B-57 Post-traumatic Stress Disorder is a Stronger Predictor of Long-term Neurobehavioral Outcome than Traumatic Brain Injury Severity in U.S. Military Service Members

Objective

The purpose of this study was to examine long-term neurobehavioral outcome in SMVs with versus without PTSD following TBI of all severities.

Methods

Participants were 536 SMVs recruited into three experimental groups (TBI, injured controls [IC], non-injured controls [NIC]). Participants completed the PTSD Checklist and the TBI-Quality of Life (TBI-QOL). Participants were divided into six subgroups based on the three experimental categories, two PTSD categories (i.e., present/absent), and two broad TBI severity categories (i.e., ‘unMTBI’ [includes uncomplicated mild TBI]; and ‘smcTBI’ [includes severe TBI, moderate TBI, and complicated mild TBI): (1) NIC/PTSD-Absent, (2) IC/PTSD-Absent, (3) unMTBI/PTSD-Absent, (4) unMTBI/PTSD-Present, (5) smcTBI/PTSD-Absent, and (6) smcTBI/PTSD-Present.

Results

There were significant main effects across the six groups for all TBI-QOL measures (p < .001). Select pairwise comparisons revealed significantly worse scores (p < .001) on all TBI-QOL measures in all PTSD-Present groups compared to the PTSD-Absent groups (i.e., Group 3v4 and 5v6; d = 0.90 to 2.11). In contrast, when controlling for PTSD, there were no significant differences between the TBI severity groups for all TBI-QOL measures (i.e., Group 3v5 and 4v6). In the TBI sample, a series of step-wise regression analyses revealed that PTSD, but not TBI severity, was consistently a strong predictor of all TBI-QOL scales (all p’s < .001), accounting for up to 64% of the variance.

Conclusions

These results provide support for the very strong influence of PTSD, but not TBI severity, on long-term neurobehavioral outcome following TBI. Concurrent PTSD and TBI of all severities should be considered a risk factor for poor long-term neurobehavioral outcome that requires ongoing monitoring.

B-58 Post-traumatic Stress Symptoms Are Associated with Worse Neuropsychological Functioning, but not Diffusion Tensor Imaging Findings, in Military Service Members Following Mild Traumatic Brain Injury

Objective

The purpose of this study was to examine neurobehavioral and neurocognitive functioning, and white matter integrity (using Diffusion Tensor Imaging [DTI]), in service members with versus without PTSD following mild traumatic brain injury (MTBI).

Method

Participants were 101 U.S. military service members who had sustained an uncomplicated MTBI (n = 80) or an injury without TBI (i.e., Injured Control [IC], n = 21) prospectively enrolled from the Walter Reed National Military Medical Center (Bethesda, Maryland). Participants completed a battery of neuropsychological tests, as well as DTI of the brain, on average 4-years post-injury. Measures of FA, MD, AD, and RD were generated for 18 regions of interest [ROIs]. Participants in the MTBI group were divided into two sub-groups based on DSM-IV-TR diagnostic criteria for PTSD: MTBI/PTSD-Present (n = 22) and MTBI/PTSD-Absent (n = 58).

Results

The MTBI/PTSD-Present group reported a significantly higher number of postconcussion symptoms, had higher scores on the majority of MMPI-2-RF scales, and had worse scores on the vast majority of cognitive domains (i.e., Attention, Processing Speed, Immediate Memory, Delayed Memory, Executive Functioning, Visuospatial Ability) compared to both the MTBI/PTSD-Absent group (all p’s < .05) and IC/PTSD-Absent group (all p’s < .05). For the DTI variables, there were no significant group differences for all DTI measures in all regions of the brain, with the exception of a handful of measures (i.e., right cingulum–cingulate gyrus, and bilaterally in the corticospinal tract).

Conclusion

These results provide support for a (a) strong relationship between PTSD and poor neurobehavioral and neurocognitive outcome following MTBI, and (b) weak relationship between PTSD and white matter integrity following MTBI.

B-46 Caring for a Service Member or Veteran following Traumatic Brain Injury Influences Caregiver Mental Health

Objective

To examine factors related to poor mental health in a sample of caregivers assisting service members/veterans (SMV) following a traumatic brain injury (TBI).

