Complicating Factors Associated with Mild Traumatic Brain Injury: Impact on Pain and Posttraumatic Stress Disorder Treatment

The nature of combat in Iraq and Afghanistan has resulted in high rates of comorbidity among chronic pain, posttraumatic stress disorder (PTSD), and mild traumatic brain injury (mTBI) in Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). Although separate evidence-based psychological treatments have been developed for chronic pain and PTSD, far less is known about how to approach treatment when these conditions co-occur, and especially when they co-occur with mTBI. To provide the best care possible for OEF/OIF Veterans, clinicians need to have a clearer understanding of how to identify these conditions, ways in which these conditions may interact with one another, and ways in which existing evidence-based treatments can be modified to meet the needs of individuals with mTBI. The purpose of the present paper is to review the comorbidity of pain, PTSD, and mTBI in OEF/OIF Veterans, and provide recommendations to clinicians who provide care to Veterans with these conditions. First, we will begin with an overview of the presentation, symptomatology, and treatment of chronic pain and PTSD. The challenges associated with mTBI in OEF/OIF Veterans will be reported and data will be presented on the comorbidity among all three of these conditions in OEF/OIF Veterans. Second, we will present recommendations for providing psychological treatment for chronic pain and PTSD when comorbid with mTBI. Finally, the paper concludes with a discussion of the need for a multidisciplinary treatment approach, as well as a call for continued research to further refine existing treatments for these conditions.     

Cognitive Sequelae of Blast-Induced Traumatic Brain Injury: Recovery and Rehabilitation

Blast-related traumatic brain injury (bTBI) poses a significant concern for military personnel engaged in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). Given the highly stressful context in which such injury occurs, psychiatric comorbidities are common. This paper provides an overview of mild bTBI and discusses the cognitive sequelae and course of recovery typical of mild TBI (mTBI). Complicating factors that arise in the context of co-morbid posttraumatic stress disorder (PTSD) are considered with regard to diagnosis and treatment. Relatively few studies have evaluated the efficacy of cognitive rehabilitation in civilian mTBI, but we discuss cognitive training approaches that hold promise for addressing mild impairments in executive function and memory, akin to those seen in OEF/OIF veterans with bTBI and PTSD. Further research is needed to address the patient and environmental characteristics associated with optimal treatment outcome.     

An examination of the roles of trauma exposure and posttraumatic stress disorder on emotion regulation strategies of Operation Iraqi Freedom,Operation Enduring Freedom,and Operation New Dawn veterans

Theories of posttraumatic stress disorder (PTSD) implicate emotional processes, including difficulties utilizing adaptive emotion regulation strategies, as critical to the etiology and maintenance of PTSD. Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn (OIF/OEF/OND) veterans report high levels of combat exposure and PTSD. We aimed to extend findings suggesting that emotion regulation difficulties are a function of PTSD, rather than combat trauma exposure or common comorbidities, to OIF/OEF/OND veterans, in order to inform models of PTSD risk and recovery that can be applied to returning veterans. We tested differences in emotion regulation, measured with the Difficulties in Emotion Regulation Scale and Emotion Regulation Questionnaire, among trauma-exposed veterans with (n = 24) or without PTSD (n = 22) and healthy civilian comparison participants (n = 27) using multivariate analyses of covariance, adjusting for major depressive disorder, anxiety disorders, and demographic variables (age, sex, and ethnicity). Veterans with PTSD reported more use of expressive suppression and more difficulties with emotion regulation than veterans without PTSD and healthy comparison participants. Groups did not differ on cognitive reappraisal. Findings suggest the key role of PTSD above and beyond trauma exposure, depression, and anxiety in specific aspects of emotion dysregulation among OIF/OEF/OND veterans. Interventions that help veterans expand and diversify their emotion regulation skills may serve as helpful adjunctive treatments for PTSD among OIF/OEF/OND veterans.     

