Understanding the impact of complicated grief on combat related posttraumatic stress disorder, guilt, suicide, and functional impairment in a clinical trial of post-9/11 service members and veterans.

BACKGROUND: Complicated grief (CG) is a bereavement-specific syndrome distinct from but commonly comorbid with posttraumatic stress disorder (PTSD). While bereavement is common among military personnel (Simon et al., 2018), there is little research on the impact of CG comorbidity on PTSD treatment outcomes. METHODS: To evaluate the impact of comorbid CG on PTSD treatment outcomes we analyzed data from a randomized trial comparing prolonged exposure, sertraline, and their combination in veterans with a primary diagnosis of combat-related PTSD (n = 194). Assessment of PTSD, trauma-related guilt, functional impairment, and suicidal ideation and behavior occurred at baseline and weeks 6, 12, and 24 during the 24-week trial. RESULTS: CG was associated with lower PTSD treatment response (odds ratio (OR) = 0.29, 95% confidence interval (CI) [0.12, 0.69], p = 0.005) and remission (OR = 0.28, 95% CI [0.11, 0.71], p = 0.007). Those with CG had greater severity of PTSD (p = 0.005) and trauma-related guilt (<0.001) at baseline and endpoint. In addition, those with CG were more likely to experience suicidal ideation during the study (CG: 35%, 14/40 vs. no CG 15%, 20/130; OR = 3.01, 95% CI [1.29, 7.02], p = 0.011). CONCLUSIONS: Comorbid CG is associated with elevated PTSD severity and independently associated with poorer endpoint treatment outcomes in veterans with combat-related PTSD, suggesting that screening and additional intervention for CG may be needed.

Gulf War Illnesses are autoimmune conditions caused by the direct effect of the nerve gas prophylaxis drug (pyridostigmine bromide) on anergic immune system lymphocytes.

Immune system dysregulation in 1991 Gulf War Veterans was caused in part by the nerve gas prophylactic drug pyridostigmine bromide (PB) by direct agonist activation of muscarinic receptors on anergic B and T lymphocytes, leading to multiple types of autoimmune illnesses, and this effect may have been potentiated by combat stress.

Relations of combat stress and posttraumatic stress disorder to 24-h plasma and cerebrospinal fluid interleukin-6 levels and circadian rhythmicity.

BACKGROUND: Acute and chronic stress can lead to a dysregulation of the immune response. Growing evidence suggests peripheral immune dysregulation and low-grade systemic inflammation in posttraumatic stress disorder (PTSD), with numerous reports of elevated plasma interleukin-6 (IL-6) levels. However, only a few studies have assessed IL-6 levels in the cerebrospinal fluid (CSF). Most of those have used single time-point measurements, and thus cannot take circadian level variability and CSF-plasma IL-6 correlations into account. METHODS: This study used time-matched, sequential 24-h plasma and CSF measurements to investigate the effects of combat stress and PTSD on physiologic levels and biorhythmicity of IL-6 in 35 male study volunteers, divided in 3 groups: (PTSD = 12, combat controls, CC = 12, and non-deployed healthy controls, HC = 11). RESULTS: Our findings show no differences in diurnal mean concentrations of plasma and CSF IL-6 across the three comparison groups. However, a significantly blunted circadian rhythm of plasma IL-6 across 24 h was observed in all combat-zone deployed participants, with or without PTSD, in comparison to HC. CSF IL-6 rhythmicity was unaffected by combat deployment or PTSD. CONCLUSIONS: Although no significant group differences in mean IL-6 concentration in either CSF or plasma over a 24-h timeframe was observed, we provide first evidence for a disrupted peripheral IL-6 circadian rhythm as a sequel of combat deployment, with this disruption occurring in both PTSD and CC groups. The plasma IL-6 circadian blunting remains to be replicated and its cause elucidated in future research.

Childhood trauma, combat trauma, and substance use in National Guard and reserve soldiers.

