Self-Reported Sleep Disturbance Mediates the Relationship Between PTSD and Cognitive Outcome in Blast-Exposed OEF/OIF Veterans

Effects of mTBI with loss of consciousness on neurobehavioral symptoms, depression, and insomnia in former collegiate and NFL football athletes

OBJECTIVE

Considering that diagnostic decisions about mTBI are often predicated on clinical symptom criteria, it is imperative to determine which initial presentation features of mTBI have prognostic significance for identifying those at high risk for long-term functional impairment.

SETTING

Zoom interview Participants: Male, former NCAA Division I, and professional-level National Football League (NFL) athletes (n = 177) between the ages of 27 and 85 (M = 54.1, SD = 14.7).

DESIGN

Cross-sectional case-control. Main Measures: History of mild TBI, history of loss of consciousness (LOC), depression symptoms, insomnia, neurobehavioral symptoms.

RESULTS

Number of mTBI exposures did not predict neurobehavioral symptoms (B = 0.21, SE = 0.18, p = 0.23), but number of mTBI + LOC events did (B = 2.27, SE = 0.64, p = <.001). Further analysis revealed that the number of mTBI + LOC events predicted neurobehavioral symptoms indirectly through both depression (B = 0.85, 95% CI = [0.27, 1.52) and insomnia (B = 0.81, 95% CI = [0.3, 1.4]). Further, the direct effect of mTBI + LOC events on neurobehavioral symptoms became non-significant when depression and insomnia were added to the model (B = 0.78, SE = 0.45, p = 0.08).

CONCLUSIONS

Findings support LOC at time of injury as an important predictor of long-term outcomes. Additionally, results suggest depression and insomnia as potential mediators in the association between mTBI + LOC and neurobehavioral symptoms. These findings provide justification for early depression and insomnia symptom monitoring following mTBI + LOC.

Single and repeated high-level blast, low-level blast, and new-onset self-reported health conditions in the U.S. Millennium Cohort Study: An exploratory investigation

Introduction

Although previous research suggests that overpressure exposure from either high-level blast (HLB) or low-level blast (LLB) are harmful to health, to date no large-scale studies with representative samples of military personnel have utilized prospective designs and self-reported measures to examine the relationships between blast exposure and health conditions. To address these limitations, this analysis of data from the Millennium Cohort Study (MCS), the largest and longest running study of U.S. service members and veterans, examined (1) whether single or repeated HLB exposure is associated with self-reported diagnoses of illness and injury, (2) whether repeated HLB is associated with greater risk than single HLB, (3) potential adverse consequences of LLB exposure using military occupation as a proxy, and (4) the combined effects of single or repeated HLB and LLB exposure.

Method

MCS participants who completed the 2011-2013 survey (N = 138,949) were classified as having been exposed to "no," "single," or "repeated" HLB exposure, and into low or high risk of exposure to LLB based on occupation. Participants self-reported diagnosis of 45 medical conditions; newly reported diagnoses were regressed on single and repeated (vs. no) HLB, occupational risk of LLB, and relevant interactions using logistic regression.

Results

Single and repeated HLB were associated with new onset of 25 and 29 diagnoses, respectively; repeated HLB exposure was associated with greater risk than single HLB exposure for five diagnoses (e.g., PTSD, depression). Occupational risk of LLB was associated with 11 diagnoses (e.g., PTSD, significant hearing loss). Additionally, 14 significant interactions were detected across 11 diagnoses.

Discussion

Findings suggest that overpressure exposure (including single HLB, repeated HLB, and occupational risk of LLB) may increase the risks of self-reporting clinical diagnoses of PTSD, hearing loss, chronic fatigue syndrome, neuropathy-caused reduced sensation in the hands and feet, depression, vision loss, sinusitis, reflux, and anemia. Furthermore, the combination of HLB and LLB exposure may be associated with greater risk of migraines, PTSD, and impaired fecundity. These findings provide further evidence of the potential adverse consequences associated with overpressure exposure and underscore the necessity of public health surveillance initiatives for blast exposure and/or safety recommendations for training and operational environments.

