The impact of PTSD, depression, and substance use disorders on disease burden and health care utilization among OEF/OIF veterans.

Growing evidence suggests that posttraumatic stress disorder (PTSD) is associated with poorer health status (e.g., more medical disease, physical symptoms, and sick visits to health care professionals) among veterans who served in Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq. We investigated whether PTSD, depression, and substance use disorders independently predicted health status over time among OEF/OIF veterans. Information regarding psychiatric and medical conditions and health care utilization was culled for 4,463 OEF/OIF veterans enrolled in Veterans Administration primary care for a period of 6 years. Data were analyzed using multilevel modeling and generalized estimating equations. Results suggest that PTSD, depression, and substance use disorders are independently associated with increased medical disease burden and mental health care utilization but not increased medical health care utilization. The association between PTSD and medical disease burden strengthened over time. These data suggest that OEF/OIF veterans with PTSD may be at risk for increasingly poorer physical health in terms of medical disease burden over time. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Posttraumatic stress symptomatology after childhood traumatic brain injury

The purpose of this study was to quantify and to identify predictors of posttraumatic stress disorder (PTSD) symptomatology after traumatic brain injury (TBI). Fifty children aged 6 to 14 years, hospitalized after TBI, were assessed soon after TBI regarding injury severity and preinjury psychiatric, socioeconomic, family functioning, and family psychiatric history status; neuroimaging was also analyzed. Psychiatric assessments were repeated 3, 6, 12, and 24 months after TBI. Only 2 of 46 (4%) subjects with at least one follow-up assessment developed PTSD. However, the frequency with which subjects experienced at least one PTSD symptom ranged from 68% in the first 3 months to 12% at 2 years in assessed children. The presence of an internalizing disorder at time of injury followed by greater injury severity were the most consistent predictors of PTSD symptomatology. It is apparent, therefore, that PTSD and subsyndromal posttraumatic stress disturbances occur despite neurogenic amnesia. These problems should be treated, particularly if symptoms persist beyond 3 months.     

Traumatic brain injury, polytrauma, and pain: Challenges and treatment strategies for the polytrauma rehabilitation.

Problem: Chronic pain conditions are common sequelae of traumatic brain injury (TBI). Unfortunately, the incidence of TBI among personnel deployed for Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) is significant, and there is growing evidence that ongoing pain, particularly headaches, will be a primary concern for these individuals. Objective: This article synthesizes empirical data from civilian and veteran populations and clinical experience with OEF/OIF personnel with polytrauma to provide recommendations for the assessment and treatment of chronic pain among those with TBI. Conclusions: The available data signal the need for the incorporation of early and aggressive pain management strategies into existing treatment models. Challenges to providing effective pain management for OEF/OIF veterans are numerous and include comorbid cognitive, medical, and emotional impairments that complicate readjustment to civilian life. It is likely that the problem of polytrauma pain and associated comorbid conditions such as posttraumatic stress disorder and postconcussive syndrome will require the development of integrated approaches to clinical care which bridge traditional subspecialty divisions. A proposed model of treatment is presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Post-acute polytrauma rehabilitation and integrated care of returning veterans: Toward a holistic approach.

Throughout the history of war, exposure to combat has been associated with clusters of physical and psychological symptoms labeled in various ways, from “hysteria” to “shell shock” in World War I to “polytrauma” in Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF). Objective: To describe the historical conceptualizations of combat injury and the ways they are relevant to developing current rehabilitation strategies, discuss the symptom complex presented by OEF/OIF veterans, and describe key elements and principles of holistic, integrated care for post-acute OEF/OIF veterans. Conclusions: A conceptualization of rehabilitation recognizing a final common pathway of functional disability and suffering is proposed, and both systematic and treatment-specific aspects at the core of a veteran-centered holistic approach are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Suicidality and veterans with a history of traumatic brain injury: Precipitating events, protective factors, and prevention strategies.