BACKGROUND: The goal of this work was to examine associations among childhood trauma, combat trauma, and substance use (alcohol problems, frequent heavy drinking [FHD], current cigarette smoking, and current/lifetime drug use) and the interaction effects of childhood trauma and combat exposure on those associations among National Guard/reserve soldiers. METHODS: Participants (N = 248) completed an electronic survey asking questions about their military experiences, physical and mental health, and substance use. Childhood trauma and combat exposure were examined jointly in regression models, controlling for age, marital satisfaction, and number of deployments. RESULTS: Childhood trauma was associated with current drug use (trend level, odds ratio [OR] = 1.44, 95% confidence interval [CI]: 0.97, 2.14; P = .072) in the main effect model; however, there was not a significant interaction with combat. Combat exposure had a significant interaction with childhood trauma on alcohol problems (b = -0.56, 95% CI: -1.12, -0.01; P = .048), FHD (b = -0.27, 95% CI: -0.47, -0.08; P = .007), and lifetime drug use (OR = 1.78, 95% CI: 1.04, 3.04; P = .035). There were no associations with either of the trauma measures and current cigarette smoking. CONCLUSIONS: These results demonstrate that childhood and combat trauma have differential effects on alcohol use, such that combat trauma may not add to the effect on alcohol use in those with greater child maltreatment but may contribute to greater alcohol use among those with low child maltreatment. As expected, childhood and combat trauma had synergistic effects on lifetime drug use. Screening for multiple types of trauma prior to enlistment and/or deployment may help to identify at-risk individuals and allow time for early intervention to prevent future adverse outcomes.

Combat, Posttraumatic Stress Disorder, and Smoking Trajectory in a Cohort of Male Australian Army Vietnam Veterans.

Background: Whether trauma exposure itself or consequent posttraumatic stress disorder (PTSD) is primarily responsible for smoking and failure to quit remains unclear. Methods: A cohort of male Australian Vietnam veterans (N = 388) was interviewed twice, 22 and 36 years after their return to Australia using standardized psychiatric diagnostic and health interviews and assessment of combat exposure. The smoking trajectory over time revealed a spectrum of outcomes (never smoked, early quitters, late quitters, and continuing smokers). Analysis used multivariate statistics to assess the relative contributions of combat trauma exposure and PTSD while controlling for potential confounders. Results: The trajectory of smoking over time revealed that 21.9% of veterans had never smoked, 45.1% had quit smoking by the time of wave 1, 16.2% were current smokers at wave 1 who had quit by the time of wave 2, 2.8% were late adopters who were current smokers, and 13.9% were continuing smokers. Smoking was associated in single-predictor models with demographics, intelligence, combat exposure, PTSD symptom clusters and diagnosis, and alcohol disorders. Multivariate analysis revealed that PTSD, combat, and intelligence were related to the smoking spectrum but, after adding demographics and other Axis I psychiatric diagnoses, only combat remained significant. No PTSD symptom cluster uniquely predicted smoking status. Conclusions: The results suggest that trauma exposure in the form of military combat may be a more robust predictor of smoking status over time than PTSD. It may be stress itself, rather than poststress disorder, that is more germane to smoking and failure to quit. Implications: Exposure to traumatic stress and development of PTSD have been implicated separately in the maintenance of smoking. This longitudinal cohort study of smoking in war veterans up to three decades postwar enabled evaluation of traumatic stress exposure in combat and the course of PTSD in smoking and quitting while controlling for intelligence, background disadvantage, and other psychiatric conditions. Combat rather than PTSD emerged as more significant to smoking status, suggesting that it may be the traumatic stress itself rather than the development of a poststress disorder that is more germane to smoking in war veterans.

Correlation between interferon γ and interleukin 6 with PTSD and resilience.

Posttraumatic Stress Disorder (PTSD) is a debilitating psychiatric disorder with decreased general health prognosis and increased mortality. Inflammation has been hypothesised to be a link between PTSD and the most common co-morbid medical disorders. However, the relationship between inflammation and PTSD is not clear. Individual inflammatory markers have shown variable associations with PTSD. This study investigates the correlations between serum cytokines, PTSD and resilience in a cohort of Caucasian Vietnam combat veterans (n = 299). After correction for multiple testing, PTSD severity was correlated with small but significant decreases in interleukin 6 and interferon γ (p = 0.004, p = 0.013, respectively) whereas resilience was correlated with increased levels of interleukin 6 and interferon γ (p = 0.023; p = 0.007, respectively). Analyses of sub-symptoms of PTSD revealed that mood and arousal symptoms showed the most significant effect on interleukin 6 and interferon γ. More research is needed to further elucidate the mechanisms underlying the relationship between cytokine levels, PTSD sub-symptoms and trauma outcomes to improve the knowledge base of differences in trauma response and the biological system.

Recurring Vivid Dreams in an Older Hmong Man With Complex Trauma Experience and Cognitive Impairment.

