychiatric functioning in post-deployed military Veterans who underwent the Veterans Health Administration's Traumatic Brain Injury (TBI) Screening and Evaluation Program and enrolled in the VA's Million Veteran Program (MVP). Veterans (N = 7483) were classified into three groups based on outcomes from the TBI Screening and Evaluation Program: (1) negative TBI screen ('Screen-'), (2) positive TBI screen but no TBI diagnosis ('Screen+/TBI-'), or (3) positive TBI screen and TBI diagnosis ('Screen+/TBI+'). Chi-square analyses revealed significant group differences across all self-reported cognitive and psychiatric health conditions (e.g., memory loss, depression), and ANCOVAs similarly showed a significant association between group and subjective symptom reporting. Specifically, the relationship between TBI group and clinical outcome (i.e., health conditions and symptoms) was such that the Screen+/TBI+ group fared the worst, followed by the Screen+/TBI- group, and finally the Screen- group. However, evaluation of effect sizes suggested that Veterans in the two Screen+ groups (Screen+/TBI+ and Screen+/TBI-) are faring similarly to one another on subjective cognitive and psychiatric functioning, but that both Screen+ groups are faring significantly worse than the Screen- group. Our results have meaningful clinical implications and suggest that Veterans who screen positive for TBI, regardless of ultimate TBI diagnosis, be eligible for similar clinical services so that both groups can benefit from valuable treatments and therapeutics. Finally, this research sets the stage for follow-up work to be conducted within MVP that will address the neurobiological underpinnings of cognitive and psychiatric distress in this population.

APOE-ε4 Is Associated With Reduced Verbal Memory Performance and Higher Emotional, Cognitive, and Everyday Executive Function Symptoms Two Months After Mild Traumatic Brain Injury

Background

Substantial variance exists in outcomes after mild traumatic brain injury (MTBI), and these differences are not fully explained by injury characteristics or severity. Genetic factors are likely to play a role in this variance.

Objectives

The aim of this study was to examine associations between the apolipoprotein (APOE)-ε4 allele and memory measures at two months post-MTBI and to evaluate whether subjective cognitive and affective symptoms were associated with APOE-ε4 status. Based on previous research, it was hypothesized that APOE-ε4 carriers would show poorer verbal memory performance compared to APOE-ε4 non-carriers.

Methods

Neuropsychological data at two months post-injury and blood samples that could be used to assess APOE genotype were available for 134 patients with MTBI (mean age 39.2 years, 62% males, 37% APOE-ε4 carriers). All patients underwent computed tomography at hospital admission and magnetic resonance imaging four weeks post-injury.

Results

The APOE-ε4 + status was associated with decreased immediate memory recall (p = 0.036; β = −0.10, 95% CI [−0.19, −0.01]). Emotional, cognitive, and everyday executive function symptoms at two months post-injury were significantly higher in APOE-ε4 carriers compared to non-carriers.

Conclusion

The APOE-ε4+ allele has a negative effect on verbal memory and symptom burden two months after MTBI.

OUP accepted manuscript

OBJECTIVE

The etiology of persistent memory complaints after concussion is poorly understood. Memory perfectionism (highly valuing memory ability and intolerance of minor memory lapses) may help explain why some people report persistent subjective memory problems in the absence of corresponding objective memory impairment. This study investigated the relationship between memory perfectionism and persistent memory complaints after concussion.

METHODS

Secondary analysis of baseline data from a randomized controlled trial. Adults (N = 77; 61% women) with persistent symptoms following concussion were recruited from outpatient specialty clinics. Participants completed the National Institutes of Health Toolbox Cognition Battery, Test of Memory Malingering-Trial 1, and questionnaires measuring memory perfectionism (Metamemory in Adulthood-Achievement subscale), forgetfulness and other postconcussion symptoms (Rivermead Postconcussion Symptoms Questionnaire; RPQ), and depression (Patient Health Questionnaire-2) at M = 17.8 weeks postinjury. Patients with versus without severe memory complaints (based on the RPQ) were compared.

RESULTS

Memory perfectionism was associated cross-sectionally with severe memory complaint, after controlling for objective memory ability, overall cognitive ability, and depression (95% confidence interval for odds ratio = 1.11-1.40). Sensitivity analyses showed that this relationship did not depend on use of specific objective memory tests nor on inclusion of participants who failed performance validity testing. In a control comparison to test the specificity of identified relationships, memory perfectionism was not associated with severe fatigue (95% confidence interval for odds ratio = 0.91-1.07).

CONCLUSIONS

Memory perfectionism may be a risk factor for persistent memory symptoms after concussion, with potential relevance to the spectrum of functional cognitive disorders more broadly.