Associations between changes in somatic and psychiatric symptoms and disability alterations in recent-era U.S. veterans

Cross-sectional work suggests that deployment-related posttraumatic sequelae are associated with increased disability in U.S. veterans deployed following the September 11, 2001 (9/11), terrorist attacks. However, few studies have examined the psychiatric and somatic variables associated with changes in functional disability over time. A total of 237 post-9/11 veterans completed comprehensive assessments of psychiatric and cognitive functioning, as well as a disability questionnaire, at baseline and 2-year follow-up. At baseline, higher levels of PTSD, depressive, and pain-related symptoms were associated with baseline global functional disability, semipartial r² = .036-.044. Changes in symptoms of PTSD, depression, pain, and sleep, but not anxiety or alcohol use, were independently associated with changes in functional disability, semipartial r² = .017-.068. Baseline symptoms of these conditions were unrelated to changes in disability, and cognitive performance was unrelated to disability at any assessment point. Together, this suggests that changes in psychiatric and somatic symptoms are tightly linked with changes in functional disability and should be frequently monitored, and even subclinical symptoms may be a target of intervention.

Prevalence of insomnia and insomnia symptoms following mild-traumatic brain injury: A systematic review and meta-analysis

Sleep is commonly disrupted following mild traumatic brain injury (mTBI), however there is a lack of consensus in the existing literature regarding the prevalence of insomnia/insomnia symptoms after injury. The aim of this review was to conduct a systematic review and meta-analysis of insomnia and insomnia symptoms' prevalence following mTBI. Full-text articles published in English in peer-reviewed journals, including adults with a clinical or self-reported mild traumatic brain injury diagnosis, were eligible for inclusion. Studies that assessed insomnia/insomnia symptoms after injury were included. Of the 2091 records identified, 20 studies were included in the review. 19 of these were meta-analysed (n = 95,195), indicating high heterogeneity among studies. Subgroup analyses indicated pooled prevalence estimates of post-mTBI insomnia disorder of 27.0% (95% CI 6.49-54.68) and insomnia symptoms of 71.7% (95% CI 60.31-81.85). The prevalence of insomnia is significantly higher in individuals who have sustained mild traumatic brain injury compared to prevalence estimates reported in the general population but high heterogeneity and methodological differences among studies make it difficult to provide reliable prevalence estimates. Future research should continue to advance our understanding of the onset, progression and impact of post-mild traumatic brain injury insomnia to promote the recovery and wellbeing of affected individuals. PROSPERO registration CRD42020168563.

Risk of Dementia in Posttraumatic Stress Disorder

Several studies have investigated the risk of dementia in posttraumatic stress disorder (PTSD) using a varying methodology. Epidemiological studies have found an increased risk of dementia with PTSD in Vietnam veterans as well as the general population. Laboratory studies reported the accelerated formation of β-amyloid and tau, which represent the primary pathology of Alzheimer's dementia in animal models of PTSD. These investigations were conducted against a background of cognitive impairment and atrophy of the hippocampus and certain cortical areas in patients with PTSD. Very few studies have investigated the pathological basis in humans for the reported association of PTSD with dementia. This important gap in the literature has recently been partly addressed by very few studies that estimated the burden of β-amyloid and tau. The PET studies did not show an association between PTSD and the specific pathology of Alzheimer's disease or signs of neurodegenerative diseases underlying other dementia syndromes. Another study demonstrated decreased plasma β-amyloid load and increased plasma β-amyloid 42/40 ratio in PTSD without PET evaluation. While PTSD is associated with an increased risk of dementia syndrome in general, there is no convincing evidence that it causes or accelerates the pathology of Alzheimer's disease, which causes the most common type of dementia. Factors that may account for the association between PTSD and a clinical diagnosis of dementia are discussed in this review.

Posttraumatic stress disorder symptoms and neurocognitive functioning in fire fighters: The mediating role of sleep problems and resilience

BACKGROUND

Firefighters are often exposed to terrible and dangerous scenes due to their duties, and thus have a high risk of developing posttraumatic stress disorder(PTSD). The purpose of the study is to examine the relationship between PTSD symptoms, sleep problems, resilience and neurocognitive functioning of firefighters, and to identify the sequential mediating effects of sleep problems and resilience on the relationship between PTSD symptoms and neurocognitive functioning (especially psychomotor speed and processing speed).

METHODS

Data were collected from 325 firefighters in eight fire departments in four regions of Korea. Subjects performed neurocognitive function tests and completed the following questionnaires: Primary Care PTSD Screening, Pittsburgh Sleep Quality Index-K and Connor-Davidson Resilience Scale-2. The correlation and dual mediation effects were analysed using SPSS 22.0 program and PROCESS macro 3.4 program.