Family support,family stress,and suicidal ideation in a combat-exposed sample of Operation Enduring Freedom/Operation Iraqi Freedom veterans

Background and Objectives: Deployment-related risk factors for suicidal ideation among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans have received a great deal of attention. Studies show that mental health symptoms mediate the association between most deployment stressors and suicidal ideation; however, family-related factors during deployment are largely unexplored. We examined posttraumatic stress disorder (PTSD) and depression symptoms as mediators of the associations between deployment family support and stress and post-deployment suicidal ideation in combat-exposed OEF/OIF veterans. Design: National cross-sectional mail survey. Methods: 1046 veterans responded to the survey. The sample for this study was 978 veterans who experienced combat. Regression-based path analyses were conducted. Results: Family support and stress had direct associations with suicidal ideation. When PTSD and depression symptoms were examined as mediators of these associations, results revealed significant indirect paths through these symptoms. Conclusions: This study contributes to the literature on suicidal ideation risk factors among OEF/OIF veterans. Deployment family support and family stress are associated with suicidal ideation; however these associations occur primarily through mental health symptomatology, consistent with findings observed for other deployment factors. This research supports ongoing efforts to treat mental health symptomatology as a means of suicide prevention.     

Sexuality among wounded veterans of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND): Implications for rehabilitation psychologists

OBJECTIVE: The sexual lives of returning Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans have only been discussed minimally in the psychological literature. Given the nature of military social and cultural contexts, the potential for exposure to combat-related stressors that may lead to posttraumatic stress disorder (PTSD), and the risk of traumatic brain injury secondary to physical injury, the potential for significant psychological and relational ramifications exists. This article focuses on the intimate relationships and sexuality of returning OIF/OEF/OND veterans within the context of their personal cultural variables and the diverse experience of being a part of military life. CONCLUSIONS: Culturally competent assessment and evidenced-based treatment approaches are highlighted to offer clinicians initial strategies to begin treatment of sexuality issues within the returning Veteran population. These clinical tools are discussed within a positive psychology approach that emphasizes healthy sexuality as a part of overall satisfactory quality of life.     

Examining Spouse/Partner Presence as a Moderator in the Relationship Between Mental Health Symptoms and Alcohol Use in OEF/OIF Veterans

Veterans from the conflicts in Afghanistan (Operation Enduring Freedom; OEF) and Iraq (Operation Iraqi Freedom; OIF) have reported elevated rates of alcohol consumption, and greater depression and posttraumatic stress disorder (PTSD) symptoms are associated with increased alcohol use. Presence of a spouse/partner, which has been associated with reduced drinking, may buffer the relationship between mental health symptoms and alcohol consumption. To examine this hypothesis, the current study utilized baseline survey data from OEF/OIF veterans (N = 325) enrolled in a brief alcohol intervention. Spouse/partner presence moderated the relationship between depression symptoms and alcohol consumption such that depression was positively associated with drinking for veterans without a spouse/partner. Exploratory analyses indicated that the relationship between depression and alcohol use may be particularly salient for veterans without a spouse/partner and a lower number of deployments. Spouse/partner presence did not moderate the relationship between PTSD symptoms and alcohol consumption. Implications of the findings are discussed.     

Predictors of PTSD Improvement with Cognitive/Exposure Group Interventions in Operation Enduring Freedom/Operation Iraqi Freedom Female Veterans

Predictors of successful PTSD outcome have been examined through individually delivered treatments. We examined predictors using a group protocol with cognitive, exposure, and skills modules. Assessments included self-report and interview (CAPS, SCID-I/II) measures at baseline, post, and six months; treatment was a 16-week, three-member group for 32 OEF/OIF women Veterans. A regression analysis showed major depressive disorder and no baseline psychiatric medication predicted PTSD improvement. PTSD improvement predicted fewer outpatient medical visits at follow-up. The results supported past research and challenged other findings (e.g., sexual assault predicts less improvement). An additional unique contribution was examining predictors in a group treatment format.     

Web-Based Intervention for Returning Veterans with Symptoms of Posttraumatic Stress Disorder and Risky Alcohol Use

