Symptom Attribution and Neuropsychological Outcomes Among Treatment-Seeking Veterans With a History of Traumatic Brain Injury.

OBJECTIVE: In this cross-sectional study, the authors aimed to examine relationships between illness perception, measured as symptom attribution, and neurobehavioral and neurocognitive outcomes among veterans with a history of traumatic brain injury (TBI). METHODS: This study included 55 treatment-seeking veterans (N=43 with adequate performance validity testing) with a remote history of TBI (80% with mild TBI). Veterans completed a clinical interview, self-report questionnaires, and a neuropsychological assessment. A modified version of the Neurobehavioral Symptom Inventory (NSI) was administered to assess neurobehavioral symptom endorsement and symptom attribution. Composite scores were calculated from standardized cognitive tests to assess specific aspects of objective cognitive functioning, including memory, executive functioning, attention and working memory, and processing speed. RESULTS: The symptoms most frequently attributed to TBI included forgetfulness, poor concentration, slowed thinking, and headaches. There was a significant positive association between symptom attribution and overall symptom endorsement (NSI total score) (r=0.675) and endorsement of specific symptom domains (NSI symptom domain scores) (r=0.506-0.674), indicating that greater attribution of symptoms to TBI was associated with greater symptom endorsement. Furthermore, linear regressions showed that symptom attribution was significantly associated with objective cognitive functioning, whereas symptom endorsement generally did not show this relationship. Specifically, greater attribution of symptoms to TBI was associated with worse executive functioning (ß=-0.34), attention and working memory (ß=-0.43), and processing speed (ß=-0.35). CONCLUSIONS: These findings suggest that veterans who routinely attribute neurobehavioral symptoms to their TBI are at greater risk of experiencing poor long-term outcomes, including elevated symptom endorsement and worse objective cognition. Although more research is needed to understand how illness perception influences outcomes in this population, these preliminary results highlight the importance of early psychoeducation regarding the anticipated course of recovery following TBI.

Baseline executive functioning moderates treatment-related changes in quality of life in veterans with posttraumatic stress disorder and comorbid traumatic brain injury.

Posttraumatic stress disorder (PTSD) treatment has been associated with improvement in quality of life (QOL); however, little is known about factors that moderate treatment-related changes in QOL, particularly cognitive factors. Executive functioning (EF) is important for success across all aspects of everyday life and predicts better psychological and physical health. EF is important to QOL, but more work is needed to better understand the association between EF and QOL improvements following interventions. We hypothesized that poorer baseline EF would be associated with less improvement in overall life satisfaction and satisfaction with health following PTSD treatment. U.S. veterans who served after the September 11, 2001 terrorist attacks (post 9-11; N = 80) with PTSD and a history of mild-to-moderate traumatic brain injury were randomized to standard cognitive processing therapy (CPT) or CPT combined with cognitive rehabilitation (SMART-CPT). Multilevel modeling was used to examine whether baseline EF performance was associated with changes in QOL scores from pretreatment to follow-up across both groups. Results indicated that poorer baseline performance on EF tests of working memory and inhibition were associated with less treatment-related improvements in general life satisfaction and satisfaction with health, rs = .26-.36. Treatment condition did not moderate any results. Future research should examine whether implementing EF-focused techniques before and/or concurrently with CPT for individuals with poorer baseline working memory and inhibition enhances QOL treatment gains, particularly in terms of general life and health-related satisfaction.

Independent and Synergistic Associations Between TBI Characteristics and PTSD Symptom Clusters on Cognitive Performance and Postconcussive Symptoms in Iraq and Afghanistan Veterans.