RESULTS

PTSD symptoms, neurocognitive functioning, sleep problems and resilience were significantly correlated with each other. In the sequential mediation model, the relationship between PTSD and psychomotor speed/processing speed was sequentially mediated by sleep problems and resilience after adjusting for demographic variables.

CONCLUSIONS

The PTSD symptoms of firefighters were related to a sequential link between sleep problems, low resilience and decreased neurocognitive function. These findings could serve as a basis for more effective and integrated interventional strategies for facilitating better neurocognitive functioning in firefighters.

Sleep disturbances following traumatic brain injury are associated with poor neurobehavioral outcomes in U.S. military service members and veterans

STUDY OBJECTIVES

This study examined whether sleep disturbances were associated with neurobehavioral outcome following a traumatic brain injury (TBI) in a well characterized group of service members and veterans.

METHODS

Six-hundred and six participants were enrolled into the Defense and Veterans Brain Injury Center, 15-Year Longitudinal TBI study. All participants completed a battery of tests measuring self-reported sleep disturbances, neurobehavioral symptoms, and Posttraumatic Stress Disorder PTSD symptoms. Data were analyzed using analysis of variance with post-hoc comparisons. Four groups were analyzed separately: uncomplicated mild TBI (MTBI); complicated mild, moderate, severe, or penetrating - combined TBI (CTBI); injured controls (IC, i.e., orthopedic or soft-tissue injury without TBI); and non-injured controls (NIC).

RESULTS

A higher proportion of the MTBI group reported moderate-severe sleep disturbances (66.5%) compared to the IC (54.9%), CTBI (47.5%), and NIC groups (34.3%). Participants classified as having Poor Sleep had significantly worse scores on the majority of TBI-QOL scales compared to those classified as having Good Sleep, regardless of TBI severity or the presence of TBI. There was a significant interaction between sleep disturbances and PTSD. While sleep disturbances and PTSD by themselves were significant factors associated with worse outcome, both factors combined resulted in worse outcome than either singularly.

CONCLUSIONS

Regardless of group (injured or NIC), sleep disturbances were common and were associated with significantly worse neurobehavioral functioning. When experienced concurrently with PTSD, sleep disturbances pose significant burden to service members and veterans.

Concussive head injury exacerbates neuropathology of sleep deprivation: Superior neuroprotection by co-administration of TiO2-nanowired cerebrolysin, alpha-melanocyte-stimulating hormone, and mesenchymal stem cells

Sleep deprivation (SD) is common in military personnel engaged in combat operations leading to brain dysfunction. Military personnel during acute or chronic SD often prone to traumatic brain injury (TBI) indicating the possibility of further exacerbating brain pathology. Several lines of evidence suggest that in both TBI and SD alpha-melanocyte-stimulating hormone (α-MSH) and brain-derived neurotrophic factor (BDNF) levels decreases in plasma and brain. Thus, a possibility exists that exogenous supplement of α-MSH and/or BDNF induces neuroprotection in SD compounded with TBI. In addition, mesenchymal stem cells (MSCs) are very portent in inducing neuroprotection in TBI. We examined the effects of concussive head injury (CHI) in SD on brain pathology. Furthermore, possible neuroprotective effects of α-MSH, MSCs and neurotrophic factors treatment were explored in a rat model of SD and CHI. Rats subjected to 48h SD with CHI exhibited higher leakage of BBB to Evans blue and radioiodine compared to identical SD or CHI alone. Brain pathology was also exacerbated in SD with CHI group as compared to SD or CHI alone together with a significant reduction in α-MSH and BDNF levels in plasma and brain and enhanced level of tumor necrosis factor-alpha (TNF-α). Exogenous administration of α-MSH (250μg/kg) together with MSCs (1×10⁶) and cerebrolysin (a balanced composition of several neurotrophic factors and active peptide fragments) (5mL/kg) significantly induced neuroprotection in SD with CHI. Interestingly, TiO₂ nanowired delivery of α-MSH (100μg), MSCs, and cerebrolysin (2.5mL/kg) induced enhanced neuroprotection with higher levels of α-MSH and BDNF and decreased the TNF-α in SD with CHI. These observations are the first to show that TiO₂ nanowired administration of α-MSH, MSCs and cerebrolysin induces superior neuroprotection following SD in CHI, not reported earlier. The clinical significance of our findings in light of the current literature is discussed.