Objectives: To increase understanding regarding precipitating and preventative factors of suicidal behavior and to highlight past experiences and recommendations regarding services aimed at suicide prevention among Veterans with a history of traumatic brain injury (TBI). Study Design: Qualitative. Participants: Sample of 13 Veterans with a history of TBI, and a history of clinically significant suicidal ideation or behavior. Method: In-person interviews were conducted and data were analyzed using a hermeneutic approach. Results: Shared precipitants noted included loss-of-self post-TBI, cognitive sequelae, and psychiatric and emotional disturbances. Common protective factors noted included social supports, a sense of purpose regarding the future, religion and spirituality, and mental health care. Means of improving care were also identified (e.g., increasing the availability of services and mental health professionals’ knowledge regarding TBI, providing more structured treatment). Conclusions: Findings highlight potential areas of importance in the assessment and treatment of suicidal Veterans with a history of TBI. Recommendations regarding means of improving care are also presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Invisible wounds, visible savings? Using microsimulation to estimate the costs and savings associated with providing evidence-based treatment for PTSD and depression to veterans of Operation Enduring Freedom and Operation Iraqi Freedom.

This research used microsimulation modeling to estimate the social costs of depression and posttraumatic stress disorder (PTSD) for the 261,827 troops deployed on June 30, 2008, for Operations Enduring Freedom and Iraqi Freedom. Given current standards of care, roughly half of these individuals will be treated for these conditions in the 2 years after they return, and 30% of those treated will receive evidence-based treatment (EBT). Our results suggest that the 2-year social costs of depression and PTSD for this cohort will be $923 million. Policy simulations evaluating the savings associated with universal access to EBT suggest that such access would generate cost savings of $138 million (15%). (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

An examination of family adjustment among Operation Desert Storm veterans.

This study examined interrelationships among combat exposure, symptoms of posttraumatic stress disorder (PTSD), and family adjustment in a sample of male and female Operation Desert Storm veterans (N = 1,512). In structural equation models for both male and female veterans, higher combat exposure was associated with higher PTSD symptoms, which in turn were associated with poorer family adjustment, although these indirect effects did not reach statistical significance. The model for female veterans evidenced a significant direct negative association between combat exposure and family adjustment when it statistically accounted for PTSD symptoms. When the relative impacts of separate PTSD symptom groupings were examined, those reflecting withdrawal/numbing symptoms and arousal/lack of control symptoms significantly and indirectly accounted for the negative effects of combat exposure on family adjustment. Study findings indicate a number of possible pathways through which war-zone deployments negatively impact military families and suggest several avenues for future research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Women who served in Iraq seeking mental health services: Relationships between military sexual trauma, symptoms, and readjustment.

Eighteen women who served in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) sought mental health services at a Veterans' Affairs (VA) medical center. Ten of the 18 women (56%) reported military sexual trauma (MST) while serving in OIF/OEF. All 10 with MST reported sexual harassment, 6 of the 10 (33% of the sample) reported unwanted physical advances, and 3 (17%) reported completed assault or rape. Fifteen women also completed a questionnaire about their experiences and the Iraq Readjustment Inventory (IRI) developed for this study. High reliability and high correlations with clinician ratings make the IRI a promising measure for future research. A comparison between those with and without MST revealed that those with MST had higher clinician ratings and IRI scores, suggesting greater difficulty with readjustment. And, while MST was significantly correlated with clinician ratings and readjustment scores, the variables "being injured" and "witnessing others injured or killed" were not. These preliminary data suggest that MST OIF/OEF women seeking mental health services is a critical factor for predicting symptoms and difficulty with readjustment to civilian life. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Toward a neuropsychological model of functional disability after mild traumatic brain injury.

Discusses investigations into the nature, causes, predictors, and treatment of functional disability after minor traumatic brain injury (TBI). Distinctions among minor head injury, mild traumatic brain injury, postconcussion syndrome, and posttraumatic stress disorder (PTSD) are clarified, and methodological and information-processing issues in minor TBI are identified. Four stages of clinical research related to minor TBI are described: identification of functional scenarios (1983–1987), development of educational materials (1985–1986), ongoing research (1988–1992), and clinical applications (1992 and continuing). Finally, a neuropsychological model of functional disability after minor TBI is presented, with implications for assessment and treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The impact of individual trauma symptoms of deployed soldiers on relationship satisfaction.