A substantial number of military personnel who have served in Iraq (Operation Iraqi Freedom; OIF) and Afghanistan (Operating Enduring Freedom; OEF) develop symptoms of posttraumatic stress disorder (PTSD) in response to their military experiences and many of these same individuals will drink in a risky or problematic manner following deployment. If left untreated, PTSD symptoms and alcohol problems can become chronic and have a significant, negative impact on the lives of veterans, their families and communities. Further, OIF and OEF service members are often reluctant to seek treatment for mental health symptoms or alcohol problems secondary to stigma. In order to reach this population it is essential that new strategies and venues for delivering evidence-based care are explored. Web-based interventions are uniquely suited to this cohort of veterans in that they have the potential to reach a significant number of veterans who commonly use the Web and who might not otherwise receive care. This article will review the prevalence of PTSD and alcohol problems among OIF and OEF veterans, common barriers they experience with accessing care in traditional mental health settings, and what is known about the effectiveness of Web-based approaches for PTSD and alcohol problems. It also describes the components of a new Web-based intervention, developed by the authors, that uses motivational enhancement and cognitive-behavioral strategies to intervene with returning veterans who report PTSD symptoms and problem drinking. Recommendations for future directions in working with returning veterans with PTSD and alcohol problems will be offered.     

Predictors of Suicidal Ideation in a Gender‐Stratified Sample of OEF/OIF Veterans

There is a growing concern about suicide among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans. We examined the role of postdeployment mental health in associations between deployment stressors and postdeployment suicidal ideation (SI) in a national sample of 2,321 female and male OEF/OIF veterans. Data were obtained via survey, and path analysis was used. For women and men, mental health symptoms largely accounted for associations between deployment stressors and SI; however, they only partly accounted for the sexual harassment and SI association among women. These findings enhance the understanding of the mental health profile of OEF/OIF veterans.     

Relation between coping and posttrauma cognitions on PTSD in a combat-trauma population

Individual differences in cognitive processes and coping behaviors play a role in the development and maintenance of posttraumatic stress disorder (PTSD). Given the large numbers of combat-exposed service members returning from the Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) conflicts, exploring individual differences in cognitive-affective processes is important for informing our understanding of PTSD etiology and early intervention in military samples. The present study examined the unique main and interactive effects of negative posttrauma cognitions (i.e., negative beliefs about self [NS], the world [NW], and self-blame [SB]) and coping strategies (i.e., positive behavioral, positive cognitive, avoidant coping, and social and emotional coping) on PTSD diagnosis within 155 (M_age = 30.7, SD = 4.48) OEF/OIF/OND combat trauma-exposed Veterans recruited from an ongoing study examining the effects of combat trauma and stress reactivity. In the final, stepwise logistic regression analysis, avoidant coping, but no other coping strategy, was significantly positively related to PTSD diagnosis in the initial step. Higher levels of NS, but not NW, were significantly associated with having a PTSD diagnosis, whereas SB was associated with decreased likelihood of PTSD, above and beyond coping strategies. A significant interaction effect was found between NS and positive cognitive coping, such that greater positive cognitive coping weakened the relationship between NS and PTSD. Examining and addressing coping behaviors and negative thoughts of self jointly may benefit assessment and intervention approaches in a combat-trauma population.     

Systemic vulnerabilities to suicide among veterans from the Iraq and Afghanistan Conflicts: review of case reports from a National Veterans Affairs Database

While suicide among recently returned veterans is of great concern, it is a relatively rare occurrence within individual hospitals and clinics. Root cause analysis (RCA) generates a detailed case report that can be used to identify system-based vulnerabilities following an adverse event. Review of a national database of RCA reports may identify common vulnerabilities and assist in the development of more robust prevention strategies. Our objective was to identify and compare common themes among reports of suicide among veterans of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) in the Veterans Affairs system. Common themes among root causes of suicide as identified in RCA reports were collected and compared as the primary outcome--systematic vulnerabilities. Actions recommended within the reports were coded as the secondary outcome--prevention strategies. Fifty-one RCA reports of OIF/OEF suicides were identified by our search. Coding generated 16 common categories among 132 root causes, and 13 categories among 108 recommended actions. Assessment of suicidal risk, coordination of care, timely access to care, and communication among providers were the most common root causes. Actions identified by RCA teams to reduce suicide included improving referral processes, staff education in suicide assessment, and follow-up with suicidal veterans. Review of multiple RCA reports can identify organizational vulnerabilities detected at the local level that may be applicable system wide. Attention to improving suicide assessment, coordination of care, and timely access may have the largest impact on reducing suicide among OIF/OEF veterans.     