OBJECTIVE: The investigators sought to evaluate the independent and interactive associations between mild traumatic brain injury (mTBI) characteristics and posttraumatic stress disorder (PTSD) symptoms with regard to postconcussive symptoms and cognition among treatment-seeking veterans of the U.S. conflicts in Iraq and Afghanistan. METHODS: Sixty-seven Iraq and Afghanistan veterans who had a history of mTBI and comorbid PTSD were grouped based on injury mechanism (blast versus nonblast) and number of lifetime mTBIs (one to two versus three or more). Independent associations between mTBI characteristics and PTSD symptom clusters were evaluated with regard to cognition and postconcussive symptoms. Follow-up analyses were conducted to determine any interactive associations between TBI characteristics and PTSD symptom clusters. RESULTS: Higher PTSD symptoms, particularly hyperarousal, were associated with poorer executive functioning and higher postconcussive symptoms. No direct relationships were observed between PTSD symptom clusters and memory or processing speed. The relationship between hyperarousal and processing speed was moderated by lifetime mTBIs, such that those with a history of at least three mTBIs demonstrated a negative association between hyperarousal and processing speed. Blast-related mTBI history was associated with reduced processing speed, compared with non-blast-related mTBI. However, an interaction was observed such that among those with blast-related mTBI history, higher re-experiencing symptoms were associated with poorer processing speed, whereas veterans without history of blast-related mTBI did not demonstrate an association between processing speed and re-experiencing symptoms. CONCLUSIONS: Higher hyperarousal and re-experiencing symptoms were associated with reduced processing speed among veterans with repetitive and blast-related mTBI history, respectively. PTSD symptoms, specifically hyperarousal, were associated with poorer executive functioning and higher postconcussive symptoms. Limited associations were found between injury characteristics and cognition chronically following mTBI. However, these results support synergistic effects of specific PTSD symptom clusters and TBI characteristics.

Self-efficacy and coping style in Iraq and Afghanistan-era veterans with and without mild traumatic brain injury and posttraumatic stress disorder.

OBJECTIVE: To examine self-efficacy and coping style in combat-exposed Veterans with and without mild traumatic brain injury (mTBI) history and posttraumatic stress disorder (PTSD). METHODS: Veterans (N = 81) were categorized into four groups: comorbid mTBI and PTSD (n = 23), PTSD-only (n = 16), mTBI-only (n = 25), and combat-exposed controls (n = 17). Outcomes included the Self-Efficacy for Symptom Management Scale and the Brief Coping Orientation to Problems Experienced. RESULTS: Significant group effects were found on self-efficacy and coping style, even when adjusting for total mTBIs and psychiatric comorbidities. Post-hoc analyses revealed that the comorbid and PTSD-only groups generally had lower self-efficacy than the mTBI-only and control groups and that the PTSD-only group used less action-focused coping than the mTBI-only and control groups. CONCLUSION: Our results suggest that self-efficacy and coping style vary as a function of mTBI history and PTSD status and that it may be important to integrate these malleable factors into interventions for this population.

Psychological Symptoms and Rates of Performance Validity Improve Following Trauma-Focused Treatment in Veterans with PTSD and History of Mild-to-Moderate TBI.

OBJECTIVE: Iraq and Afghanistan Veterans with posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) history have high rates of performance validity test (PVT) failure. The study aimed to determine whether those with scores in the invalid versus valid range on PVTs show similar benefit from psychotherapy and if psychotherapy improves PVT performance. METHOD: Veterans (N = 100) with PTSD, mild-to-moderate TBI history, and cognitive complaints underwent neuropsychological testing at baseline, post-treatment, and 3-month post-treatment. Veterans were randomly assigned to cognitive processing therapy (CPT) or a novel hybrid intervention integrating CPT with TBI psychoeducation and cognitive rehabilitation strategies from Cognitive Symptom Management and Rehabilitation Therapy (CogSMART). Performance below standard cutoffs on any PVT trial across three different PVT measures was considered invalid (PVT-Fail), whereas performance above cutoffs on all measures was considered valid (PVT-Pass). RESULTS: Although both PVT groups exhibited clinically significant improvement in PTSD symptoms, the PVT-Pass group demonstrated greater symptom reduction than the PVT-Fail group. Measures of post-concussive and depressive symptoms improved to a similar degree across groups. Treatment condition did not moderate these results. Rate of valid test performance increased from baseline to follow-up across conditions, with a stronger effect in the SMART-CPT compared to CPT condition. CONCLUSION: Both PVT groups experienced improved psychological symptoms following treatment. Veterans who failed PVTs at baseline demonstrated better test engagement following treatment, resulting in higher rates of valid PVTs at follow-up. Veterans with invalid PVTs should be enrolled in trauma-focused treatment and may benefit from neuropsychological assessment after, rather than before, treatment.