Risk factors for decline in cognitive performance following deployment-related mild traumatic brain injury: A preliminary report

Thorough identification of risk factors for delayed decline in cognitive performance following combat-related mild traumatic brain injury (mTBI) is important for guiding comprehensive post-deployment rehabilitation. In a sample of veterans who reported at least one deployment-related mTBI, preliminary results indicate that factors including a history of loss of consciousness over 1 min, current obesity and hypertension, and Black race were more prevalent in those with decreased scores on a measure of memory function. These factors should be considered by clinicians and researchers working with current and former military personnel.

Predictors and Correlates of Perceived Cognitive Decline in Retired Professional Rugby League Players

Objective: Rugby league is an international full-contact sport, with frequent concussive injuries. Participation in other full-contact sports such as American football has been considered to be a risk factor for neuropsychiatric sequelae later-in-life, but little research has addressed the mental and cognitive health of retired professional rugby league players. We examined predictors and correlates of perceived (self-reported) cognitive decline in retired National Rugby League (NRL) players. Methods: Participants were 133 retired male elite level rugby league players in Australia. Participants completed clinical interviews, neuropsychological testing, and self-report measures. The Informant Questionnaire on Cognitive Decline in the Elderly, self-report (IQCODE-Self), measured perceived cognitive decline. Results: The median age of the sample was 55.0 (M = 53.1, SD = 13.9, range = 30-89) and the median years of education completed was 12.0 (M = 11.9, SD = 2.6, range = 7-18). The retired players reported a median of 15.0 total lifetime concussions (M = 28.0, SD = 36.6, range = 0-200). The mean IQCODE-Self score was 3.2 (SD = 0.5; Range = 1.3-5.0); 10/133 (7.5%) and 38/133 (28.6%) scored above conservative and liberal cutoffs for cognitive decline on the IQCODE-Self, respectively. Perceived cognitive decline was positively correlated with current depressive symptoms, negatively correlated with years of professional sport exposure and resilience, and unrelated to objective cognition and number of self-reported concussions. A multiple regression model with perceived cognitive decline regressed on age, concussion history, professional rugby league exposure, depression, resilience, objective cognitive functioning, daytime sleepiness, and pain severity showed depression as the only significant predictor. Conclusion: This is the first large study examining subjectively experienced cognitive decline in retired professional rugby league players. Similar to studies from the general population and specialty clinics, no relationship was found between objective cognitive test performance and perceived cognitive decline. Depressive symptoms emerged as the strongest predictor of perceived cognitive decline, suggesting that subjective reports of worsening cognition in retired elite rugby league players might reflect psychological distress rather than current cognitive impairment.

Apolipoprotein e (APOE) ε4 genotype influences memory performance following remote traumatic brain injury in U.S. military service members and veterans

The purpose of this study was to examine the association between the apolipoprotein E (APOE) ε4 allele and neurocognitive functioning following traumatic brain injury (TBI) in military service members and veterans (SMVs). Participants included 176 SMVs with a history of remote TBI (≥1 year post-injury), categorized into mild (n = 100), moderate (n = 40), and severe (n = 36) TBI groups. Participants completed a neuropsychological assessment and APOE genotyping (n = 46 ε4+, n = 130 ε4-). Neurocognitive composite scores representing memory, executive functioning, and visual processing speed were computed. ANCOVAs adjusting for race, education, combat exposure, and PTSD symptom severity showed a significant main effect of ε4 on the memory composite, such that ε4+ SMVs exhibited poorer memory performance than ε4- SMVs. When ε2 allele carriers were removed from the analyses, associations with memory were strengthened, demonstrating a possible protective effect of the ε2 allele. No main effect of TBI group was identified on any cognitive composite, nor were there any significant TBI group × ε4 status interactions for any cognitive composite. Future studies with larger samples are needed to verify these findings, but our results suggest an important relationship between ε4 status and memory functioning following remote TBI of all severities.

Altered gray matter structural covariance networks at both acute and chronic stages of mild traumatic brain injury

Cognitive and emotional impairments observed in mild traumatic brain injury (mTBI) patients may reflect variances of brain connectivity within specific networks. Although previous studies found altered functional connectivity (FC) in mTBI patients, the alterations of brain structural properties remain unclear. In the present study, we analyzed structural covariance (SC) for the acute stages of mTBI (amTBI) patients, the chronic stages of mTBI (cmTBI) patients, and healthy controls. We first extracted the mean gray matter volume (GMV) of seed regions that are located in the default-mode network (DMN), executive control network (ECN), salience network (SN), sensorimotor network (SMN), and the visual network (VN). Then we determined and compared the SC for each seed region among the amTBI, the cmTBI and the healthy controls. Compared with healthy controls, the amTBI patients showed lower SC for the ECN, and the cmTBI patients showed higher SC for the both DMN and SN but lower SC for the SMN. The results revealed disrupted ECN in the amTBI patients and disrupted DMN, SN and SMN in the cmTBI patients. These alterations suggest that early disruptions in SC between bilateral insula and the bilateral prefrontal cortices may appear in amTBI and persist into cmTBI, which might be potentially related to the cognitive and emotional impairments.