INTRODUCTION: Health care workers need to consider the culture and ethnic preferences prevalent in the Hmong community in order to provide optimal care. We describe an older Hmong man to illustrate the challenges faced and competencies needed by primary care. CASE PRESENTATION: An 80-year-old non-English speaking Hmong man with diabetes, nerve sheath tumor, and hypertension presented to the outpatient clinic with his grandson complaining of sleep problems. He had had 2 vivid recurring dreams during the previous few months. Memory assessment was significant for dementia. DISCUSSION: This case addresses the complexity in taking care of a non-English speaking Hmong older man who has memory loss, trauma in adulthood, multiple caregivers, and sleep problems. CONCLUSIONS: A careful history from patient and family to get to know their cultural preferences and attitudes was helpful. Identification of the primary caregiver was critical in providing care.

A Double-Blind, Randomized, Controlled Pilot Trial of N-Acetylcysteine in Veterans With Posttraumatic Stress Disorder and Substance Use Disorders.

OBJECTIVE: The antioxidant N-acetylcysteine is being increasingly investigated as a therapeutic agent in the treatment of substance use disorders (SUDs). This study explored the efficacy of N-acetylcysteine in the treatment of posttraumatic stress disorder (PTSD), which frequently co-occurs with SUD and shares impaired prefrontal cortex regulation of basal ganglia circuitry, in particular at glutamate synapses in the nucleus accumbens. METHODS: Veterans with PTSD and SUD per DSM-IV criteria (N = 35) were randomly assigned to receive a double-blind, 8-week course of N-acetylcysteine (2,400 mg/d) or placebo plus cognitive-behavioral therapy for SUD (between March 2013 and April 2014). Primary outcome measures included PTSD symptoms (Clinician-Administered PTSD Scale, PTSD Checklist-Military) and craving (Visual Analog Scale). Substance use and depression were also assessed. RESULTS: Participants treated with N-acetylcysteine compared to placebo evidenced significant improvements in PTSD symptoms, craving, and depression (ß values < -0.33; P values < .05). Substance use was low for both groups, and no significant between-group differences were observed. N-acetylcysteine was well tolerated, and retention was high. CONCLUSIONS: This is the first randomized controlled trial to investigate N-acetylcysteine as a pharmacologic treatment for PTSD and SUD. Although preliminary, the findings provide initial support for the use of N-acetylcysteine in combination with psychotherapy among individuals with co-occurring PTSD and SUD. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02499029.

Heart rate variability: Pre-deployment predictor of post-deployment PTSD symptoms.

Heart rate variability is a physiological measure associated with autonomic nervous system activity. This study hypothesized that lower pre-deployment HRV would be associated with higher post-deployment post-traumatic stress disorder (PTSD) symptoms. Three-hundred-forty-three Army National Guard soldiers enrolled in the Warriors Achieving Resilience (WAR) study were analyzed. The primary outcome was PTSD symptom severity using the PTSD Checklist - Military version (PCL) measured at baseline, 3- and 12-month post-deployment. Heart rate variability predictor variables included: high frequency power (HF) and standard deviation of the normal cardiac inter-beat interval (SDNN). Generalized linear mixed models revealed that the pre-deployment PCL*ln(HF) interaction term was significant (p<0.0001). Pre-deployment SDNN was not a significant predictor of post-deployment PCL. Covariates included age, pre-deployment PCL, race/ethnicity, marital status, tobacco use, childhood abuse, pre-deployment traumatic brain injury, and previous combat zone deployment. Pre-deployment heart rate variability predicts post-deployment PTSD symptoms in the context of higher pre-deployment PCL scores.

Serum concentrations of TNF-α and its soluble receptors during psychotherapy in German soldiers suffering from combat-related PTSD.

BACKGROUND: Changes in serum concentrations of tumor necrosis factor-α (TNF-α) and its soluble receptors (sTNF-R) p55 and p75 have been shown to be associated with various psychiatric treatments. SUBJECTS AND METHODS: Before and after treatment, serum levels of TNF-α, sTNF-R p55 and sTNF-R p75 were measured in 38 German soldiers who had been deployed abroad and suffered from combat-related post-traumatic stress disorder (PTSD). Patients were randomized either to inpatient psychotherapy (N=21) including eye movement desensitization and reprocessing (EMDR) or to outpatient clinical management (N=17). Symptoms of PTSD were measured using the Post-traumatic Stress Diagnostic Scale (PDS). RESULTS: The PDS score significantly decreased across time in both groups. Serum concentrations of TNF-α increased, while sTNF-R p55 and sTNF-R p75 levels decreased significantly. After the treatment period, we could not detect any significant difference regarding TNF-α, sTNF-R p55 or sTNF-R p75 levels between the inpatient psychotherapy group and the outpatient clinical management control group. CONCLUSIONS: This relatively small clinical study suggests that specific inpatient psychotherapy but also non-specific supportive outpatient treatment for PTSD are associated with changes in the TNF-α system. This may represent an immunological effects or side effects of psychotherapy.