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.

Mild Traumatic Brain Injury Burden Moderates the Relationship Between Cognitive Functioning and Suicidality in Iraq/Afghanistan-Era Veterans.

OBJECTIVES: Suicidal ideation (SI) is highly prevalent in Iraq/Afghanistan-era veterans with a history of mild traumatic brain injury (mTBI), and multiple mTBIs impart even greater risk for poorer neuropsychological functioning and suicidality. However, little is known about the cognitive mechanisms that may confer increased risk of suicidality in this population. Thus, we examined relationships between neuropsychological functioning and suicidality and specifically whether lifetime mTBI burden would moderate relationships between cognitive functioning and suicidal ideation. METHODS: Iraq/Afghanistan-era Veterans with a history of mTBI seeking outpatient services (N = 282) completed a clinical neuropsychological assessment and psychiatric and postconcussive symptom questionnaires. RESULTS: Individuals who endorsed SI reported more severe post-traumatic stress disorder (PTSD), depression, and postconcussive symptoms and exhibited significantly worse memory performance compared to those who denied SI. Furthermore, mTBI burden interacted with both attention/processing speed and memory, such that poorer performance in these domains was associated with greater likelihood of SI in individuals with a history of three or more mTBIs. The pattern of results remained consistent when controlling for PTSD, depression, and postconcussive symptoms. CONCLUSIONS: Slowed processing speed and/or memory difficulties may make it challenging to access and use past experiences to solve current problems and imagine future outcomes, leading to increases in hopelessness and SI in veterans with three or more mTBIs. Results have the potential to better inform treatment decisions for veterans with history of multiple mTBIs. (JINS, 2019, 25, 79-89).

The Role of Pain Catastrophizing in Cognitive Functioning Among Veterans With a History of Mild Traumatic Brain Injury.

OBJECTIVE: To determine the role of pain catastrophizing (PC) in neuropsychological functioning in veterans with a history of mild traumatic brain injury (TBI). PARTICIPANTS: Thirty-nine Iraq and Afghanistan combat veterans evaluated in the post-acute phase following mild TBI. METHODS: Participants underwent psychiatric and TBI clinical interviews, neuropsychological tests, and self-report assessments of PC, pain intensity, depression, and posttraumatic stress disorder symptoms. Cognitive functioning composite scores of executive functioning, processing speed, and learning and memory were created. Composites were entered as dependent variables into separate linear regressions to examine relations with PC. RESULTS: Greater PC was associated with worse executive functioning and processing speed even when controlling for confounding variables. CONCLUSIONS: One's interpretation of pain, in addition to pain intensity, has implications for cognitive functioning. Future research is encouraged to determine whether adaptive pain coping mechanisms improve cognitive functioning or, alternatively, whether cognitive rehabilitation strategies reduce PC.

Contributions to Executive Dysfunction in Operation Enduring Freedom/Operation Iraqi Freedom Veterans With Posttraumatic Stress Disorder and History of Mild Traumatic Brain Injury.