Characteristics and Impact of U.S. Military Blast-Related Mild Traumatic Brain Injury: A Systematic Review

As a result of armed conflict, head trauma from exposure to blasts is an increasing critical health issue, particularly among military service members. Whilst numerous studies examined the burden of blast-related brain injuries on service members', few systematic reviews have been published. This work provides a comprehensive summary of the evidence on blast-related mild traumatic brain injury (mTBI) burden in active U.S. military service members and inactive Veterans, describing characteristics and outcomes. Records published up to April 2017 were identified through a search of PubMed, Web of Science, Scopus, Ovid MEDLINE, and Cochrane Library. Records-based and original research reporting on U.S. military service members and Veterans with mild blast TBI were included. Data on subject characteristics, exposure, diagnostic criterion, and outcomes were extracted from included studies using a standardized extraction form and were presented narratively. Of the 2,290 references identified by the search, 106 studies with a total of 37,515 participants met inclusion criteria for blast-related mTBI. All but nine studies were based out of military or Veteran medical facilities. Unsurprisingly, men were over-represented (75–100%). The criteria used to define blast-related mTBI were consistent; however, the methodology used to ascertain whether individuals met those criteria for diagnosis were inconsistent. The diagnosis, most prevalent among the Army, heavily relied on self-reported histories. Commonly reported adverse outcomes included hearing disturbances and headaches. The most frequently associated comorbidities were post-traumatic stress disorder, depression, anxiety, sleep disorders, attention disorders, and cognitive disorders. The primary objective of this review was to provide a summary of descriptive data on blast-related mTBI in a U.S. military population. Low standardization of the methods for reaching diagnosis and problems in the study reporting emphasize the importance to collect high-quality data to fill knowledge gaps pertaining to blast-related mTBI.

Neuropsychological Impact of Trauma-Related Mental Illnesses: A Systematic Review of Clinically Meaningful Results

A trauma history is present in approximately 90% of adults in the United States. Comparatively, lifetime post-traumatic stress disorder (PTSD) prevalence is only 8.3% (Kilpatrick et al. Journal of Traumatic Stress, 26, 537-547, 2013). A neuropsychological understanding of trauma is essential to effective trauma-informed assessments and treatments. Prior reviews have focused on PTSD, specific neuropsychological domains, and statistically rather than clinically significant results. The current systematic review investigated standardized test performance across neuropsychological domains in participants with trauma histories and any psychiatric diagnosis. The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. From 2350 records, the search returned 21 eligible studies: 8 for combat trauma, 2 for childhood trauma, 2 for intimate partner violence and sexual assault, 2 for accidental trauma, 1 for refugee trauma, and 6 for unspecified trauma. Mean neuropsychological scores ranged from low to high average, with one mean verbal memory score in the borderline range. These findings diverge from reports of between-group differences or experimental task performance, which suggest greater levels of static cognitive impairment. Current results are limited by lack of distinction between trauma types in the literature, a dearth of cognitive domains examined, wide use of self-report trauma measures, and publication and outcome reporting biases. Clinical implications for assessment and rehabilitation are discussed in relation to clinical significance, state versus trait based changes, intra-individual variability, changes from pre- to post-trauma, and within-group variability in resilience. Future directions are recommended in consideration of cultural factors, prospective and follow-up designs, and psychiatric diagnosis.

"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.

Traumatic brain injury and sleep disturbances in combat-exposed service members and veterans: Where to go next?

OBJECTIVE

To synthesize the current evidence on sleep disturbances in military service members (SMs) and veterans with traumatic brain injury (TBI).

METHODS

An electronic literature search first identified abstracts published from 2008-2018 inclusively referencing sleep, TBI, and military personnel from Operation Enduring Freedom, Operation Iraqi Freedom, Operation New Dawn, and Persian Gulf veterans. Selection criteria eliminated studies on non-combat TBI, open or penetrating injuries, and articles where the relationship between sleep and TBI was not directly examined. Articles on all military branches and components, those currently serving and veterans-ranging from medical chart reviews to clinical trials, were included. Forty-one articles were selected for full text-review.