The Savage Organizational Scoring System for the Rey-Osterrieth Complex Figure Test: Norms and New Data From Veterans in a Traumatic Brain Injury Clinic

The Rey-Osterrieth Complex Figure Test (RCFT) permits quantifying diverse cognitive abilities, including executive function (EF). We evaluated the psychometric properties of a scoring procedure for the RCFT, the Savage Organizational Scoring System (SOSS), that awards points for drawing the largest structural elements of the figures as continuous wholes. This was a two-phase study: first, we conducted a systematic literature search for studies using the SOSS, and aggregated previously published data for healthy controls to create a normative database; second, we observed performances from veterans evaluated for traumatic brain injury (TBI), examining the reliability of their SOSS scores, the SOSS correlations with two EF measures and the participants' self-reported cognitive functioning, and then compared their mean scores to normative expectations. Across our literature-derived normative database, the aggregated mean SOSS score was 4.12 (SD = 1.72), which was marginally higher than that of our veteran participants evaluated for TBI, 3.72 (SD = 1.79). The SOSS had modest internal consistency (α = .59). Unlike the criterion EF measures, the SOSS was not significantly related to self-reported cognitive functioning. The SOSS shared a small, significant correlation with Trails B and Shipley Abstraction; but RCFT Copy scores were more strongly related to these tests, and the SOSS added no significant incremental predictive value beyond the RCFT Copy score. However, SOSS scores did predict RCFT Recall beyond RCFT Copy scores. We conclude that the SOSS has modest reliability and is predictive of RCFT Recall scores, but it is not strongly correlated with other EF measures, and it is only minimally affected by mild TBI.

Effect of blast-related mTBI on the working memory system: a resting state fMRI study

Reduced working memory is frequently reported by Veterans with a history of blast-related mild traumatic brain injury (mTBI), but can be difficult to quantify on neuropsychological measures. This study aimed to improve our understanding of the impact of blast-related mTBI on the working memory system by using resting state functional magnetic resonance imaging (fMRI) to explore differences in functional connectivity between OEF/OIF/OND Veterans with and without a history of mTBI. Participants were twenty-four Veterans with a history of blast-related mTBI and 17 Veterans who were deployed but had no lifetime history of TBI. Working memory ability was evaluated with the Auditory Consonants Trigrams (ACT) task. Resting state fMRI was used to evaluate intrinsic functional connectivity from frontal seed regions that are known components of the working memory network. No significant group differences were found on the ACT, but the imaging analyses revealed widespread hyper-connectivity from the frontal seed regions in the Veterans with a history of mTBI relative to the deployed control group. Further, within the mTBI group, but not the control group, better performance on the ACT was associated with increased functional connectivity to multiple brain regions, including cerebellar components of the working memory network. These results were present after controlling for age, PTSD symptoms, and estimated premorbid IQ, and suggest that long-term alterations in the functional connectivity of the working memory network following blast-related mTBI may reflect a compensatory change that contributes to intact performance on an objective measure of working memory.

The power of appraisals in predicting PTSD symptom improvement following cognitive rehabilitation: A randomized clinical trial

BACKGROUND

Patients with PTSD often voice concern over their perceived change in cognitive functioning. However, these negative appraisals do not always align with objective neuropsychological performance, yet are strongly predictive of PTSD symptom severity and self-reported functional impairment.

METHODS

The present study involves a secondary analysis examining the role of appraisals of a subsample of 81 adults with full or subthreshold PTSD on treatment outcomes in a randomized controlled trial investigating the effectiveness of a cognitive rehabilitation treatment, Strategic Memory and Reasoning Training (n = 38), compared to a psychoeducation control arm, the Brain Health Workshop (n = 43). Neither condition addressed PTSD symptoms, focusing instead on cognitive skills training and psychoeducation about the brain.

RESULTS

Intent-to-treat models showed statistically significant improvements for both groups on composite scores of executive functioning and memory. Additionally, both groups experienced clinically significant reductions in PTSD symptoms (assessed via the Clinician-Administered PTSD Interview) and the SMART group showed fewer negative appraisals about cognitive functioning following training. Change in appraisals of cognitive functioning was associated with change in PTSD as well as change in quality of life, with no differential associations based on group status. In contrast, neurocognitive test score changes were not associated with change in symptoms or functional outcomes.

LIMITATIONS

We did not collect data on other appraisals (e.g., self-efficacy), which could have further elucidated pathways of change.

CONCLUSIONS

Our findings suggest that interventions that do not directly target PTSD symptoms can lead to PTSD symptom change via change in appraisals of functioning.