What does the literature say about the needs of veterans in the areas of health?

This paper reports on a systematic review undertaken in 2013 aimed at identifying evidence and dismissing some of the myths surrounding the needs of the veteran community. Papers were retrieved from a wide range of sources to ensure that literature covered the key areas of health concerns and focused also on time spent in service. Of the twenty eight papers reviewed categories relating to mental health (including PTSD and suicide), the use of alcohol, trauma, hearing loss, cancer and obesity were identified. Outcomes from the review established that while early service leavers were the most vulnerable there were also aspects within service that had an impact on future life events such as the type of leadership experienced, the cohesion of the unit and facing combat situations. The use of alcohol as a coping mechanism is also considered prevalent with adverse effects as is the worry of family situations at home. The impact of service life on the veteran, especially if suffering trauma will have long lasting psychological and physical outcomes, although it is recognised that veterans in the main have excellent physical and psychological strength and many physical illnesses are not greatly exaggerated from that of the general public.

[Military psychiatry in a theatre of operations: on mission in Mali]. / Psychiatre militaire sur un théâtre d'opérations: en mission au Mali.

The recent missions of military psychiatrists in the theatres of operation underline the reactivity of the French healthcare system, focused on the expertise of the combat unit doctor. Operation Serval in Mali illustrates in particular the methods of medical-psychological support in exceptional situations, across a vast geographical area and in very difficult climatic conditions. The concept of "forward psychiatry" has a particularly important role to play in the early screening and treatment of psychological disorders in order to preserve the operational capacity of the deployed personnel.

Longitudinal changes of telomere length and epigenetic age related to traumatic stress and post-traumatic stress disorder.

Several studies have reported an association between traumatic stress and telomere length suggesting that traumatic stress has an impact on ageing at the cellular level. A newly derived tool provides an additional means to investigate cellular ageing by estimating epigenetic age based on DNA methylation profiles. We therefore hypothesise that in a longitudinal study of traumatic stress both indicators of cellular ageing will show increased ageing. We expect that particularly in individuals that developed symptoms of post-traumatic stress disorder (PTSD) increases in these ageing parameters would stand out. From an existing longitudinal cohort study, ninety-six male soldiers were selected based on trauma exposure and the presence of symptoms of PTSD. All military personnel were deployed in a combat zone in Afghanistan and assessed before and 6 months after deployment. The Self-Rating Inventory for PTSD was used to measure the presence of PTSD symptoms, while exposure to combat trauma during deployment was measured with a 19-item deployment experiences checklist. These groups did not differ for age, gender, alcohol consumption, cigarette smoking, military rank, length, weight, or medication use. In DNA from whole blood telomere length was measured and DNA methylation levels were assessed using the Illumina 450K DNA methylation arrays. Epigenetic ageing was estimated using the DNAm age estimator procedure. The association of trauma with telomere length was in the expected direction but not significant (B=-10.2, p=0.52). However, contrary to our expectations, development of PTSD symptoms was associated with the reverse process, telomere lengthening (B=1.91, p=0.018). In concordance, trauma significantly accelerated epigenetic ageing (B=1.97, p=0.032) and similar to the findings in telomeres, development of PTSD symptoms was inversely associated with epigenetic ageing (B=-0.10, p=0.044). Blood cell count, medication and premorbid early life trauma exposure did not confound the results. Overall, in this longitudinal study of military personnel deployed to Afghanistan we show an acceleration of ageing by trauma. However, development of PTSD symptoms was associated with telomere lengthening and reversed epigenetic ageing. These findings warrant further study of a perhaps dysfunctional compensatory cellular ageing reversal in PTSD.

Marijuana, expectancies, and post-traumatic stress symptoms: a preliminary investigation.