Methods

Caregivers (N = 201, 96.0% female; 86.1% spouse; Age: M = 39.2 years, SD = 10.2) of SMVs following a mild, moderate, severe, or penetrating TBI were recruited from Walter Reed National Military Medical Center (Maryland) and community outreach to participate in the Defense and Veterans Brain Injury Center 15-Year Longitudinal TBI Study (Sec721 NDAA FY2007). Caregivers completed the SF-36v2 Health Survey (SF-36v2), Caregiver Appraisal Scale (CAS), Mayo-Portland Adaptability Inventory-4 (MPAI-4), and Caregiver Questionnaire. The sample was divided into two mental health groups: Poor (n = 108) and Good Mental Health (n = 93).

Results

A higher proportion of caregivers in the Poor Mental Health group reported worse functioning on the SF-36v2 and CAS scales (d = .43 to d = 2.09), except CAS Ideology; helping with symptoms of depression, post-traumatic stress disorder (PTSD), and physical expressions of irritability, anger, or aggression (p’s < .01); less time for themselves (d = .42); more unmet needs (d = .87); an impact on employment (p = .00); and burdensome out-of-pocket caregiving expenses (p = .04). A higher proportion of SMVs of caregivers in the Poor Mental Health group had a mild TBI; worse scores on the MPAI-4 scales (d = .29 to d = .64); PTSD, depression, or other anxiety; received mental health and physical rehabilitation treatment; and did not have significant hospitalization post-injury (p = .04 to p = < .001).

Conclusions

Services for caregivers helping SMVs with comorbid mental health problems are required to ensure the burden of care does not undermine the caregiver’s health and impact the SMV’s recovery and reintegration.

B-60 Resilience is Associated with Overall Health-related Quality of Life in Caregivers of Service Members and Veterans Following Traumatic Brain Injury

Objective

To examine the influence of caregiver resilience on health-related quality of life (HRQOL) in caregivers of service members/veterans (SMVs) following a traumatic brain injury (TBI).

Methods

Caregivers (N = 346, Female = 96.2%; Spouse = 91.0%%; Age: M = 40.6 years) of SMVs following a mild, moderate, severe, or penetrating TBI were recruited from Walter Reed National Military Medical Center and via community outreach to participate in the Defense and Veterans Brain Injury Center 15-Year Longitudinal TBI Study (Sec721 NDAA FY2007). Caregivers completed the Caregiver Appraisal Scale and 15 HRQOL measures. Caregivers were divided into three groups using the Resilience scale from the TBI-QOL: (1) Low Resilience [n = 125], (2) Moderate Resilience [n = 122], and (3) High Resilience [n = 99].

Results

There were significant main effects across groups for all HRQOL measures (ps < .001). The Low Resilience group had consistently worse scores compared to both the Moderate and High Resilience groups (d = .50-1.60). The largest effect sizes were found for the Caregiving Satisfaction, Anxiety, Depression, Anger, Social Isolation, Perceived Stress, Caregiver Strain, and Feelings of Loss-Self scales (d = .91-1.60). Step-wise regression analyses revealed that Perceived Stress was the most significant predictor of resilience (R2 = 33.3%), with Caregiver Satisfaction (R2change = 5.0%), Depression (R2change = 1.8%), Caregiver Mastery (R2change = 1.7), Caregiver Specific Anxiety (R2change = 1.2) and Feelings of Loss-Self (R2change = 1.1%) contributing some additional variance in subsequent steps.

Conclusions

There was a moderate to high relationship between resilience and overall HRQOL in caregivers of SMVs following TBI. Targeted interventions to increase caregiver resilience may be warranted to ensure that burden of care does not undermine the caregiver’s heath and impact the SMV’s recovery and reintegration.

Die Dermatologische Klinik am UniversitätsSpital Zürich heute

Die Dermatologische Klinik des UniversitätsSpitals Zürich fokussiert als eines der renommiertesten universitären Zentren Europas primär darauf, eine fundierte, breite und möglichst innovative Grundversorgung der Patientinnen und Patienten sicherzustellen. Dies basierend auf einer aktiven und sehr zielgerichteten klinischen und Grundlagen-Forschung in den Bereichen schwere entzündliche Hautkrankheiten und Dermatoonkologie unter der Prämisse und langjährigen Tradition der translationalen Forschung. Ziel ist es, mit einem hochprofessionellen Mitarbeiterstab und entsprechender Nachwuchsförderung die führende Position der Klinik und ihre Kompetitivität auf die Zukunft langfristig zu halten und weiter zu entwickeln durch innovativste Forschung und Behandlung/Diagnostik-Methoden in der Patientenversorgung. Der Rolle in der Gesellschaft als führendes Dermatologie-Zentrum wird die Klinik gerecht durch engen Austausch mit den zuweisenden Ärzten – in Sinne der Weitergabe von aktuellstem Knowhow für die Patienten in den Praxen. Durch gezielte Öffentlichkeitsarbeit soll das Bewusstsein der Bevölkerung auf häufige und risikoreiche Hautkrankheiten sensibilisiert und damit das Verständnis für das Fach der Dermatologie gestärkt werden.

