Understanding Sequelae of Injury Mechanisms and Mild Traumatic Brain Injury Incurred during the Conflicts in Iraq and Afghanistan: Persistent Postconcussive Symptoms and Posttraumatic Stress Disorder

War-Related Illness and Injury Study Center, Washington DC VA Medical Center, Washington, DC 20422, USA.
American journal of epidemiology (Impact Factor: 5.23). 07/2008; 167(12):1446-52. DOI: 10.1093/aje/kwn068
Source: PubMed


A cross-sectional study of military personnel following deployment to conflicts in Iraq or Afghanistan ascertained histories of combat theater injury mechanisms and mild traumatic brain injury (TBI) and current prevalence of posttraumatic stress disorder (PTSD) and postconcussive symptoms. Associations among injuries, PTSD, and postconcussive symptoms were explored. In February 2005, a postal survey was sent to Iraq/Afghanistan veterans who had left combat theaters by September 2004 and lived in Maryland; Washington, DC; northern Virginia; and eastern West Virginia. Immediate neurologic symptoms postinjury were used to identify mild TBI. Adjusted prevalence ratios and 95% confidence intervals were computed by using Poisson regression. About 12% of 2,235 respondents reported a history consistent with mild TBI, and 11% screened positive for PTSD. Mild TBI history was common among veterans injured by bullets/shrapnel, blasts, motor vehicle crashes, air/water transport, and falls. Factors associated with PTSD included reporting multiple injury mechanisms (prevalence ratio = 3.71 for three or more mechanisms, 95% confidence interval: 2.23, 6.19) and combat mild TBI (prevalence ratio = 2.37, 95% confidence interval: 1.72, 3.28). The strongest factor associated with postconcussive symptoms was PTSD, even after overlapping symptoms were removed from the PTSD score (prevalence ratio = 3.79, 95% confidence interval: 2.57, 5.59).