RESULTS

Twenty-four papers estimated the prevalence of sleep disturbances in TBI. Eight studies demonstrated the contribution of common co-occurring conditions, most notably posttraumatic stress disorder, to the relationship between disrupted sleep and TBI. Ten studies differentiated sleep profiles between military SMs and veterans with and without acute TBI and detected significant differences in sleep disturbances across the course of injury. Longitudinal studies were scarce but helped to establish the temporal relationship between sleep disturbances and TBI and isolate sleep-related mechanisms influencing TBI prognosis. Only three studies reported on interventions for improving sleep quality and TBI symptoms. Systematic research testing assessments and interventions that target sleep disturbances for improving sleep, TBI symptoms, and long-term functional outcomes were identified as critical knowledge gaps.

CONCLUSION

Findings unequivocally establish that sleep disturbances are highly prevalent in SMs and veterans with TBI. However, studies testing the effectiveness of treatments for improving sleep in military groups with TBI have been limited and their results inconsistent. This review highlights a critical opportunity for advancing military medicine through future research aimed at identifying and testing sleep-focused treatments in SMs and veterans with combat-related TBI.

Blast concussion and posttraumatic stress as predictors of postcombat neuropsychological functioning in OEF/OIF/OND veterans

OBJECTIVES

Many combat veterans exhibit cognitive limitations of uncertain origin. In this study, we examined factors that predict cognitive functioning by considering effects of blast-related concussion (BRC), non-blast-related concussion (NBRC), and posttraumatic stress disorder (PTSD) symptoms. Analyses specifically tested whether (a) BRC and NBRC were distinct in their prediction of cognitive performance; (b) a dose-response relationship existed between recurrent concussion (BRC and NBRC) and cognitive impairment; and (c) PTSD symptoms mediated the relationship between BRC and cognitive performance.

METHOD

Two hundred eighty veterans with combat zone deployment histories completed semistructured clinical interviews to define BRC and NBRC histories, current and past mental health disorders, and dimensional ratings of PTSD symptomatology. Participants were also administered a number of neuropsychological measures to appraise cognitive functioning.

RESULTS

A structural equation model (SEM) suggested that BRC and NBRC were not distinct in their prediction of cognitive performance, and there was no evidence that recurrent concussion (blast or nonblast) was directly associated with cognitive performance. BRC was significantly associated with PTSD symptoms (r = .24), PTSD symptoms were significantly associated with cognitive performance in the SEM (r = -.27), and PTSD symptoms significantly mediated the link between BRC and cognitive performance (p = .03).

CONCLUSIONS

These results suggest that concussion history fails to directly contribute to cognitive performance, regardless of mechanism (blast or nonblast) and recurrence. BRC is nonetheless unique in its contribution to PTSD and PTSD-related cognitive deficits. Results support interventions specific to PTSD management in the interest of promoting neuropsychological functioning among war veterans. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Neurobehavioral Management of the Polytrauma Veteran

Since the inception of the Afghanistan and Iraq wars, an increasing number of veterans have sought treatment from the Department of Veterans Affairs for combat-related injuries. Many veterans experience postconcussive symptoms, traumatic stress, chronic pain, sensory deficits, and/or headaches. The goal of this article was to highlight some of the challenges treatment providers may face, while providing rehabilitation specialists with important evaluation and treatment considerations in working with this population to maximize outcomes for these veterans.

Neurocognitive and Information Processing Biases in Posttraumatic Stress Disorder

PURPOSE OF REVIEW

We review recent research addressing neurocognitive and information processing abnormalities in posttraumatic stress disorder (PTSD), including studies informing direction of causality. We additionally consider neurocognition in the context of co-morbid mild traumatic brain injury (TBI) and psychosocial treatments for PTSD.

RECENT FINDINGS

Learning, memory, attention, inhibitory functions, and information processing biases frequently accompany PTSD, reflecting potential bi-directional relationships with PTSD. Although mild TBI is associated with increased risk of PTSD development and maintenance, TBI does not typically contribute significantly to sustained neurocognitive deficits in individuals with PTSD. Whereas better learning and memory is associated with mildly enhanced response to psychosocial interventions, such interventions may also improve neurocognitive performance and can be effectively provided to patients with TBI history. PTSD is associated with cognitive abnormalities in processing both emotionally relevant and emotionally neutral information and, although mild, may underlie some PTSD symptom expression.