Charity B. Breneman’s research while affiliated with Henry M Jackson Foundation and other places

Introduction During military service, sleep/wake patterns are often altered due to irregular or unpredictable operational schedules, non-conducive sleeping conditions (e.g., threatening environments), and/or time zone changes. The lack of consistency in sleep-wake patterns during military service may precipitate sleep disturbances post-military. This analysis examined the associations between objective sleep parameters and self-reported measures of health in veterans with Gulf War Illness (GWI). Methods Participants included 86 veterans with GWI (Mage= 54.1±7.1 y, 87.2% male) who wore an actigraphy monitor on their non-dominant wrist for 24 hours per day for seven consecutive days during a baseline assessment. Actigraphy data were manually scored using the manufacturer’s software to derive parameters of sleep timing, duration, and quality/continuity (time in bed [TIB], midpoint of sleep, total sleep time [TST], sleep efficiency [SE], wake after sleep onset [WASO], number of awakenings (NWAK), motor activity counts [MAC], and mean motor activity during TIB [AMEAN]). Participants completed several questionnaires: Patient Health Questionnaire (depression), Posttraumatic Symptom Checklist (PTSD), PROMIS® Adult Short Form v1.0 – Pain Interference, and Pittsburgh Sleep Quality Index. Associations between objective sleep parameters and self-reported measures of health were examined using Spearman’s rank correlations. Results Many of the participants (n=62; 72.1%) slept less than six hours per night with some sleeping less than five (n=36; 41.9%). Participants on average slept 5.3±1.6 h (SD), had 27.6±10.4 awakenings, 83.8±33.2 min of WASO, and a SE of 72.7±8.3% per night. Spearman correlations revealed that MAC and AMEAN were positively related to self-reported sleep quality (rho= 0.35, 0.33, respectively), depression (rho= 0.27, 0.30), PTSD (rho= 0.22, 0.28), and pain interference (rho= 0.26, 0.24; p< 0.05 for all). WASO and SE were also significantly related to subjective sleep quality (rho= 0.27, -0.31; p< 0.01). Conclusion Objective parameters of poor sleep quality and continuity (MAC, AMEAN, WASO, SE) were associated with poor self-reported sleep quality and greater symptoms of depression, PTSD, and pain interference in veterans with GWI. Future research will assess variability in sleep timing and profiles of sleep characteristics and their impact on functional health outcomes. Support (if any) Veterans Affairs, Office of Research and Development, Clinical Science Research and Development under Merit Review Grant #SPLD-013-13S.

Background The shift toward a patient-centered and whole health care model offers a promising approach for the management of symptoms among veterans with chronic multisymptom illness (CMI). A behavioral intervention aimed at reducing cognitive control dysregulation which is a component of impairments common among veterans with CMI may be helpful. Therefore, a pilot study was conducted to explore the feasibility, safety, and acceptability of a telehealth mental and physical (MAP) training intervention among veterans with CMI. Methods Utilizing a two-arm randomized trial, participants were either randomized to 8 weeks of a directed MAP training protocol (dMAP) that received weekly guidance via text messaging or 8 weeks of self-guided MAP training (sgMAP) which did not receive guidance aside from the intervention goals. The MAP intervention was the same for both groups except for the delivery and consisted of two MAP training sessions and one telephone health coaching session per week. The primary aim of the study was to evaluate the feasibility (e.g., recruitment, retention, and adherence rates; amount of missing data), safety (e.g., adverse events), and acceptability (e.g., satisfaction) of a telehealth MAP intervention. Results Out of 44 potentially eligible veterans, 26 were randomized to either the dMAP group (n = 13) or the sgMAP group (n = 13), resulting in a recruitment rate of 59% (26/44 patients). Two participants withdrew after randomization, resulting in 24 participants used for analyses. The retention rates at endpoint and 3-month follow-up were 79.2% (19/24; dMAP:sgMAP = 9:10) and 62.5% (15/24; dMAP:sgMAP = 7:8), respectively. Participants completed an average of 48.2% of the MAP sessions (7.7/16 sessions; dMAP:sgMAP = 7.9:7.5 sessions) and 82.8% of the health coaching sessions (6.6/8 sessions; dMAP:sgMAP = 7.2:6.2 sessions). Missing data was minimal, and no adverse events related to the study were reported. Acceptability was high as veterans were satisfied with the wearables and valued the health coaching support. Conclusions This pilot study provides insights into the feasibility of a large-scale randomized control trial that promotes meditation and physical activity to augment cognitive control to facilitate self-regulation. Future efforts should expand recruitment strategies and add internal data quality monitoring. Trial registration NCT04164667, retrospectively registered November 12, 2019, https://clinicaltrials.gov/study/NCT04164667