Previous work suggests that people might turn to marijuana to alleviate the symptoms of post-traumatic stress disorder (PTSD) and associated distress. Expectancy theories emphasize that the use of drugs correlates with their anticipated effects. The current study examined multivariate links among marijuana use, PTSD symptoms, and expectancies for marijuana-induced changes in those symptoms. Over 650 combat-exposed, male veterans who used marijuana at least once per week completed measures of PTSD symptoms, marijuana expectancies, and marijuana use in an Internet survey. Participants generally expected marijuana to relieve PTSD symptoms, especially those related to intrusions and arousal. Symptoms, expectancies for relief of symptoms, and marijuana consumption correlated significantly. Regressions revealed significant indirect effects of symptoms on use via expectancies, but no significant interactions of expectancies and symptoms. Combat-exposed veterans who use marijuana appear to use more as the magnitude of PTSD symptoms and their expectations of marijuana-induced relief of those symptoms increase. These results emphasize the importance of PTSD treatments in an effort to keep potential negative effects of marijuana to a minimum. They also underscore the import of expectancies in predicting marijuana use.

Prevalence and correlates of mental health problems in Canadian Forces personnel who deployed in support of the mission in Afghanistan: findings from postdeployment screenings, 2009-2012.

OBJECTIVE: An important minority of military personnel will experience mental health problems after overseas deployments. Our study sought to describe the prevalence and correlates of postdeployment mental health problems in Canadian Forces personnel. METHOD: Subjects were 16 193 personnel who completed postdeployment screening after return from deployment in support of the mission in Afghanistan. Screening involved a detailed questionnaire and a 40-minute, semi-structured interview with a mental health clinician. Mental health problems were assessed using the Patient Health Questionnaire and the Posttraumatic Stress Disorder Checklist-Civilian Version. Logistic regression was used to explore independent risk factors for 1 or more of 6 postdeployment mental health problems. RESULTS: Symptoms of 1 or more of 6 mental health problems were seen in 10.2% of people screened; the most prevalent symptoms were those of major depressive disorder (3.2%), minor depression (3.3%), and posttraumatic stress disorder (2.8%). The strongest risk factors for postdeployment mental health problems were past mental health care (adjusted odds ratio [AOR] 2.89) and heavy combat exposure (AOR 2.57 for third tertile, compared with first tertile). These risk groups might be targeted in prevention and control efforts. In contrast to findings from elsewhere, Reservist status, deployment duration, and number of previous deployments had no relation with mental health problems. CONCLUSIONS: An important minority of personnel will disclose symptoms of mental health problems during postdeployment screening. Differences in risk factors seen in different nations highlight the need for caution in applying the results of research in one population to another.

Military sexual trauma interacts with combat exposure to increase risk for posttraumatic stress symptomatology in female Iraq and Afghanistan veterans.

OBJECTIVE: Sexual trauma during military service is increasingly recognized as a substantial public health problem and is associated with detrimental effects on veteran mental health. In this study, we examined associations between childhood trauma, military sexual trauma (MST), combat exposure, and military-related posttraumatic stress symptomatology (PTSS) in the Women Veterans Cohort Study (WVCS), a community-based sample of veterans who served in the recent conflicts in Iraq and Afghanistan. METHOD: From July 2008 to December 2011, 365 female veterans completed a survey that assessed combat exposure, military sexual trauma, military-related PTSS (assessed using the PTSD [posttraumatic stress disorder] Checklist-Military Version), and demographic, life history, and other psychopathology variables. RESULTS: High rates of childhood trauma (59.7%) and MST (sexual assault = 14.7%; sexual harassment = 34.8%) were observed in this sample. A hierarchical regression revealed that active duty status, childhood trauma, combat exposure, and MST were independently associated with increased severity of military-related PTSS (Ps < .05). Moreover, a significant interaction emerged between MST and combat exposure in predicting military-related PTSS (P = .030), suggesting that the relationship between combat exposure and PTSS was altered by MST status. Specifically, under conditions of high combat exposure, female veterans with MST had significantly higher PTSS compared to female veterans without MST. CONCLUSIONS: Taken together, results suggest that exposure to multiple traumas during military service may have synergistic effects on posttraumatic stress symptoms in female veterans. Moreover, our findings highlight the importance of prevention efforts to protect female veterans from the detrimental effects of MST, particularly those who are exposed to high levels of combat.

Screening for violence risk in military veterans: predictive validity of a brief clinical tool.