Predeployment, deployment, and postdeployment risk factors for posttraumatic stress symptomatology in female and male OEF/OIF veterans

[Correction Notice: An erratum for this article was reported in Vol 120(4) of Journal of Abnormal Psychology (see record 2011-19996-001). In the article there was an error in the affiliation bylines for Rani Elwy and Susan Eisen. Their affiliations should have been listed as Edith Nourse Rogers Memorial Veterans Hospital and Department of Health Policy and Management, Boston University School of Public Health.] Prior research on risk factors for posttraumatic stress symptomatology (PTSS) in war-exposed Veterans has revealed both direct and indirect mechanisms of risk that span predeployment, deployment, and postdeployment timeframes. The aims of the present study were to identify the mechanisms through which previously documented risk factors contribute to PTSS in a national sample of 579 female and male Veterans deployed to Afghanistan for Operation Enduring Freedom (OEF) or to Iraq for Operation Iraqi Freedom (OIF), as well as to examine the extent to which results mirror associations observed among Vietnam Veterans (King, King, Foy, Keane, & Fairbank, 1999). Consistent with conservation of resources (COR) theory (Hobfoll, 1989, 2001), findings indicated that PTSS is accounted for by multiple chains of risk, many originating in predeployment experiences that place Veterans at risk for additional stress exposure, and foretell difficulty accessing resources in the face of subsequent stressors. Importantly, the majority of previously documented mechanisms were replicated in this study, suggesting key pathways through which risk factors may contribute to PTSS across different Veteran populations. Results also revealed a number of novel risk mechanisms for OEF/OIF female Veterans, particularly with respect to the role of deployment family relationships in risk for PTSS.     

Interplay Between Service Era,PTSD Symptom Expression,and Treatment Completion Among Veterans

The current veteran population has grown significantly as a result of 3 recent major conflicts: Vietnam, Persian Gulf War, and Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF). Despite a strong presence in VA PTSD specialty clinics nationwide, little is known about how these veteran cohort groups differ in PTSD symptom presentation. Additionally, it is unclear how variations in PTSD symptom presentation may in turn affect treatment adherence and completion. Understanding factors associated with treatment dropout from exposure-based therapy for PTSD is an important area of study, as individuals who drop out of treatment are likely to remain symptomatic and experience significant impairment across a number of psychosocial domains. The present study examined the relationship between service theater affiliation and pretreatment symptom expression as predictors of treatment completion in a sample of 164 veterans. Although treatment completion did not differ by service era, study data revealed statistically significant differences in initial PTSD symptom expression. Implications of the results and future directions are discussed.     

The Importance of Group Cohesion in Inpatient Treatment of Combat-Related PTSD

Abstract

Post-traumatic stress disorder (PTSD) is the most widespread mental illness resulting from exposure to combat, necessitating an increase in the provision of group therapy. This pilot study examined the efficacy of, and treatment outcome predictors associated with, group inpatient treatment of combat-related PTSD. Participants included 38 active duty military personnel deployed during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), diagnosed with PTSD, and consecutive admissions to an inpatient PTSD treatment facility. A paired samples t-test revealed significant change in symptom severity and global functioning between pre- and post-treatment. Multiple regression analyses supported the predictive utility of baseline symptomatology and group cohesion (> 50% of the variance in treatment outcome), highlighting the importance of group cohesion in the efficacy of group treatment for combat-related PTSD.     

Examining Relationships Among Ethnicity,PTSD, Life Functioning,and Comorbidity in Female OEF/OIF Veterans

There is much literature on posttraumatic stress disorder (PTSD) and male combat veterans, but little on PTSD by gender and ethnicity among women combat veterans. We examine ethnic differences in PTSD and comorbid disorders among 37 Hispanic, 27 White, and 15 Native female Operaton Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) combat veterans. Participants completed the Clinician-Administered PTSD Scale (CAPS), the Structured Clinical Interview for DSM-IV, Axis I (SCID-Axis I and II), Life Events Checklist (LEC), Military Stress Exposure Questionnaire (MSEQ), and the Medical Outcomes Study Short Form-36 (SF-36). Hispanics differed from Whites in having less education, more trauma exposure, higher levels of PTSD, mood disorder comorbidity, and poorer physical and emotional functioning. Natives differed from Whites with more trauma exposure, higher levels of PTSD, poorer emotional functioning, and higher rates of Cluster B PDs.     