OBJECTIVE: Posttraumatic stress disorder (PTSD), history of mild traumatic brain injury (mTBI), and executive function (EF) difficulties are prevalent in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. We evaluated the contributions of injury variables, lower-order cognitive component processes (processing speed/attention), and psychological symptoms to EF. PARTICIPANTS: OEF/OIF Veterans (N = 65) with PTSD and history of mTBI were administered neuropsychological tests of EF and self-report assessments of PTSD and depression. RESULTS: Those impaired on one or more EF measures had higher PTSD and depression symptoms and lower processing speed/attention performance than those with intact performance on all EF measures. Across participants, poorer attention/processing speed performance and higher psychological symptoms were associated with worse performance on specific aspects of EF (eg, inhibition and switching) even after accounting for injury variables. Although direct relationships between EF and injury variables were equivocal, there was an interaction between measures of injury burden and processing speed/attention such that those with greater injury burden exhibited significant and positive relationships between processing speed/attention and inhibition/switching, whereas those with lower injury burden did not. CONCLUSION: Psychological symptoms as well as lower-order component processes of EF (attention and processing speed) contribute significantly to executive dysfunction in OEF/OIF Veterans with PTSD and history of mTBI. However, there may be equivocal relationships between injury variables and EF that warrant further study. Results provide groundwork for more fully understanding cognitive symptoms in OEF/OIF Veterans with PTSD and history of mTBI that can inform psychological and cognitive interventions in this population.

Trait motivation moderates neural activation associated with goal pursuit.

Research has indicated that regions of left and right dorsolateral prefrontal cortex (DLPFC) are involved in integrating the motivational and executive function processes related to, respectively, approach and avoidance goals. Given that sensitivity to pleasant and unpleasant stimuli is an important feature of conceptualizations of approach and avoidance motivation, it is possible that these regions of DLPFC are preferentially activated by valenced stimuli. The present study tested this hypothesis by using a task in which goal pursuit was threatened by distraction from valenced stimuli while functional magnetic resonance imaging data were collected. The analyses examined whether the impact of trait approach and avoidance motivation on the neural processes associated with executive function differed depending on the valence or arousal level of the distractor stimuli. The present findings support the hypothesis that the regions of DLPFC under investigation are involved in integrating motivational and executive function processes, and they also indicate the involvement of a number of other brain areas in maintaining goal pursuit. However, DLPFC did not display differential sensitivity to valence.

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.

Mechanisms through which executive dysfunction influences suicidal ideation in combat-exposed Iraq and Afghanistan veterans.

OBJECTIVE: Executive dysfunction has previously been associated with suicidality, but it remains unclear how deficits in executive functioning contribute to increased suicidal thoughts and behaviors. Although it has been proposed that poorer executive functioning leads to difficulty generating and implementing appropriate coping strategies to regulate distress and inhibit suicidal thoughts and behaviors, studies have not systematically examined these relationships. Therefore, the present study examined various hypotheses to elucidate the mechanisms through which executive dysfunction influences suicidal ideation (SI) in combat-exposed Iraq/Afghanistan veterans. METHOD: Veterans who endorsed SI were compared to those who denied SI on demographic and diagnostic variables and measures of neuropsychological functioning, psychological symptoms, coping styles, and combat experiences. Serial mediation models were tested to examine mechanistic relationships among executive functioning, psychological distress, coping, and SI. RESULTS: Those who endorsed SI had worse executive functioning, greater psychological distress, and greater avoidant coping relative to those who denied SI. Serial mediation model testing indicated a significant indirect path, such that executive dysfunction increased psychological distress, which in turn increased avoidant coping, leading to SI. CONCLUSIONS: Findings support and extend previous hypotheses regarding how executive functioning contributes to increased risk of suicidality via increased distress and avoidant coping. Intervention efforts focused on reducing suicidality may benefit from techniques that enhance executive functioning (e.g. computerized training, cognitive rehabilitation) and in turn reduce distress prior to targeting coping strategies.

White matter integrity, suicidal ideation, and cognitive dysfunction in combat-exposed Iraq and Afghanistan Veterans.