Objective The ImPACT Post-Concussion Symptom Scale (PCSS) is widely used to document post-concussion symptoms. This study investigated the structural patterns of PCSS using spectral co-clustering on data from U.S. diplomats and their families who served in Cuba and China, who reported experiencing Anomalous Health Incidents (AHIs). Method Clinicians at the University of Pennsylvania evaluated 65 individuals with potential AHI exposure (Median age-group = 35–45 years; 73.84% in Cuba; 49.23% females). PCSS feature scores were discretized into 4-level symptom severity expressions: none, mild, moderate, and severe. The preprocessed data were fit with spectral co-clustering model to extract optimal number of biclusters, by measuring scree plot with principal component analysis and Calinski-Harabasz (CH) score. Final model was also evaluated by CH score and a random label t-test to compare the significance of the clustering results. Results Overall, spectral co-clustering yielded two biclusters with CH score of 20.29 and random label t-test of p < 0.001, suggesting reasonable clustering quality. Biclustering identified two sets of interpretable PCSS symptom characteristics. Cluster centroids X and Y (IDs retracted) were estimated using Manhattan distance, summarizing symptom characteristics of each cluster. More precisely, centroid X represented mild to moderate symptom profiles (e.g., headache, dizziness, drowsiness, and nervousness), while centroidY represented a relative absence of symptoms, except for mild nervousness and emotionality. Conclusion The spectral co-clustering of PCSS reveals patterns of elevated symptoms in one cluster and minimal symptom burden in the other, similar to outcomes observed after mild TBI. These patterns can guide future research directions and ultimately improve patient outcomes in various medical contexts.

Objective To examine the association between actigraphy-based sleep parameters and neuropsychological health in Veterans with Gulf War Illness (GWI). Methods Objective sleep data was obtained from 85 GW Veterans (Mage = 54.2, 79% Male) using an actigraphy monitor (Phillips Respironics Actiwatch-2) worn for 24 hours/day for seven consecutive days. Actigraphy data was manually scored to define time in bed (TIB), and total sleep time (TST), wake after sleep onset (WASO), number of awakenings (NWAK), and motor activity counts (MAC) during sleep were derived using the device software. Participants completed a battery of questionnaires: Patient Health Questionnaire (PHQ-9), Posttraumatic Symptom Checklist (PCL-5), and Pittsburgh Sleep Quality Index (PSQI). Cognitive function was assessed using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Correlation analysis was conducted to discover associations between sleep parameters, self-reported measures, and cognitive function. Results MAC was positively correlated with elevated scores on PSQI (r = 0.35, p < 0.01), PHQ-9 (r = 0.26, p < 0.05), and PCL-5 (r = 0.26, p < 0.05), and negatively correlated with RBANS Total Index score (r = −0.27, p < 0.05). WASO was also positively correlated with PSQI scores (r = 0.29, p < 0.01). TIB and TST were positively correlated with age (r = 0.25, r = 0.28; all p < 0.05). Conclusion Objective parameters of disrupted sleep – nocturnal MAC and WASO – were associated with greater self-reported sleep disturbance. MAC was additionally correlated with increased self-reported symptoms of depression and PTSD, as well as lower performance on a measure of objective cognitive function. This study identifies aspects of sleep disruption as potential sleep intervention targets related to both mood and cognitive symptoms.