Research traditionally has focused on the development of individual symptoms in those who experienced trauma directly but has overlooked the interpersonal impact of trauma. The current study reports data from 45 male Army soldiers who recently returned from a military deployment to Iraq (Operation Iraqi Freedom) or Afghanistan (Operation Enduring Freedom) and their female spouses/partners. The results indicated that increased trauma symptoms, particularly sleep problems, dissociation, and severe sexual problems, in the soldiers significantly predicted lower marital/relationship satisfaction for both soldiers and their female partners. The results suggest that individual trauma symptoms negatively impact relationship satisfaction in military couples in which the husband has been exposed to war trauma. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Olfactory dysfunction, gambling task performance and intracranial lesions after traumatic brain injury.

Objective: To estimate the incidence of olfactory dysfunction across traumatic brain injury (TBI) severity and decision-making deficits with regard to intracranial lesions' location and laterality. Method: A 1-year prospective study including 115 participants (16–55 years) with mild, moderate, and severe TBI. The Brief Smell Identification Test was used 3 months postinjury with a follow-up testing of olfactory dysfunction at 1 year. The Iowa Gambling Task (IGT) and 3 tasks of the Delis–Kaplan Executive Function System were administered 3-months postinjury. MRI was performed 1-year postinjury and TBI severity groups were then divided with respect to frontal, fronto-temporal, diffuse, and no lesions. Results: The incidence of olfactory dysfunction was estimated to be 22.3% at 3 months and 13.5% at 1 year. No significant differences were found on olfactory dysfunction across TBI severity at either check. Anosmia was identified in 10% with severe TBI and 3% with mild TBI. Olfactory dysfunction was associated with verbal fluency tasks. Repeated-measures analysis of variance revealed no significant effect over blocks on IGT, and no main group or interaction effects regarding TBI severity, lesions' location, or laterality. IGT performance at 3-months postinjury was deficient in 83% of persons with intracranial lesions and 71% of those without lesions. Conclusions: Olfactory dysfunction is independent of TBI severity, showing improvements in one third of cases from 3- to 12-months postinjury. However, anosmia was related to TBI severity. There is evidence for marked decision-making deficits after TBI, all subgroups performed similarly and failed to develop an advantageous strategy over time. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of attempted thought suppression in acute stress disorder

The debate continues over whether a posttraumatic response occurs in those who have sustained a traumatic brain injury (TBI). The aim of this study was to investigate the incidence of acute stress disorder (ASD) in the mild TBI population. Patients who sustained a mild TBI after a motor vehicle accident (N = 79) were assessed for the presence of ASD. ASD was diagnosed in 13.9% of patients, and 5.1% were diagnosed with subsyndromal ASD. Dissociative, reexperiencing, and avoidance symptoms were found to have moderate to high predictive power. This study highlights the significant number of patients who experience an acute trauma response after TBI and raises the possibility that those with ASD denote those for whom an early intervention may prevent longer-term psychopathology. Diagnostic difficulties in defining ASD after TBI are discussed.     

Meal patterns in the SENECA study of nutrition and the elderly in Europe: assessment method and preliminary results on the role of the midday meal

This study compared the acute stress disorder and post-traumatic stress disorder (PTSD) symptom profiles in motor vehicle accident survivors who sustained a mild traumatic brain injury (MTBI) or no TBI. Consecutive adult patients who sustained a MTBI (n = 79) and no TBI (n = 92) were assessed for acute stress disorder within 1 month of their trauma and reassessed for PTSD (MTBI: n = 63; non-TBI; n = 72) 6-months post-trauma. Comparable rates of acute stress disorder and PTSD were reported in MTBI and non-TBI patients. Intrusive memories and fear and helplessness in response to the trauma were reported less frequently by MTBI than non-TBI patients at the acute phase. Six-months post-trauma fewer MTBI patients than non-TBI reported fear and helplessness in response to the trauma. These findings suggest that, whereas impaired consciousness at the time of a trauma may reduce the frequency of traumatic memories in the initial month post-trauma, MTBI does not result in a different profile of longer-term PTSD.     