White matter alterations in frontolimbic circuits and poorer cognitive functioning have been observed in individuals endorsing suicidality across numerous psychiatric conditions. However, relationships between white matter integrity, cognition, and suicidality in Veterans are poorly understood, particularly for those at increased risk for suicide due to mental health conditions (e.g., posttraumatic stress disorder, depression) and traumatic brain injury history. We (1) examined white matter alterations in combat-exposed Iraq/Afghanistan Veterans with and without suicidal ideation (SI) and (2) investigated relationships between white matter integrity and neuropsychological functioning in regions that differed between SI groups. No group differences were found regarding psychiatric diagnoses. Participants with SI had lower fractional anisotropy (FA) in the posterior corona radiata, superior corona radiata, and superior longitudinal fasciculus relative to those without SI. Worse processing speed/attention performance was associated with lower FA in the superior longitudinal fasciculus, while worse executive functioning performance was associated with lower FA in the superior corona radiata and superior longitudinal fasciculus. Memory performance was not associated with FA. These findings suggest that white matter integrity may be involved in cognitive dysfunction and increased risk for SI. Interventions that target cognitive dysfunction may ameliorate SI, and in turn, reduce risk for suicide among Veterans.

Baseline sleep quality moderates symptom improvement in veterans with comorbid PTSD and TBI receiving trauma-focused treatment.

Poor sleep quality is common among Veterans with posttraumatic stress disorder (PTSD) and history of traumatic brain injury (TBI). However, the relationship between sleep quality and treatment outcomes following trauma-focused interventions is less well-understood in this population. We sought to better understand whether 1) sleep quality changed as a result of trauma-focused treatment and 2) if baseline sleep quality moderated psychological and neurobehavioral treatment outcomes. Our sample consisted of 100 Iraq/Afghanistan era Veterans with PTSD and history of mild to moderate TBI who were randomized to one of two trauma-focused treatments: 1) Cognitive Processing Therapy (CPT) or 2) combined CPT and Cognitive Symptom Management and Rehabilitation Therapy (SMART-CPT). Self-reported sleep quality, psychiatric symptoms (PTSD and depression), and neurobehavioral concerns were assessed at multiple timepoints throughout the study. Multilevel modeling showed sleep quality did not improve, regardless of treatment condition. However, worse baseline sleep quality was associated with less improvement in PTSD symptoms and cognitive complaints. There was no effect of baseline sleep quality on change in depression symptoms. These findings suggest that more targeted treatments to address sleep quality either prior to or in conjunction with trauma-focused therapy may help to improve treatment outcomes for Veterans with comorbid PTSD and TBI history.

Factors associated with employment and work perception in combat-exposed veterans.

PURPOSE/OBJECTIVE: The purpose of this study was 2-fold: (a) to evaluate whether perception of work ability is associated with employment status in a sample of combat-exposed veterans, and (b) to determine whether the same sets of variables that are associated with employment status are also associated with perception of work ability. Research Method/Design: In this cross-sectional study, veterans (N = 83) underwent a neuropsychological assessment and completed questionnaires assessing demographic characteristics, combat-related experiences, and psychiatric and neurobehavioral/health-related symptoms. Primary outcomes of interest were employment status (unemployed vs. employed) and veterans' perception of whether their ability to work has declined due to an ongoing condition (yes vs. no). RESULTS: A chi-square analysis revealed a significant relationship between perception of work ability and employment status. Additionally, psychiatric and neurobehavioral/health-related symptoms were associated with employment status and perception of work ability, whereas demographic characteristics (i.e., service-connected disability rating) and combat-related experiences (i.e., mTBI history) were only associated with perception of work ability. Objective cognitive functioning was not associated with employment status or perception of work ability. CONCLUSIONS/IMPLICATIONS: Although preliminary, results suggest that perception of work ability is an important factor to consider when evaluating employment-related outcomes in veterans. Moreover, results indicate that while there is some overlap among the variables associated with employment status and perception of work ability, additional variables are linked with perception of work ability. Taken together, these findings suggest that perception of one's ability to work and factors that influence it may be particularly important treatment targets in the veteran population. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Post-concussive symptom endorsement and symptom attribution following remote mild traumatic brain injury in combat-exposed Veterans: An exploratory study.