Cognitive Training for Mild Traumatic Brain Injury and Posttraumatic Stress Disorder

Although there is evidence of mild cognitive impairments for many individuals with mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD), little research evaluating the effectiveness of cognitive training interventions has been conducted. This randomized controlled trial examined the effectiveness of a 9-h group cognitive training targeting higher-order functions, Strategic Memory Advanced Reasoning Training (SMART), compared to a 9-h psychoeducational control group in improving neurocognitive functioning in adults with mTBI and PTSD. A sample of 124 adults with histories of mild TBI (n = 117) and/or current diagnoses of PTSD (n = 84) were randomized into SMART (n = 66) or Brain Health Workshop (BHW; n = 58) and assessed at three time points: baseline, following training, and 6 months later. Participants completed a battery of neurocognitive tests, including a test of gist reasoning (a function directly targeted by SMART) as well as tests of verbal, visual, and working memory and executive functioning, functions commonly found to be mildly impaired in mTBI and PTSD. The two groups were compared on trajectories of change over time using linear mixed-effects models with restricted maximum likelihood (LMM). Contrary to our hypothesis that SMART would result in superior improvements compared to BHW, both groups displayed statistically and clinically significant improvements on measures of memory, executive functioning, and gist reasoning. Over 60% of the sample showed clinically significant improvements, indicating that gains can be found through psychoeducation alone. A longer SMART protocol may be warranted for clinical samples in order to observe gains over the comparison group.

Response inhibition in Veterans with a history of mild traumatic brain injury: The role of self-reported complaints in objective performance

INTRODUCTION

Although objective deficits in response inhibition (RI) have been detected in civilians with mild traumatic brain injury (mTBI), it remains unclear whether objective RI is worse in military Veterans with mTBI despite the prevalence of self-reported disinhibition. Assessing RI in Veterans is critical due to their unique characteristics, including combat and blast exposure, in addition to the prevalence of psychiatric comorbidity. Therefore, the aims of this study were to (1) examine RI performance in Veterans with mTBI compared to non-mTBI Veterans and (2) compare RI performance in well-defined subgroups of mTBI Veterans with and without self-reported complaints of disinhibition to non-mTBI Veterans.

METHOD

53 mTBI Veterans and 37 non-mTBI Veterans completed a Go/No-Go RI task and measures of self-reported disinhibition (Frontal Systems Behavior Scale) and psychiatric symptoms. ANCOVAs covarying for mood and demographics compared RI performances of the non-mTBI Veterans to (1) the total sample of mTBI Veterans (n= 53) and to (2) mTBI Veterans with elevated (t-score ≥ 60; mTBI-SubjDis; n= 23) and low (t-score < 60; mTBI-NoSubjDis; n= 30) levels of self-reported disinhibition.

RESULTS

There were no significant differences in RI between the mTBI group as a whole and the non-mTBI Veterans group. However, when Veterans with mTBI were divided into groups by clinically-significant concern about their disinhibition, the mTBI-SubjDis group demonstrated significantly worse RI than the mTBI-NoSubjDis and non-mTBI Veteran groups. No significant differences in RI performance were observed between the mTBI-NoSubjDis and non-mTBI Veteran groups.

CONCLUSIONS

Results indicate that mTBI Veterans with elevated levels of self-reported disinhibition show diminished performance on objective measures of RI, independent of mood. Findings highlight the unique contribution of subjective complaints on executive functioning in mTBI, and they underscore the importance of assessing cognitive complaints in order to identify those most at risk for poor-long term outcomes.

Neuropsychological Performance and Subjective Symptom Reporting in Military Service Members With a History of Multiple Concussions: Comparison With a Single Concussion, Posttraumatic Stress Disorder, and Orthopedic Trauma

OBJECTIVE

To examine differences in objective neurocognitive performance and subjective cognitive symptoms in individuals with a history of a single concussion, multiple concussions, orthopedic injuries, and posttraumatic stress disorder (PTSD).

METHOD

Participants included 116 military service members who sustained a mild traumatic brain injury (mTBI) during combat deployment. Subjects were subdivided into groups based on concussion frequency: a single concussion (n = 42), 2 concussions (n = 21), and 3 or more concussions (n = 53). Eighty-one subjects sustained an orthopedic injury (n = 60) during deployment or were diagnosed with PTSD (n = 21), but had no history of mTBI. Subjects completed a battery of neuropsychological tests and self-report measures of postconcussive symptoms, PTSD symptoms, and psychopathology.

RESULTS

No differences were found among the concussion groups on a composite neuropsychological measure. The PTSD group had the highest number of symptom complaints, with the 2-concussion and 3-plus-concussion groups being most similar to the PTSD group. The concussion groups showed a nonsignificant pattern of increasing distress with increasing number of concussions.

CONCLUSIONS

The current findings are consistent with meta-analytic results showing no differential effect on neuropsychological functioning due to multiple concussions. Results also support the burden of adversity hypothesis suggesting increasing symptom levels with increasing psychological or physically traumatic exposures.