Military Veterans' Experiences with Suicidal Ideation: Implications for Intervention and Prevention

We sought to understand Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans' experiences with suicidal ideation. Semi‐structured interviews with 34 OEF/OIF veterans addressed circumstances leading up to disclosure of suicidal ideation during brief clinical assessments. We used an iterative, inductive and deductive thematic analysis approach. Results revealed three pervasive, persistent domains that reinforce the uniqueness of veteran suicidal thoughts: military culture, difficult deployment experiences, and postdeployment adjustment challenges. Within postdeployment, we identified four themes that serve as intervention targets: adjusting to civilian culture, changes to sense of self, feeling overwhelmed by stressors, and lacking life purpose or meaning.     

Virtual reality goes to war: a brief review of the future of military behavioral healthcare

Numerous reports indicate that the incidence of posttraumatic stress disorder (PTSD) in returning OEF/OIF military personnel is creating a significant healthcare challenge. These findings have served to motivate research on how to better develop and disseminate evidence-based treatments for PTSD. Virtual Reality delivered exposure therapy for PTSD has been previously used with reports of positive outcomes. This article details how virtual reality applications are being designed and implemented across various points in the military deployment cycle to prevent, identify and treat combat-related PTSD in OIF/OEF Service Members and Veterans. The summarized projects in these areas have been developed at the University of Southern California Institute for Creative Technologies, a U.S. Army University Affiliated Research Center, and this paper will detail efforts to use virtual reality to deliver exposure therapy, assess PTSD and cognitive function and provide stress resilience training prior to deployment.     

Neuropsychological Sequelae of PTSD and TBI Following War Deployment among OEF/OIF Veterans

Posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are highly prevalent among Veterans of the conflicts in Iraq and Afghanistan. These conditions are associated with common and unique neuropsychological and neuroanatomical changes. This review synthesizes neuropsychological and neuroimaging studies for both of these disorders and studies examining their co-occurrence. Recommendations for future research, including use of combined neuropsychological and advanced neuroimaging techniques to study these disorders alone and in concert, are presented. It is clear from the dearth of literature that addiitonal studies are required to examine and understand the impact of specific factors on neurocognitive outcome. Of particular relevance are temporal relationships between PTSD and mTBI, risk and resilience factors associated with both disorders and their co-occurrence, and mTBI-specific factors such as time since injury and severity of injury, utilizing comprehensive, yet targeted cognitive tasks.     

Buffering Effects of Benefit Finding in a War Environment

Benefit finding (BF) has been extensively examined after exposure to traumatic events. However, less research has examined BF as a buffer against the negative effects of an ongoing stressful event. Data from 1,925 U.S. Army soldiers deployed in support of Operation Iraqi Freedom (OIF) was used to examine whether BF would moderate the relationship between combat exposure and posttraumatic stress disorder (PTSD) and depression. Regression analyses revealed that BF was associated with lower levels of PTSD and depression. However, we found that BF during the combat deployment was found to moderate the combat exposure–PTSD relationship, such that the relationship was stronger when BF was low. Results are discussed in terms of BF being a form of meaning-based coping that may help soldiers adjust to the challenges of war.     

Clinical Effectiveness of an Intensive Outpatient Program for Integrated Treatment of Posttraumatic Stress Disorder and Mild Traumatic Brain Injury

Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) are pervasive consequences of the post-9/11 conflicts. Treatment of PTSD and mTBI has historically occurred separately and sequentially, which does not reflect the overlapping etiology of symptoms and may attenuate or delay recovery. This paper describes an integrated 2-week treatment program using prolonged exposure and cognitive symptom management and rehabilitation therapy to comprehensively treat PTSD and cognitive complaints attributed to mTBI, regardless of etiology. To minimize potential iatrogenic effects of treating presumed mTBI-related symptoms, a central focus of the program was to instill expectations of full recovery. Thirty patients with full or subclinical PTSD and self-reported TBI history completed the PTSD+TBI treatment program. Results indicated that self-reported PTSD, depression, and neurobehavioral symptoms significantly decreased following treatment, while satisfaction with participation in social roles increased. These preliminary effectiveness data indicate that PTSD complicated by mTBI history can be effectively treated within a 2-week intensive outpatient program.