The purpose of this study was to examine rates of and relationships between "post-concussive" symptom endorsement and symptom attribution in Veterans with a history of mild traumatic brain injury (mTBI). This cross-sectional, exploratory study included 48 combat-exposed Iraq/Afghanistan Veterans with remote history of mTBI. All Veterans completed clinical interviews and self-report questionnaires assessing sociodemographic factors, injury and combat-related variables, psychiatric distress, self-efficacy, and coping style. To assess symptom endorsement and symptom attribution, a modified version of the Neurobehavioral Symptom Inventory was administered. Results showed that the most commonly endorsed "post-concussive" symptoms were several non-specific symptoms, while the symptoms most frequently attributed to mTBI included forgetfulness, poor concentration, and headaches. Furthermore, although there were some overlapping correlates of both symptom endorsement and symptom attribution, unique variables were associated with each domain. Specifically, symptom endorsement was uniquely associated with measures of psychiatric distress, while symptom attribution was uniquely associated with having a history of loss of consciousness and a greater degree of combat exposure. Taken together, results suggest that endorsement of symptoms may be significantly impacted by the presence of mental health comorbidities, but that perceptions or beliefs as to why symptoms are occurring are related more to mTBI and combat-related characteristics. Findings offer potential avenues for therapeutic intervention, emphasize the importance of psychoeducation, and highlight the need to consider using alternate terminology for these symptoms that promotes recovery and minimizes misattribution of symptoms.

Associations Between Multiple Remote Mild TBIs and Objective Neuropsychological Functioning and Subjective Symptoms in Combat-Exposed Veterans.

OBJECTIVE: The purpose of this study was to evaluate relationships between multiple mild traumatic brain injuries (mTBIs) and objective and subjective clinical outcomes in a sample of combat-exposed Veterans, adjusting for psychiatric distress and combat exposure. METHOD: In this cross-sectional study, 73 combat-exposed Iraq/Afghanistan Veterans were divided into three groups based on mTBI history: 0 mTBIs (n = 31), 1-2 mTBIs (n = 21), and 3+ mTBIs (n = 21). Veterans with mTBI were assessed, on average, 7.78 years following their most recent mTBI. Participants underwent neuropsychological testing and completed self-report measures assessing neurobehavioral, sleep, and pain symptoms. RESULTS: MANCOVAs adjusting for psychiatric distress and combat exposure showed no group differences on objective measures of attention/working memory, executive functioning, memory, and processing speed (all p's > .05; ηp2 = .00-.06). In contrast, there were significant group differences on neurobehavioral symptoms (p's = < .001-.036; ηp2 = .09-.43), sleep difficulties (p = .037; ηp2 = .09), and pain symptoms (p < .001; ηp2 = .21). Pairwise comparisons generally showed that the 3+ mTBI group self-reported the most severe symptoms, followed by comparable symptom reporting between the 0 and 1-2 mTBI groups. CONCLUSIONS: History of multiple, remote mTBIs is associated with elevated subjective symptoms but not objective neuropsychological functioning in combat-exposed Veterans. These results advance understanding of the long-term consequences of repetitive mTBI in this population and suggest that Veterans with 3+ mTBIs may especially benefit from tailored treatments aimed at ameliorating specific neurobehavioral, sleep, and pain symptoms.