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).

Performance Validity, Neurocognitive Disorder, and Post-concussion Symptom Reporting in Service Members with a History of Mild Traumatic Brain Injury

Objective

To examine the influence of different performance validity test (PVT) cutoffs on neuropsychological performance, post-concussion symptoms, and rates of neurocognitive disorder and postconcussional syndrome following mild traumatic brain injury (MTBI) in active duty service members.

Method

Participants were 164 service members (Age: M = 28.1 years [SD = 7.3]) evaluated on average 4.1 months (SD = 5.0) following injury. Participants were divided into three mutually exclusive groups using original and alternative cutoff scores on the Test of Memory Malingering (TOMM) and the Effort Index (EI) from the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS): (a) PVT-Pass, n = 85; (b) Alternative PVT-Fail, n = 53; and (c) Original PVT-Fail, n = 26. Participants also completed the Neurobehavioral Symptom Inventory.

Results

The PVT-Pass group performed better on cognitive testing and reported fewer symptoms than the two PVT-Fail groups. The Original PVT-Fail group performed more poorly on cognitive testing and reported more symptoms than the Alternative PVT-Fail group. Both PVT-Fail groups were more likely to meet DSM-5 Category A criteria for mild and major neurocognitive disorder and symptom reporting criteria for postconcussional syndrome than the PVT-Pass group. When alternative PVT cutoffs were used instead of original PVT cutoffs, the number of participants with valid data meeting cognitive testing criteria for neurocognitive disorder or postconcussional syndrome decreased dramatically.

Conclusion

PVT performance is significantly and meaningfully related to overall neuropsychological outcome. By using only original cutoffs, clinicians and researchers may miss people with invalid performances.

SMART-CPT for veterans with comorbid post-traumatic stress disorder and history of traumatic brain injury: a randomised controlled trial

OBJECTIVE

To better concurrently address emotional and neuropsychological symptoms common in veterans with comorbid post-traumatic stress disorder (PTSD) and history of traumatic brain injury (TBI), we integrated components of compensatory cognitive training from the Cognitive Symptom Management and Rehabilitation Therapy (CogSMART) programme into cognitive processing therapy (CPT) for PTSD to create a hybrid treatment, SMART-CPT (CogSMART+CPT). This study compared the efficacy of standard CPT with SMART-CPT for treatment of veterans with comorbid PTSD and history of TBI reporting cognitive symptoms.

METHODS

One hundred veterans with PTSD, a history of mild to moderate TBI and current cognitive complaints were randomised and received individually delivered CPT or SMART-CPT for 12 weeks. Participants underwent psychological, neurobehavioural and neuropsychological assessments at baseline, on completion of treatment and 3 months after treatment.

RESULTS

Both CPT and SMART-CPT resulted in clinically significant reductions in PTSD and postconcussive symptomatology and improvements in quality of life. SMART-CPT resulted in additional improvements in the neuropsychological domains of attention/working memory, verbal learning/memory and novel problem solving.

CONCLUSION

SMART-CPT, a mental health intervention for PTSD, combined with compensatory cognitive training strategies, reduces PTSD and neurobehavioural symptoms and also provides added value by improving cognitive functioning.

Neurobehavioral symptom validity and performance validity in veterans: Evidence for distinct outcomes across data types

Self-reported traumatic brain injury (TBI) is common in combat veterans, and identification of psychiatric and neuropsychological consequences following TBI has become a priority for veteran healthcare. Given the importance of accurately capturing symptoms potentially related to TBI in VA settings, validity metrics are frequently used to evaluate both neuropsychological testing validity and the validity of symptom self-reports. The Validity-10 of the Neurobehavioral Symptom Inventory is one such metric that was designed to evaluate symptom over-reporting and thus identify individuals who may produce inconclusive testing profiles. However, the Validity-10's ability to predict objective effort during neuropsychological testing has not been sufficiently explored in veterans. Clinical evaluation data were collected from 295 veterans seeking treatment in a VA TBI clinic. We examined whether the Validity-10 can predict invalid performance on a battery of neuropsychological tests. Validity-10 was a poor predictor of performance validity metrics. Results provide a conceptual replication of earlier work demonstrating that performance and symptom validity are divergent. As such, separate evaluation of these domains is warranted during evaluations conducted in veteran TBI populations.

Chronic Effects of Neurotrauma Consortium (CENC) multicentre study interim analysis: Differences between participants with positive versus negative mild TBI histories

OBJECTIVES

Compare characteristics and outcomes of combat-exposed military personnel with positive versus negative mild traumatic brain injury (mTBI) histories.

SETTING

Recruitment was from registration lists and ambulatory clinics at four veterans administration hospitals.

PARTICIPANTS

Consented veterans and service members completing initial evaluation by September 2016 (n = 492).

DESIGN

Observational with cross-sectional analyses.