DSM-5 Clinical/legal Challenges Regarding the USA's Death Penalty

Introduction

In May 2013, the American Psychiatric Association (APA) published the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in order to bring America's clinical professionals in concert with the World Health Organization's (WHO) international classifications, notably the ICD-10-CM. This effort was met with considerable resistance and changes were delayed until November 2015. Major social-cultural differences between the United States and its European and other North American partners (Canada and Mexico) poses challenges in critical forensic areas such as the clinical/legal assessment of death qualified offenders – a status unique to the USA.

Objective/aims

To articulate the clinical/legal differences between the previous DSM's (III; III-R; IV) and the DSM-5 and how the new language provides greater ambiguity in defining the mental status requirements for Mens Rea – competence to understand one's actions.

Methods

Present the major legal issues surrounding the US death penalty and brought before the US Supreme Court including: Furman v. Georgia (1972); Greg v. Georgia (1976); Jared v. Texas (1976); Proffit v. Florida (1976); Adkins v. Virginia (2002); Roper v. Simmons (2005); Miller v. Alabama (2012): … and legislative actions such as Rosa's Law (Public Law 111-256; 2010).

Results/conclusions

Advocacy groups pushed Rosa's Law to mental retardation with – intellectual and developmental disability. This change is reflected in the DSM-5 whereby mental retardation (MR) was once relegated to axis II, is now classified under intellectual disabilities (ID) given the impression that it is a transitory (correctable) and not a fix (organ disability) clinical condition.

Disclosure of interest

The author has not supplied his declaration of competing interest.

Military culture and sexual issues: The sex-stress phenomenon

Introduction

Sex abuse within the military has long been an open-secret afflicting both male and female veterans whose etiology is often attributed to character deficits (personality disorders or paraphilic disorders). Few studies look at the sex-stress phenomenon as a feature of military life itself and the role this plays in sex abuse within the military milieu. While much attention is focused on US forces, this problem in endemic within military cultures per se. The recent sex abuse scandal involving the French military in the Central African Republic illustrates the pervasiveness of the problem.

Objectives/aims

To explore the psycho-cultural mechanisms of stress and its sexual expression and how certain scenarios within the military milieu exacerbates this impulse-control reaction. To address the relationship of the availability of sex-release options – without and/or without the military population (and how increased enlistment of women has changed the nature of the target population in today's military).

Methods

Look at the problem historically (from WWII – present) with particular illustrations. Evaluate common (often failed) approaches to addressing the problem, including the fallacy that superior officer know best how to handle these cases. Explain the psycho/physiology of the sex-stress phenomenon – mechanism of the hypothalamic-pituitary-adrenal-gonad axis. Look at the relationship between sex-trauma and suicides among veterans.

Results/conclusions

Offer a viable assessment/diagnostic of sexual problems within the military culture along with a treatment model that offers both psychotherapeutic (cognitive-behavioral protocols…) as well as identifying acute clinical symptoms that may respond to psychotropic medications.

Disclosure of interest

The author has not supplied his declaration of competing interest.

Axon diameter and axonal transport: In vivo and in vitro effects of androgens

Testosterone is a sex hormone involved in brain maturation via multiple molecular mechanisms. Previous human studies described age-related changes in the overall volume and structural properties of white matter during male puberty. Based on this work, we have proposed that testosterone may induce a radial growth of the axon and, possibly, modulate axonal transport. In order to determine whether this is the case we have used two different experimental approaches. With electron microscopy, we have evaluated sex differences in the structural properties of axons in the corpus callosum (splenium) of young rats, and tested consequences of castration carried out after weaning. Then we examined in vitro the effect of the non-aromatizable androgen Mibolerone on the structure and bidirectional transport of wheat-germ agglutinin vesicles in the axons of cultured sympathetic neurons. With electron microscopy, we found robust sex differences in axonal diameter (males>females) and g ratio (males>females). Removal of endogenous testosterone by castration was associated with lower axon diameter and lower g ratio in castrated (vs. intact) males. In vitro, Mibolerone influenced the axonal transport in a time- and dose-dependent manner, and increased the axon caliber as compared with vehicle-treated neurons. These findings are consistent with the role of testosterone in shaping the axon by regulating its radial growth, as predicted by the initial human studies.