OBJECTIVE: Violence toward others is a serious problem among a subset of military veterans. The authors evaluated the predictive validity of a brief decision support tool to screen veterans for problems with violence and identify potential candidates for a comprehensive risk assessment. METHOD: Data on risk factors at an initial wave and on violent behavior at 1-year follow-up were collected in two independent sampling frames: a national random-sample survey of 1,090 Iraq and Afghanistan veterans and in-depth assessments of 197 dyads of veterans and collateral informants. Risk factors (lacking money for basic needs, combat experience, alcohol misuse, history of violence and arrests, and anger associated with posttraumatic stress disorder) were chosen based on empirical support in published research. Scales measuring these risk factors were examined, and items with the most robust statistical association with outcomes were selected for the screening tool. Regression analyses were used to derive receiver operating characteristic curves of sensitivities and specificities, with area under the curve providing an index of predictive validity. RESULTS: The resultant 5-item screening tool, called the Violence Screening and Assessment of Needs (VIO-SCAN), yielded area-under-the-curve statistics ranging from 0.74 to 0.78 for the national survey and from 0.74 to 0.80 for the in-depth assessments, depending on level of violence analyzed. CONCLUSIONS: Although the VIO-SCAN does not constitute a comprehensive violence risk assessment and cannot replace fully informed clinical decision making, it is hoped that the screen will provide clinicians with a rapid, systematic method for identifying veterans at higher risk of violence, prioritizing those in need a full clinical workup, structuring review of empirically supported risk factors, and developing plans collaboratively with veterans to reduce risk and increase successful reintegration in the community.

Cancer-related PTSD symptoms in a veteran sample: association with age, combat PTSD, and quality of life.

OBJECTIVE: The diagnosis and treatment of cancer is a potentially traumatic experience that may evoke posttraumatic stress symptoms (PTSS) among survivors. This paper describes the rates of endorsement of cancer-related PTSS along with the relationship of demographic, cancer, and combat variables on PTSS and quality of life. METHODS: Veterans (N = 166) with head and neck, esophageal, gastric, or colorectal cancers were recruited through tumor registries at two regional Veterans Administration Medical Centers. Standardized scales were used to assess self-report of PTSS, combat, and quality of life. RESULTS: Most participants (86%) reported experiencing at least some cancer-related PTSS; 10% scored above a clinical cutoff for probable PTSD. In linear regressions, younger age and current combat PTSS were associated with cancer-related PTSS, whereas disease and treatment characteristics were not; in turn, cancer-related PTSS were negatively associated with physical and social quality of life. CONCLUSIONS: Individual characteristics and psychosocial factors may play a larger role than disease-related variables in determining how an individual responds to the stress of cancer diagnosis and treatment. Given the rates of reported cancer-related PTSS in this sample, and other non-veteran samples, clinicians should consider screening these following diagnosis and treatment, particularly in younger adults and those with previous trauma histories.

Screening for postdeployment conditions: development and cross-validation of an embedded validity scale in the neurobehavioral symptom inventory.

OBJECTIVE: To develop and cross-validate internal validity scales for the Neurobehavioral Symptom Inventory (NSI). PARTICIPANTS: Four existing data sets were used: (1) outpatient clinical traumatic brain injury (TBI)/neurorehabilitation database from a military site (n = 403), (2) National Department of Veterans Affairs TBI evaluation database (n = 48 175), (3) Florida National Guard nonclinical TBI survey database (n = 3098), and (4) a cross-validation outpatient clinical TBI/neurorehabilitation database combined across 2 military medical centers (n = 206). RESEARCH DESIGN: Secondary analysis of existing cohort data to develop (study 1) and cross-validate (study 2) internal validity scales for the NSI. MAIN MEASURES: The NSI, Mild Brain Injury Atypical Symptoms, and Personality Assessment Inventory scores. RESULTS: Study 1: Three NSI validity scales were developed, composed of 5 unusual items (Negative Impression Management [NIM5]), 6 low-frequency items (LOW6), and the combination of 10 nonoverlapping items (Validity-10). Cut scores maximizing sensitivity and specificity on these measures were determined, using a Mild Brain Injury Atypical Symptoms score of 8 or more as the criterion for invalidity. Study 2: The same validity scale cut scores again resulted in the highest classification accuracy and optimal balance between sensitivity and specificity in the cross-validation sample, using a Personality Assessment Inventory Negative Impression Management scale with a T score of 75 or higher as the criterion for invalidity. CONCLUSIONS: The NSI is widely used in the Department of Defense and Veterans Affairs as a symptom-severity assessment following TBI, but is subject to symptom overreporting or exaggeration. This study developed embedded NSI validity scales to facilitate the detection of invalid response styles. The NSI Validity-10 scale appears to hold considerable promise for validity assessment when the NSI is used as a population-screening tool.