MAIN MEASURES

Multimodal assessments including structured interviews, record review, questionnaires, neuroendocrine labs and neurocognitive and sensorimotor performance.

RESULTS

In unadjusted comparisons to those absent lifetime mTBI, the mTBI positive group (84%) had greater combat exposure, more potential concussive events, less social support and more comorbidities, including asthma, sleeping problems and post-traumatic stress disorder. They also fared worse on all sensory and pain symptom scores and self-reported functional and global outcomes. They had poorer scores on Wechsler Adult Intelligence Scale-IV coding (processing speed), TMT-B (visual-motor integration and executive function) and two posturography subtests, but were otherwise equal to TBI negative participants on neurocognitive and sensorimotor testing and neuroendocrine levels.

CONCLUSIONS

Although differences in characteristics exist which were not adjusted for, participants with historical mTBI have greater symptomatology and life functioning difficulties compared with non-TBI. Performance measures were less dissimilar between groups. These findings will guide further research within this accruing cohort.

Heterotopic Ossification Formation Following a Simple Concussion: A Case Report

CASE

A 19-year-old woman presented with a 3-month history of an enlarging lesion on the proximal aspect of the femur. After imaging studies and a biopsy had been performed, the mass was determined to represent heterotopic ossification (HO). The only known risk factor was a history of concussion. The mass was resected and, as of the 12-month follow-up, had not recurred.

CONCLUSION

HO is a potentially serious complication of ossification in soft tissues that can develop secondary to several disease states; it commonly occurs following traumatic brain injury. To our knowledge, this is the only case report that describes HO associated with a concussion and no other risk factors.

Retrospective and Prospective Memory Among OEF/OIF/OND Veterans With a Self-Reported History of Blast-Related mTBI

OBJECTIVES

To evaluate prospective and retrospective memory abilities in Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans with and without a self-reported history of blast-related mild traumatic brain injury (mTBI).

METHODS

Sixty-one OEF/OIF/OND Veterans, including Veterans with a self-reported history of blast-related mTBI (mTBI group; n=42) and Veterans without a self-reported history of TBI (control group; n=19) completed the Memory for Intentions Test, a measure of prospective memory (PM), and two measures of retrospective memory (RM), the California Verbal Learning Test-II and the Brief Visuospatial Memory Test-Revised.

RESULTS

Veterans in the mTBI group exhibited significantly lower PM performance than the control group, but the groups did not differ in their performance on RM measures. Further analysis revealed that Veterans in the mTBI group with current PTSD (mTBI/PTSD+) demonstrated significantly lower performance on the PM measure than Veterans in the control group. PM performance by Veterans in the mTBI group without current PTSD (mTBI/PTSD-) was intermediate between the mTBI/PTSD+ and control groups, and results for the mTBI/PTSD- group were not significantly different from either of the other two groups.

CONCLUSIONS

Results suggest that PM performance may be a sensitive marker of cognitive dysfunction among OEF/OIF/OND Veterans with a history of self-reported blast-related mTBI and comorbid PTSD. Reduced PM may account, in part, for complaints of cognitive difficulties in this Veteran cohort, even years post-injury. (JINS, 2018, 24, 324-334).

Hyperarousal Symptoms Explain the Relationship Between Cognitive Complaints and Working Memory Performance in Veterans Seeking PTSD Treatment

OBJECTIVE

Comorbidity and symptom overlap between traumatic brain injury and posttraumatic stress disorder (PTSD) in veterans returning from deployment present challenges with respect to differential diagnosis and treatment. Both conditions frequently manifest with attention and working memory deficits, though the underlying neuropsychological basis differs. This study evaluated whether hyperarousal symptoms explain the relationship between subjective and objective measures of cognition in a veteran sample.

PARTICIPANTS AND PROCEDURES

One-hundred three veterans completed the military version of the PTSD Checklist (PCL), the Neurobehavioral Symptom Inventory, and the Wechsler Memory Scale, 3rd edition digit span task with adequate effort.

RESULTS

Hierarchical regression suggested that hyperarousal, but not other PTSD symptoms, explained the relationship between neurobehavioral symptoms and cognitive functioning. This relationship was present regardless of whether veterans met full PTSD diagnostic criteria or screened positive on a traumatic brain injury screener and was robust to other moderators.

CONCLUSION

These findings highlight the importance of considering traumatic brain injury and PTSD symptom overlap, particularly the relationship between hyperarousal symptoms and attention and working memory deficits, in conceptualizing cases and treatment planning.

