Algorithm for Symptom Attribution and Classification Following Possible Mild Traumatic Brain Injury.

OBJECTIVE: To present a heuristic model of a symptom attribution and classification algorithm (SACA) for mild traumatic brain injury (mTBI). SETTING: VA Polytrauma sites. PARTICIPANTS: 422 Veterans. DESIGN: Cross-sectional. MAIN MEASURES: SACA, Comprehensive TBI Evaluation (CTBIE), Structured TBI Diagnostic Interview, Minnesota Multiphasic Personality Inventory (MMPI-2-RF), Letter Memory Test, Validity-10. RESULTS: SACA and CTBIE diagnoses differ significantly (P < .01). The CTBIE, compared with SACA, attributes 16% to 500% more symptoms to mTBI, behavioral health (BH), mTBI + BH and symptom resolution. Altering SACA criteria indicate that (1) CTBIE determination of cognitive impairment yields 27% to 110% more mTBI, mTBI + BH and symptom resolution diagnoses, (2) ignoring timing of symptom onset yields 32% to 76% more mTBI, mTBI + BH and Other Condition diagnoses, (3) Proportion of sample having questionably valid profiles using structured TBI diagnostic interview and MMPI-2-RF and Letter Memory Test is 26% whereas with CTBIE item number 23 and Validity-10 is 6% to 26%, (4) MMPI-2-RF F-scale is the only measure identifying Veterans with posttraumatic amnesia for more than 24 hours as having questionably valid profiles. CONCLUSIONS: Symptom attribution-based diagnoses differ when using status quo versus the SACA. The MMPI-2-RF F-scale, compared with the Validity-10 and Letter Memory Test, may be more precise in identifying questionably valid profiles for mTBI + BH. The SACA provides a framework to inform clinical practice, resource allocation, and future research.

The Effects of Mild Traumatic Brain Injury, Post-Traumatic Stress Disorder, and Combined Mild Traumatic Brain Injury/Post-Traumatic Stress Disorder on Returning Veterans.

United States veterans of the Iraqi (Operation Iraqi Freedom [OIF]) and Afghanistan (Operation Enduring Freedom [OEF]) conflicts have frequently returned from deployment after sustaining mild traumatic brain injury (mTBI) and enduring stressful events resulting in post-traumatic stress disorder (PTSD). A large number of returning service members have been diagnosed with both a history of mTBI and current PTSD. Substantial literature exists on the neuropsychological factors associated with mTBI and PTSD occurring separately; far less research has explored the combined effects of PTSD and mTBI. The current study employed neuropsychological and psychological measures in a sample of 251 OIF/OEF veterans to determine whether participants with a history of mTBI and current PTSD (mTBI+PTSD) have poorer cognitive and psychological outcomes than participants with mTBI only (mTBI-o), PTSD only (PTSD-o), or veteran controls (VC), when groups are comparable on intelligence quotient, education, and age. The mTBI+PTSD group performed more poorly than VC, mTBI-o, and PTSD-o groups on several neuropsychological measures. Effect size comparisons suggest small deleterious effects for mTBI-o on measures of processing speed and visual attention and small effects for PTSD-o on measures of verbal memory, with moderate effects for mTBI+PTSD on the same variables. Additionally, the mTBI+PTSD group was significantly more psychologically distressed than the PTSD-o group, and PTSD-o group was more distressed than VC and mTBI-o groups. These findings suggest that veterans with mTBI+PTSD perform significantly lower on neuropsychological and psychiatric measures than veterans with mTBI-o or PTSD-o. The results also raise the possibility of mild but persisting cognitive changes following mTBI sustained during deployment.

Pharmacotherapy regimens among patients with posttraumatic stress disorder and mild traumatic brain injury.

OBJECTIVE: The purpose of this study was to determine if veterans with posttraumatic stress disorder (PTSD) and mild traumatic brain injury (TBI) are treated differently pharmacologically than patients with PTSD alone. METHODS: A retrospective evaluation of PTSD pharmacotherapy of Operation Enduring Freedom/Operation Iraqi Freedom veterans with PTSD (N=707) was conducted between April 1, 2007, and March 31, 2009. A total of 45 veterans had suffered a mild TBI. RESULTS: Compared with the patients with PTSD alone, the patients with PTSD and TBI were more likely to be prescribed an antidepressant (p<.001), a sedative-hypnotic (p<.001), or an antipsychotic (p=.024). The patients with TBI were also significantly more likely to receive psychotropic polypharmacy (p=.001) and to receive higher doses of psychiatric medications (p=.03). CONCLUSIONS: The differences in drug therapy found in this study may indicate that patients with TBI and PTSD respond differently to treatment than patients with PTSD alone.