The enigma of "hidden" traumatic brain injury

OBJECTIVE: To examine individuals with "hidden" traumatic brain injury (TBI), defined in this study as those who sustained a blow to the head, with altered mental status, and experienced a substantial number of the cognitive, behavioral, and emotional sequelae typically associated with brain injury but did not make the causal connection between the injury and its consequences. DESIGN: Comparison of four groups of individuals matched for age, gender, years of education, and duration of loss of consciousness. SETTING: This study of hidden TBI followed the identification of 143 individuals who, within a larger study of people with TBI who live in the community, identified themselves as "nondisabled" (they were to be part of the comparison sample) but who had experienced a blow to the head that left them at minimum dazed and confused. PARTICIPANTS: 21 of these 143 individuals also reported large numbers of symptoms (eg, headaches, memory problems) associated with TBI. This group (Hidden TBI-High Symptoms group) was compared to three other matched samples: one with known TBI (Known Mild TBI group) and one with no disability (No Disability group) (both of which were drawn from the larger study), and one group of individuals who identified themselves as having no disability but who had experienced a blow to the head that resulted in a few symptoms (Head Trauma-Low Symptoms group). MAIN OUTCOME MEASURES: All study participants were administered an interview that incorporated several existing instruments documenting levels of reported symptoms, emotional well-being/distress, and vocational/social handicaps. RESULTS: The Hidden TBI-High Symptoms group was found to be similar to the Known Mild TBI group in terms of the number and types of symptoms experienced, whereas the Head Trauma-Low Symptoms group was similar in this respect to the No Disability group. The two former groups also evidenced high levels of emotional distress, whereas the two latter groups did not. However, on measures of handicap, the Hidden TBI-High Symptoms and Head Trauma-Low Symptoms groups were similar to the No Disability group and dissimilar from the Known Mild TBI group in that the last group experienced vocational handicap, in particular, whereas the other groups did not. Conclusions: We conclude that hidden TBI occurs at a nontrivial level (7% of our nondisabled sample). Also, individuals with hidden TBI (with persistent symptoms), unlike those with known mild TBI, are likely to experience emotional distress but not vocational handicap following injury.     

Hitting home: Relationships between recent deployment, posttraumatic stress symptoms, and marital functioning for Army couples.

Using a sample of 434 couples consisting of active duty Army husbands married to civilian wives, relationships between recent deployment, current posttraumatic stress disorder (PTSD) symptoms, and a range of marital outcomes were investigated. Self-reports from both husbands and wives regarding relationship functioning did not differ between couples who were and were not separated due to deployment in the prior year. However, deployment in the past year was related to higher levels of current PTSD symptoms for husbands, and husbands' current PTSD symptoms were associated with lower marital satisfaction, confidence in the relationship, positive bonding between the spouses, parenting alliance, and dedication to the relationship for both husbands and wives. In addition, husbands' current PTSD symptoms were associated with higher levels of negative communication for both husbands and wives, and lower satisfaction with sacrifice for the relationship for husbands. Once positive bonding, negative communication, and parenting alliance were controlled, husband PTSD symptoms no longer significantly predicted marital satisfaction for wives. Husband PTSD symptoms continued to exert a significant, but reduced, unique effect on husband marital satisfaction once these variables were accounted for. The results provide greater understanding of the relationship of deployment/PTSD symptoms and marital functioning and suggest areas for intervention with military couples. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Neuropsychological test performance in soldiers with blast-related mild TBI.

This exploratory study was conducted to increase understanding of neuropsychological test performance in those with blast-related mild traumatic brain injury (mTBI). The two variables of interest for their impact on test performance were presence of mTBI symptoms and history of posttraumatic stress disorder (PTSD). Forty-five soldiers postblast mTBI, 27 with enduring mTBI symptoms and 18 without, completed a series of neuropsychological tests. Seventeen of the 45 met criteria for PTSD. The Paced Auditory Serial Addition Test (Frencham, Fox, & Mayberry, 2005; Spreen & Strauss, 1998) was the primary outcome measure. Two-sided, 2-sample t tests were used to compare scores between groups of interest. Presence of mTBI symptoms did not impact test performance. In addition, no significant differences between soldiers with and without PTSD were identified. Standard neuropsychological assessment may not increase understanding about impairment associated with mTBI symptoms. Further research in this area is indicated. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A diathesis-stress model of posttraumatic stress disorder: Ecological, biological, and residual stress pathways.