Available from: Elisa R Braver, Jan 16, 2014
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    • "The symptoms shared among mild TBI, PTSD and depression include, for example , headache, insomnia, fatigue, irritability, cognitive dysfunction , and chronic pain (Hoge et al. 2008; Iverson 2005), all which can be considered independently existing clinical processes or as components of a complex syndrome (Scholten et al. 2012). These symptoms and conditions also frequently co-occur, which further complicates clinical understanding and may ultimately impede treatment and recovery (Carlson et al. 2010, 2011; Hill et al. 2009; Schneiderman et al. 2008; Vanderploeg et al. 2012; Vanderploeg 2007; Walker et al. 2012). Despite the complex comorbidity of these conditions, the current clinical practice guideline for treatment of mild TBI (concussion) calls for single disease focused treatment and symptom-based management (Management of Concussion/ mTBI Working Group 2009). "
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    ABSTRACT: U. S. veterans of Iraq and Afghanistan are known to have a high prevalence of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and depression, which are often comorbid and share many symptoms. Attempts to describe this cohort by single diagnoses have limited our understanding of the complex nature of this population. The objective of this study was to identify subgroups of Iraq and Afghanistan veterans (IAVs) with distinct compositions of symptoms associated with TBI, PTSD, and depression. Our cross-sectional, observational study included 303,716 IAVs who received care in the Veterans Health Administration in 2010-2011. Symptoms and conditions were defined using International Classification of Diseases, Ninth Revision codes and symptom-clusters were identified using latent class analysis. We identified seven classes with distinct symptom compositions. One class had low probability of any condition and low health care utilization (HCU) (48 %). Other classes were characterized by high probabilities of mental health comorbidities (14 %); chronic pain and sleep disturbance (20 %); headaches and memory problems (6 %); and auditory problems (2.5 %). Another class had mental health comorbidities and chronic pain (7 %), and the last had high probabilities of most symptoms examined (3 %). These last two classes had the highest likelihood of TBI, PTSD, and depression and were identified as high healthcare utilizers. There are subgroups of IAVs with distinct clusters of symptom that are meaningfully associated with TBI, PTSD, depression, and HCU. Additional studies examining these veteran subgroups could improve our understanding of this complex comorbid patient population.
    Brain Imaging and Behavior 05/2015; 9(3). DOI:10.1007/s11682-015-9402-8 · 4.60 Impact Factor
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    • "In this study, we determined that DES scores (13.3) were higher among healthy soldiers than among the normal population. This observation is consistent with the findings of previous studies (Ross et al., 1988). Our study results also demonstrated that the levels of dissociation of soldiers with PTSD who experienced traumatic events were higher than those of soldiers without PTSD who experienced similar traumatic events. "
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    ABSTRACT: Dissociation is a disruption of and/or discontinuity in the normal, subjective integration of one or more aspects of psychological functioning, including memory, identity, consciousness, perception, and motor control. A limited number of studies investigated combat-related dissociation. The primary aim of this study was to evaluate the relationship between dissociative symptoms and combat-related trauma. This study included 184 individuals, including 84 patients who were exposed to combat and diagnosed with posttraumatic stress disorder (PTSD) (Group I), 50 subjects who were exposed to combat but were not diagnosed with PTSD (Group II), and 50 healthy subjects without combat exposure (Group III). The participants were evaluated using the Dissociative Experiences Scale (DES) to determine their total and sub-factor (i.e., amnesia, depersonalization/derealization, and absorption) dissociative symptom levels. In addition, Group I and Group II were compared with respect to the relationship between physical injury and DES scores. The mean DES scores (i.e., total and sub-factors) of Group I were higher than those of Group II (p<0.001), and Group II's mean DES scores (i.e., total and sub-factors) were higher than those of Group III (p<0.001). Similarly, the number of subjects with high total DES scores (i.e.,>30) was highest in Group I, followed by Group II and Group III. When we compared combat-exposed subjects with high total DES scores, Group I had higher scores than Group II. In contrast, no relationship between the presence of bodily injury and total DES scores could be demonstrated. In addition, our results demonstrated that high depersonalization/derealization factor scores were correlated with bodily injury in PTSD patients. A similar relationship was found between high absorption factor scores and bodily injury for Group II. Our results demonstrated that the level of dissociation was significantly higher in subjects with combat-related PTSD than in subjects without combat-related PTSD. In addition, combat-exposed subjects without PTSD also had higher dissociation levels than healthy subjects without combat experience.
    European Journal of Psychotraumatology 04/2015; 6:26657. DOI:10.3402/ejpt.v6.26657 · 2.40 Impact Factor
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    • "The nonspecificity of PCS poses particular diagnostic difficulty in veterans who sustained mTBI during deployment, given the high rate of comorbid psychiatric conditions in this population [Fear et al., 2009; Hoge et al., 2008]. Despite evidence that some symptoms in the chronic stage may be associated with mTBI-related neuropathology [Bigler and Maxwell, 2012], recent behavioral studies of veterans with self-reported mTBI suggest that PCS symptoms are linked primarily to mental health symptoms [Belanger et al., 2010; Hoge et al., 2008; Lippa et al., 2010; Schneiderman et al., 2008; Verfaellie et al., 2013]. However, it is possible that in vivo characterization of traumatic axonal injury, as is possible with diffusion tensor imaging (DTI), may provide a more sensitive means to assess whether chronic PCS relate to neuropathology associated with mTBI. "
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    ABSTRACT: Blast-related mild traumatic brain injury (mTBI) is a common injury among Iraq and Afghanistan military veterans due to the frequent use of improvised explosive devices. A significant minority of individuals with mTBI report chronic postconcussion symptoms (PCS), which include physical, emotional, and cognitive complaints. However, chronic PCS are non-specific and are also associated with mental health disorders such as posttraumatic stress disorder (PTSD). Identifying the mechanisms that contribute to chronic PCS is particularly challenging in blast-related mTBI, where the incidence of co-morbid PTSD is high. In this study, we examined whether blast-related mTBI is associated with diffuse white matter changes, and whether these neural changes are associated with chronic PCS. Ninety OEF/OIF Veterans were assigned to one of three groups including a blast-exposed no-TBI group, a blast-related mTBI without loss of consciousness (LOC) group (mTBI-LOC), and a blast-related mTBI with LOC group (mTBI+LOC). PCS were measured with the Rivermead Postconcussion Questionnaire. Results showed that participants in the mTBI+LOC group had more spatially heterogeneous white matter abnormalities than those in the no-TBI group. These white matter abnormalities were significantly associated with physical PCS severity even after accounting for PTSD symptoms, but not with cognitive or emotional PCS severity. A mediation analysis revealed that mTBI+LOC significantly influenced physical PCS severity through its effect on white matter integrity. These results suggest that white matter abnormalities are associated with chronic PCS independent of PTSD symptom severity and that these abnormalities are an important mechanism explaining the relationship between mTBI and chronic physical PCS.
    Human Brain Mapping 04/2015; in press. DOI:10.1002/hbm.23022 · 5.97 Impact Factor
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