Objective This preliminary research examined symptom differences on the Neurobehavioral Symptom Inventory (NSI) and Post Traumatic Stress Disorder Checklist DSM-5 (PCL-5) for Explosive Ordnance Disposal (EOD) and Non-EOD Veterans receiving care at the Washington DC-War Related Illness and Injury Study Center (DC-WRIISC) Veterans Administration Medical Center. EOD Veterans have extensive repetitive blast-exposure histories, exposure to environmental toxins, and operated under high-stress/allostatic load throughout their careers. Therefore, we aim to understand how these unique occupational exposures influence long-term health outcomes for EOD Veterans. Method Eligible participants (N = 39, Mage = 51 years (SD = 9.5 years); EOD, n = 21) completed comprehensive interdisciplinary evaluations, self-report questionnaires, were combat deployed, and experienced traumatic brain injury. Total and component scores for the NSI (affective, cognitive, somatic, vestibular, and validity-10) and PCL-5 (criterion B-E symptom clusters), and total score for the Holmes-Rahe Life Stress Inventory, (HRLSI) were included. Results Regression analysis revealed overall NSI severity was positively correlated to PCL-5 total scores for both groups (EOD: F(1,19) = 25.30, p < 0.001); (Non-EOD: F(1,16) = 25.48, p < 0.001). However, significant differences in symptom presentation were noted between groups. NSI Cognitive scores were positively correlated with PCL-5 component scores for Criterion B for EOD (F(3,17) = 8.40, p < 0.001) and Criterion E for Non-EOD (F(3,14) = 24.32, p < 0.001). Post-hoc analysis suggested stress/resiliency may further contribute to group differences (HRLSI; Non-EOD, F(2,12) = 33.96, p < 0.001). Conclusion DC-WRIISC Veterans often present with cognitive concerns and complex medical presentations. Our findings suggest the presence of unique symptom presentations that may improve diagnostic formulation, treatment planning, and engagement. These findings highlight the need for continued research examining the influence occupational exposures have on Veteran health.

Objective The mood-congruency hypothesis suggests that an individual’s attentional resources align with their current emotional state. We investigated whether attention to emotion-eliciting stimuli, as measured by eye-tracking, could be associated with psychological outcomes in Vietnam Veterans. Method We enrolled 117 Vietnam-theater Veterans (MeanAge = 69.5 years; SD = 3.4 years) and measured time to first fixation (TFF) and total fixation duration (TFD) while participants viewed emotional human faces (HAPPY, SAD, ANGRY) paired with neutral expressions (NEUTRAL). Participants completed 60 trials for different emotion-neutral pairs and completed self-report measures of posttraumatic stress disorder (PTSD) using the PTSD Checklist-5 (PCL-5) and posttraumatic growth (PTG) using the PTG Inventory. Linear fixed-effects models (MATLAB, R2023a) were employed to examine self-report measures, focusing on attentional bias toward emotional faces in Model-1, and considering both emotional and neutral faces in Model-2. Results In Model-1, PTG was negatively related to TFF on HAPPY (p < 0.05), but positively related to TFD on SAD (p < 0.001). These findings align with PTG theory, suggesting that struggling with negative emotions may stimulate PTG. Moreover, PTSD symptom severity was negatively associated with TFF on HAPPY (p < 0.05) and positively associated with TFF on NEUTRAL (p < 0.01). In Model-2, greater PTG was associated with longer TFD on both HAPPY (p < 0.05) and NEUTRAL (p < 0.001). Interestingly, greater PTSD symptom severity was associated with longer TFD on HAPPY (p < 0.05) and NEUTRAL (p < 0.001) stimuli. Conclusions Our findings highlight the complex relationship between attentional allocation, emotional stimuli, and psychological outcomes in Vietnam Veterans. Future research will explore these dynamics and the clinical utility of eye tracking.

Introduction Military exposures may present a cumulative load and increased individual susceptibility to negative health outcomes. Currently, there are no comprehensive and validated environmental exposure assessment tools covering the full spectrum of occupational and environmental exposures for Veterans. The Veterans Affairs (VA) War Related Illness and Injury Study Center in Washington, DC, developed the Veteran Military Occupational and Environmental Exposure Assessment Tool (VMOAT) to establish a structured, comprehensive self-report tool that captures military and non-military occupational and environmental exposures. The VMOAT is clinically insightful, modular, and flexible for adding novel exposures, meeting the needs of modern evolving threats and exposures in both clinical and research settings. This manuscript reviews the ongoing development and validation plans for the VMOAT. Materials and Methods The VMOAT is a self-reported structured questionnaire, and VMOAT 1.0 was developed to cover an individual’s 3 life phases (pre, during, post-military service); 5 exposure domains (chemical, physical, biological, injuries including ergonomic, and psychological stress exposures, plus military preventive health measures); and 64 specific exposures nested within exposure categories. VMOAT 1.0 addresses exposure dose (frequency, duration, proximity, route), and can be administered online via VA approved Qualtrics survey software. VMOAT 1.0 to 2.0 updates began in December 2022 with changes focused on readability, streamlining the exposure history, refining the exposure metrics, and improving the skip logic embedded within the survey design. Results The initial VMOAT 1.0 development included face and construct validation with expert internal and external academic and military collaborators, undergoing an iterative 5-cycle review as well as sample testing among a small group of Veterans. The VMOAT 1.0 was used in Institutional Review Board (IRB)-approved longitudinal study, which has been examined preliminarily to compare the VMOAT 1.0 with other exposure assessments and to compare responses of Explosive Ordnance Disposal Veterans, a high occupational exposure cohort, to non-Explosive Ordnance Disposal Veterans. Ongoing VMOAT 2.0 updates will include integration of experiences from piloting the VMOAT 1.0 as well as additional face and content validation and survey cognitive testing with Veterans. VMOAT 2.0 data will improve the development of exposure-informed models using composite survey data to create scored- and scale-based exposure metrics for specific exposures and exposure domains. These data will highlight the effectiveness of the VMOAT as a structured comprehensive occupational and environmental exposure assessment instrument. Conclusions VMOAT development supports the 2022 Promise to Address Comprehensive Toxics Act and fits into the existing VA exposure assessment approach as a standardized, comprehensive self-reported exposure assessment tool. It can be utilized as a stand-alone instrument or supplemented by clinician interviews in research or specialty evaluation programs. The collected VMOAT self-report information on military occupational and environmental exposures will allow direct evaluation with objective measures of exposure and health outcomes. These data outcomes have a high potential to guide the DoD and VA environmental exposure risk mitigation and risk communication efforts.