The symptoms captured within the contemporary diagnostic definition of posttraumatic stress disorder (PTSD) have been studied for more than 100 years. Yet, even with increasingly advanced discoveries regarding the etiology of PTSD, a comprehensive and up-to-date etiological model that incorporates both medical and psychological research has not been described and systematically studied. The diathesis-stress model proposed here consolidates existing medical and psychological research data on etiological factors associated with PTSD into 3 causal pathways: residual stress, ecological, and biological. In combination, these pathways illuminate how PTSD might develop and who might be at higher risk for developing the disorder. Research and treatment implications related to the diathesis-stress model are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pretreatment predictors of dropout from cognitive behavioral therapy for PTSD in Iraq and Afghanistan war veterans.

Cognitive–behavioral therapies (CBTs) can be effective treatments for posttraumatic stress disorder (PTSD) but their effectiveness is limited by high rates of premature dropout. Few studies have compared pretreatment characteristics of treatment completers and dropouts, and only one has examined these factors in Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) Veterans. This study analyzed archival clinical data from 117 OEF/OIF Veterans evaluated and treated through a Veterans Affairs PTSD clinic. High numbers dropped out of treatment (68%). Treatment dropouts (n = 79) and completers (n = 38) differed significantly on Minnesota Multiphasic Personality Inventory-2 (MMPI-2) scales, PTSD symptom severity, and age. Regression analyses identified one MMPI-2 scale, TRT (negative treatment indicators), and age as unique but modest predictors of dropout. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Community violence exposure, adverse childhood experiences, and posttraumatic distress among urban development workers.

The current study examines community violence exposure among 284 urban community development workers located in five U.S. cities. Adulthood exposure to community violence, history of adverse childhood experiences (ACEs), and current symptoms of posttraumatic distress (PTSD) were assessed to test the hypothesis that a personal history of ACEs moderates the relationship between community violence exposure and PTSD symptom severity. Seventy-five percent of urban development workers reported direct community violence victimization, 71% reported a history of at least one ACE, and 14% of the sample met probable diagnostic criteria for PTSD. A multiple regression analysis confirmed that ACEs and indirect adulthood community violence exposure were significantly positively related to the severity of PTSD symptoms. These variables accounted for a small amount of variance in PTSD. Direct exposure to community violence and the interaction between ACEs and community violence did not contribute significant variance to the model. The implications and limitations are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Health status, somatization, and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder

OBJECTIVE: A two-part study was conducted to examine the health status of Vietnam veterans with posttraumatic stress disorder (PTSD). In part 1, veterans with and without PTSD were compared on health behaviors and on self-reported and physician-rated health problems. Consistency of self-report with physician rating for health problems across the two groups was compared. In part 2, the association between health status and PTSD symptom severity, depression, somatization, and health behaviors in PTSD patients was evaluated. METHOD: In part 1, 276 combat veterans (225 with PTSD and 51 without PTSD) provided health status information, and medical records were reviewed. In part 2, 225 PTSD patients completed standardized PTSD severity, somatization, and depression measures. RESULTS: When analyses controlled for age, socioeconomic status, minority status, combat exposure, alcohol use, and pack-year history, veterans with PTSD reported and were rated as having a greater number of health problems than veterans without PTSD. Agreement between self-report and physician ratings for both groups ranged from low to moderate. Level of agreement between patient and physician was similar across groups. In the analysis of veterans with PTSD, somatization and PTSD symptom severity were significantly related to self-report of health problems, whereas only PTSD symptom severity was related to physician-rated health. Pack-year history was significantly related to self-reported health status in both groups. CONCLUSIONS: The presence and severity of PTSD in veterans were associated with greater physical health problems and conditions. Psychological variables (e.g., PTSD status, PTSD severity, somatization) and a behavioral variable (pack-year history) were related to health status.