The Association Between PTSD and Functional Outcome Is Mediated by Perception of Cognitive Problems Rather Than Objective Neuropsychological Test Performance

Posttraumatic stress disorder (PTSD) has been consistently linked to poorer functional outcomes, including quality of life, health problems, and social and occupational functioning. Less is known about the potential mechanisms by which PTSD leads to poorer functional outcomes. We hypothesized that neurocognitive functioning and perception of cognitive problems would both mediate the relationship between PTSD diagnosis and functioning. In a sample of 140 veterans of the recent wars and conflicts in Iraq and Afghanistan, we assessed PTSD symptoms, history of traumatic brain injury (TBI), depression, self-report measures of quality of life, social and occupational functioning, and reintegration to civilian life, as well as perception of cognitive problems. Veterans also completed a comprehensive neuropsychological battery of tests. Structural equation modeling revealed that perception of cognitive problems, but not objective neuropsychological performance, mediated the relationship between PTSD diagnosis and functional outcomes after controlling for TBI, depression, education, and a premorbid IQ estimate, b = -6.29, 95% bias-corrected bootstrapped confidence interval [-11.03, -2.88], showing a large effect size. These results highlight the importance of addressing appraisals of posttrauma cognitive functioning in treatment as a means of improving functional outcomes.

Predictors of Postdeployment Functioning in Combat-Exposed U.S. Military Veterans

Posttraumatic stress disorder (PTSD) and sequelae of mild traumatic brain injury (mTBI) are presumed to contribute to reintegration difficulties in combat-exposed veterans. Yet their relative impacts on postdeployment functioning are not well understood. The current study used structural equation modeling (SEM) to clarify the extent to which symptoms of internalizing disorders (e.g., depression, anxiety), mTBI symptoms, and cognitive performance are associated with functional impairment in 295 combat-exposed veterans. SEM results showed that internalizing symptoms most significantly predicted functional impairment (r = 0.72). Blast mTBI and cognitive performance were associated with internalizing (r = 0.24 and -0.25, respectively), but functional impairment was only modestly related to cognition (r = -0.17) and unrelated to mTBI. These results indicate that internalizing symptoms are the strongest predictor of functioning in trauma-exposed veterans, exceeding the effects of mTBI and cognitive performance. This evidence supports prioritizing interventions that target internalizing psychopathology to improve functioning in cases of co-occurring PTSD and mTBI.

Compromised Neurocircuitry in Chronic Blast-Related Mild Traumatic Brain Injury

The aim of this study was to apply recently developed automated fiber segmentation and quantification methods using diffusion tensor imaging (DTI) and DTI-based deterministic and probabilistic tractography to access local and global diffusion changes in blast-induced mild traumatic brain injury (bmTBI). Two hundred and two (202) male active US service members who reported persistent post-concussion symptoms for more than 6 months after injury were recruited. An additional forty (40) male military controls were included for comparison. DTI results were examined in relation to post-concussion and post-traumatic stress disorder (PTSD) symptoms. No significant group difference in DTI metrics was found using voxel-wise analysis. However, group comparison using tract profile analysis and tract specific analysis, as well as single subject analysis using tract profile analysis revealed the most prominent white matter microstructural injury in chronic bmTBI patients over the frontal fiber tracts, that is, the front-limbic projection fibers (cingulum bundle, uncinate fasciculus), the fronto-parieto-temporal association fibers (superior longitudinal fasciculus), and the fronto-striatal pathways (anterior thalamic radiation). Effects were noted to be sensitive to the number of previous blast exposures, with a negative association between fractional anisotropy (FA) and time since most severe blast exposure in a subset of the multiple blast-exposed group. However, these patterns were not observed in the subgroups classified using macrostructural changes (T2 white matter hyperintensities). Moreover, post-concussion symptoms and PTSD symptoms, as well as neuropsychological function were associated with low FA in the major nodes of compromised neurocircuitry. Hum Brain Mapp 38:352-369, 2017. © 2016 Wiley Periodicals, Inc.

Red flags in the clinical interview may forecast invalid neuropsychological testing

OBJECTIVE

Evaluating assessment validity is expected in neuropsychological evaluation, particularly in cases with identified secondary gain, where malingering or somatization may be present. Assessed with standalone measures and embedded indices, all within the testing portion of the examination, research on validity of self-report in the clinical interview is limited. Based on experience with litigation-involved examinees recovering from mild traumatic brain injury (mTBI), it was hypothesized that inconsistently reported date of injury (DOI) and/or loss of consciousness (LOC) might predict invalid performance on neurocognitive testing.

METHOD

This archival study examined cases of litigation-involved mTBI patients seen at an outpatient neuropsychological practice in Philadelphia, PA. Coded data included demographic variables, performance validity measures, and consistency between self-report and medicolegal records.

RESULTS

A significant relationship was found between the consistency of examinees' self-report with records and their scores on performance validity testing, X² (1, N = 84) = 24.18, p < .01, Φ = .49. Post hoc testing revealed significant between-group differences in three of four comparisons, with medium to large effect sizes. A final post hoc analysis found significance between the number of performance validity tests (PVTs) failed and the extent to which an examinee incorrectly reported DOI r(83) = .49, p < .01. Using inconsistently reported LOC and/or DOI to predict an examinee's performance as invalid had a 75% sensitivity and a 75% specificity.