Objective: This analysis explored relationships between mental health symptoms and conditions and cognitive function in a cohort of Vietnam-era women veterans from the Health of Vietnam Era Veteran Women's Study (HealthViEWS). Methods: Vietnam-era women veterans completed a mail survey assessing self-reported symptom severity of posttraumatic stress disorder (PTSD) and depression. A telephone-based structured interview assessed mental health conditions and cognitive function (telephone interview for cognitive status [TICS]). Participants were categorized using a TICS threshold of ≤29 to designate possible cognitive impairment versus nonimpaired. Separate logistic regression models were used to determine associations between possible cognitive impairment and each self-reported and interviewer-rated assessment of PTSD and depression while adjusting for age, education, race, marital status, and wartime service location. Results: The sample consisted of 4,077 women veterans who were ≥60 years old and completed the TICS. Of these women, 7.20% were categorized with possible cognitive impairment. Logistic regression models indicated that self-reported PTSD and depression symptom severity were each significantly associated with higher odds of possible cognitive impairment (adjusted odds ratios [aOR]: 1.03 [95% confidence interval [CI]: 1.02-1.04] and 1.07 [95% CI: 1.04-1.09], respectively). Women veterans with a probable diagnosis of depression had higher odds of possible cognitive impairment compared to those without depression (aOR: 1.61 [95% CI: 1.07-2.42]). No association was found for probable diagnosis of PTSD. Conclusions: Although further examination remains necessary, results suggest that Vietnam-era women veterans with self-reported PTSD and depression symptom severity or a probable diagnosis of depression may benefit from screening of cognitive function to inform clinical care.

Military Veterans often experience a range of sleep disorders that significantly impact their physical and psychological wellbeing. Current study describes prevalence and age differences (≥65 to ≤74yrs; n =193)) vs. (≥75 to ≤ 90yrs; n =157) across insomnia, obstructive sleep apnea (OSA), nightmare disorder (ND), and posttraumatic stress disorder (PTSD). Vietnam Veterans (N = 350; AgeMean= 74.4 [SD= 3.6]) completed a survey (online or paper) of their sleep experiences and PTSD as part of a cross-sectional study. Veterans were mostly White (95%), male (97.7%), from the Army (55%), with some or two-year college (43%), and currently married (76%). Insomnia was screened positive in 27.7% of the Veterans, OSA in 58.6%, ND in 5.7%, and PTSD in 18.6%. There were significant mean differences in insomnia and PTSD across age groups (t(348) = 2.43, p = .016) and (t(348) = 2.06, p =.04), respectively, with younger age group showing higher insomnia, and PTSD. There were no significant mean differences in OSA and ND. Pearson correlation analyses yielded important associations. Insomnia was significantly positively correlated with PTSD (r= .60), OSA (r= .33), and ND (r= .51). PTSD was significantly positively correlated with OSA (r= .30) and ND (r= .67). ND was significantly positively correlated with OSA (r= .22). There were no significant differences in the associations across the two age groups. Recognizing and addressing various sleep disorders and comorbid PTSD are crucial to improving the quality of life of Veterans. Results emphasize need for comprehensive assessment of sleep disorders and PTSD among Veterans.