Reward anticipation and punishment anticipation are instantiated in the brain via opponent mechanisms.

fMRI investigations have examined the extent to which reward and punishment motivation are associated with common or opponent neural systems, but such investigations have been limited by confounding variables and methodological constraints. The present study aimed to address limitations of earlier approaches and more comprehensively evaluate the extent to which neural activation associated with reward and punishment motivation reflects opponent or shared systems. Participants completed a modified monetary incentive delay task, which involved the presentation of a cue followed by a target to which participants were required to make a speeded button press. Using a factorial design, cues indicated whether monetary reward and/or loss (i.e., cues signaled probability of reward, punishment, both, or neither) could be expected depending upon response speed. Neural analyses evaluated evidence of (a) directionally opposing effects by testing for regions of differential activation for reward and punishment anticipation, (b) mutual inhibition by testing for interactive effects of reward and punishment anticipation within a factorial design, and (c) opposing effects on shared outputs via a psychophysiological interaction analysis. Evidence supporting all three criteria for opponent systems was obtained. Collectively, present findings support conceptualizing reward and punishment motivation as opponent forces influencing brain and behavior and indicate that shared activation does not suggest the operation of a common neural mechanism instantiating reward and punishment motivation.

Evaluation of objective and subjective clinical outcomes in combat veterans with and without mild TBI and PTSD: A four-group design.

Introduction: Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) are highly prevalent comorbid conditions in military Veterans. However, lack of appropriate comparison groups has clouded interpretation of the chronic effects of these conditions. The present study evaluated the neuropsychological, psychiatric/neurobehavioral, and functional outcomes associated with mTBI and PTSD in a well-characterized sample of combat-exposed Veterans. Method: Participants included 73 Iraq/Afghanistan Veterans (91.8% male; age: M = 34.00, SD = 6.39) divided into four groups: mTBI-only (n = 23), PTSD-only (n = 14), comorbid mTBI + PTSD (n = 19), and combat-control (CC; n = 17). Participants were administered a neuropsychological assessment and completed questionnaires assessing psychiatric/neurobehavioral symptoms and functional outcomes. Results: Kruskal-Wallis H-tests showed no group differences across measures of neuropsychological functioning; however, there were significant differences across groups on all psychiatric/neurobehavioral variables examined. In general, the comorbid and PTSD-only groups endorsed the most severe symptoms, followed by the mTBI-only and CC groups, respectively. As for functional outcomes, the comorbid and PTSD-only groups had higher rates of service-connection disability and greater perceived decline in work and education-related abilities, relative to the mTBI-only and CC groups, despite similar proportions of Veterans employed or in school in each group. Conclusions: Findings suggest that Veterans with comorbid mTBI + PTSD and PTSD alone are at greatest risk for experiencing long-lasting subjective distress, including negative perceptions of their ability to work or pursue an education, despite being comparable to mTBI-only and CC Veterans on objective measures of functioning. Our results highlight the importance of emphasizing mental health treatment in this population.

Mild traumatic brain injury characteristics do not negatively influence cognitive processing therapy attendance or outcomes.

Some providers have expressed hesitation about the appropriateness of PTSD treatment for veterans with a history of mild traumatic brain injury (mTBI), given concerns that TBI-related sequelae may negatively affect PTSD treatment and/or should be the focus of treatment instead. However, research suggests that those with a history of mTBI can benefit from evidence-based PTSD treatment. To extend these findings, we examined whether specific mTBI injury markers were associated with PTSD treatment attendance and response. Iraq/Afghanistan-era veterans with PTSD and history of mTBI (N = 88) all received Cognitive Processing Therapy (CPT; either standard CPT without the trauma account or SMART-CPT, a modified version of CPT that included cognitive rehabilitation strategies). Analyses examined whether time since injury, presence of loss of consciousness (LOC) or posttraumatic amnesia (PTA), and number and mechanism of mTBIs were associated with treatment attendance or response. None of the five injury variables examined were associated with number of treatment sessions attended. Multilevel modeling indicated that injury variables did not moderate treatment response (across treatment conditions) in terms of change in PTSD and depression symptoms. There was a three-way interaction showing that individuals who denied ever experiencing LOC exhibited a greater decrease in PTSD and depression symptoms in standard CPT relative to those in the SMART-CPT. Thus, a history of mTBI should not preclude individuals from receiving standard CPT, regardless of injury characteristics. In fact, PTSD treatment should often be a first line of treatment for these veterans, given evidence of a mental health etiology to persistent post-concussive symptoms.