CONCLUSION

Examinees whose reported DOI or LOC differs from records may be more likely to fail one or more PVTs, suggesting possible symptom exaggeration and/or under performance on cognitive testing.s.

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.

Assessing for mild TBI among Iraq and Afghanistan veterans: Outcomes of injury severity and neurological factors

OBJECTIVE

To investigate injury severity markers and neurological symptoms associated with clinician-confirmed mild traumatic brain injury (TBI) among Iraq and Afghanistan veterans.

SETTING

Department of Veterans Affairs (VA) medical centre and five affiliated community-based outpatient clinics.

PARTICIPANTS

Three hundred and fifty Iraq and Afghanistan veterans with positive initial VA TBI screens between 1 April 2007 and 1 June 2010 and clinician-confirmed TBI status by 1 December 2010.

METHODS

Retrospective-cohort study of medical record data. Main measures included clinician-confirmed TBI status, injury severity markers (e.g. loss of consciousness (LOC), post-traumatic amnesia (PTA) or confusion/disorientation) and neurological symptoms.

RESULTS

Among veterans who screened positive on the initial VA TBI and then received a clinician evaluation, 60% were confirmed to have a TBI diagnosis. Veterans reporting at least one LOC, confusion or PTA were almost 18-times more likely to receive a confirmed TBI diagnosis. Odds of clinician-confirmed TBI were 2.5-3-times greater among those who endorsed dizziness, poor coordination, headaches, nausea, vision problems and/or irritability, compared to those not endorsing these symptoms. Nausea had greatest utility for confirming a TBI.

CONCLUSIONS

Identification of neurologic symptoms that most contribute to a clinician-confirmed diagnosis of TBI has potential for streamlining detection of TBI and symptoms needed for treatment.

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.

Factors Associated with Word Memory Test Performance in Persons with Medically Documented Traumatic Brain Injury

OBJECTIVES

(1) To examine the rate of poor performance validity in a large, multicenter, prospectively accrued cohort of community dwelling persons with medically documented traumatic brain injury (TBI), (2) to identify factors associated with Word Memory Test (WMT) performance in persons with TBI.

METHOD

This was a prospective cohort, observational study of 491 persons with medically documented TBI. Participants were administered a battery of cognitive tests, questionnaires on emotional distress and post-concussive symptoms, and a performance validity test (WMT). Additional data were collected by interview and review of medical records.

RESULTS

One hundred and seventeen participants showed poor performance validity using the standard cutoff. Variable cluster analysis was conducted as a data reduction strategy. Findings revealed that the 10 cognitive tests and questionnaires could be summarized as 4 indices of emotional distress, speed of cognitive processing, verbal memory, and verbal fluency. Regression models revealed that verbal memory, emotional distress, age, and injury severity (time to follow commands) made unique contribution to prediction of poor performance validity.

CONCLUSIONS

Poor performance validity was common in a research sample of persons with medically documented TBI who were not evaluated in conjunction with litigation, compensation claims, or current report of symptoms. Poor performance validity was associated with poor performance on cognitive tests, greater emotional distress, lower injury severity, and greater age. Many participants expected to have residual deficits based on initial injury severity showed poor performance validity.

Acute post-traumatic stress symptoms and age predict outcome in military blast concussion

High rates of adverse outcomes have been reported following blast-related concussive traumatic brain injury in US military personnel, but the extent to which such adverse outcomes can be predicted acutely after injury is unknown. We performed a prospective, observational study of US military personnel with blast-related concussive traumatic brain injury (n = 38) and controls (n = 34) enrolled between March and September 2012. Importantly all subjects returned to duty and did not require evacuation. Subjects were evaluated acutely 0-7 days after injury at two sites in Afghanistan and again 6-12 months later in the United States. Acute assessments revealed heightened post-concussive, post-traumatic stress, and depressive symptoms along with worse cognitive performance in subjects with traumatic brain injury. At 6-12 months follow-up, 63% of subjects with traumatic brain injury and 20% of controls had moderate overall disability. Subjects with traumatic brain injury showed more severe neurobehavioural, post-traumatic stress and depression symptoms along with more frequent cognitive performance deficits and more substantial headache impairment than control subjects. Logistic regression modelling using only acute measures identified that a diagnosis of traumatic brain injury, older age, and more severe post-traumatic stress symptoms provided a good prediction of later adverse global outcomes (area under the receiver-operating characteristic curve = 0.84). Thus, US military personnel with concussive blast-related traumatic brain injury in Afghanistan who returned to duty still fared quite poorly on many clinical outcome measures 6-12 months after injury. Poor global outcome seems to be largely driven by psychological health measures, age, and traumatic brain injury status. The effects of early interventions and longer term implications of these findings are unknown.