Subsyndromal posttraumatic stress disorder is associated with health and psychosocial difficulties in veterans of Operations Enduring Freedom and Iraqi Freedom

Background: This study examined health and psychosocial correlates of subsyndromal/partial posttraumatic stress disorder (PTSD) and full PTSD in veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). Methods: Five hundred and fifty‐seven OEF/OIF veterans in Connecticut completed measures of PTSD and health and psychosocial functioning. Results: A total 22.3% of the sample met screening criteria for partial PTSD and 21.5% for full PTSD. Veterans with partial PTSD reported an intermediate level of impairment (e.g., health ratings, work problems, relationship problems) relative to veterans without PTSD and veterans with full PTSD. Conclusions: These results suggest that subsyndromal/partial PTSD is associated with significant health and psychosocial difficulties and underscore the importance of assessing for partial PTSD in OEF/OIF veterans. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.     

The prevalence of posttraumatic stress disorder in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans: A meta-analysis

Literature on posttraumatic stress disorder (PTSD) prevalence among Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans report estimates ranging from 1.4% to 60%. A more precise estimate is necessary for projecting healthcare needs and informing public policy. This meta-analysis examined 33 studies published between 2007 and 2013 involving 4,945,897 OEF/OIF veterans, and PTSD prevalence was estimated at 23%. Publication year and percentage of Caucasian participants and formerly active duty participants explained significant variability in prevalence across studies. PTSD remains a concern for a substantial percentage of OEF/OIF veterans. To date, most studies have estimated prevalence among OEF/OIF veterans using VA medical chart review. Thus, results generalize primarily to the prevalence of PTSD in medical records of OEF/OIF veterans who use VA services. Additional research is needed with randomly selected, representative samples administered diagnostic interviews. Significant financial and mental health resources are needed to promote recovery from PTSD.     

Time, before, and after time: temporal self and social appraisals in posttraumatic stress disorder

Background and objectives

In the aftermath of a traumatic event, individuals may engage in a series of comparisons in which they appraise their current functioning in relation to how they functioned prior to the traumatic event, as well as how they anticipate functioning in the future. In addition, trauma-exposed individuals may also appraise their functioning in relation to other individuals exposed to the same or similar types of traumatic events. We examine whether PTSD and non-PTSD classified individuals differ in temporal self and social appraisals.

Methods

Operation Enduring/Iraqi Freedom (OEF/OIF) combat-veterans with and without PTSD appraised their own past, current, and anticipated future functioning, as well as hypothetical other OEF/OIF veterans functioning across the same three temporal points.

Results

Individuals without PTSD appraised their own functioning as progressively improving across time. In contrast, individuals with PTSD viewed their current pre-trauma current self more favorably than their current or anticipated future self. Both groups appraised hypothetical other OEF/OIF veterans improving with time, yet individuals with PTSD evaluated other OEF/OIF veterans more favorably than those without PTSD.

Limitations

Limitations of the study include a cross-sectional design, precluding causality; the lack of a non-trauma exposed group, relatively small sample, and all-male gender of participants limit the generalizability to other populations.

Conclusions

PTSD and non-PTSD individuals differ in self and social appraisals when asked to evaluate past, present, and future functioning. Further research needs to better understand the extent to which these differences are associated with resilience to or maintenance of PTSD symptoms.     

Combined PTSD and depressive symptoms interact with post-deployment social support to predict suicidal ideation in Operation Enduring Freedom and Operation Iraqi Freedom veterans

Rates of suicide are alarmingly high in military and veteran samples. Suicide rates are particularly elevated among those with post-traumatic stress disorder (PTSD) and depression, which share overlapping symptoms and frequently co-occur. Identifying and confirming factors that reduce, suicide risk among veterans with PTSD and depression is imperative. The proposed study evaluated, whether post-deployment social support moderated the influence of PTSD–depression symptoms on, suicidal ideation among Veterans returning from Iraq and Afghanistan using state of the art clinical, diagnostic interviews and self-report measures. Operations Enduring and Iraqi Freedom (OEF/OIF) Veterans (n=145) were invited to, participate in a study evaluating returning Veterans? experiences. As predicted, PTSD–depression, symptoms had almost no effect on suicidal ideation (SI) when post-deployment social support was high; however, when, post-deployment social support was low, PTSD–depression symptoms were positively associated with, SI. Thus, social support may be an important factor for clinicians to assess in the context of PTSD and, depressive symptoms. Future research is needed to prospectively examine the inter-relationship, between PTSD/depression and social support on suicidal risk, as well as whether interventions to, improve social support result in decreased suicidality.     

Sexual Problems Predict PTSD and Depression Symptom Change Among Male OEF/OIF Veterans Completing Exposure Therapy

Objective: A growing literature documents frequent sexual problems among Operations Enduring/Iraqi Freedom (OEF/OIF) veterans with post-traumatic stress disorder (PTSD). However, there has been no examination of how (1) sexual problems may be affected by evidenced-based psychotherapy for PTSD or (2) how the presence of sexual problems might impact effectiveness of evidenced-based psychotherapy for PTSD. As such, the present study investigated associations among symptoms of PTSD, depression, and problems with sexual desire and arousal among 45 male OEF/OIF veterans receiving behavioral activation and therapeutic exposure (BA-TE), an evidence-based behavior therapy targeting co-occurring symptoms of PTSD and depression. Method: Participants completed clinical interviews and several questionnaires including measures of sexual arousal, sexual desire, PTSD symptoms, and depression symptoms at baseline and after completion of 8 sessions of BA-TE treatment. A records review was also conducted to assess for relevant medication use. Results: Overall, sexual desire and sexual arousal problems did not improve during the course of treatment. Moreover, veterans with co-occurring sexual problems at baseline evidenced significantly less improvement in symptoms of PTSD and depression across treatment as compared to veterans without sexual problems. Conclusions: These findings suggest that veterans with co-occurring symptoms of PTSD and sexual problems may require additional assessment and treatment considerations in order to improve their treatment outcomes for both primary psychiatric symptoms as well as sexual problems. Future research on combination treatments of medication for sexual problems and psychotherapy for PTSD is needed.     

Suicidal ideation in treatment-seeking Veterans of Operations Enduring Freedom and Iraqi Freedom: the role of coping strategies, resilience, and social support

Background

Recent epidemiologic studies have found an increased risk of suicide among Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF-OIF) with psychiatric disorders. However, little is known about whether variables other than psychiatric conditions, such as coping strategies, resilience, and social support, may be related to suicidality in this population.

Methods

A total of 167 OEF-OIF Veterans seeking behavioral or primary care services completed a survey containing measures of combat exposure, psychopathology, pain, psychological resilience, social support, and cognitive coping strategies.

Results

Thirty-six respondents (21.6%) reported contemplating suicide in the two weeks prior to completing the survey. Compared to suicide non-contemplators, suicide contemplators were older, and more likely to screen positive for depression and posttraumatic stress disorder (PTSD), and to report a deployment-related pain condition or complaint. They also scored higher on measures of worry, self-punishment, and cognitive-behavioral avoidance strategies, and lower on measures of psychological resilience and postdeployment social support. Multivariate analysis revealed that a positive depression screen, and higher scores on measures of self-punishment and cognitive-social avoidance coping were positively associated with suicidal ideation, while higher scores on measures of psychological resilience (i.e., positive acceptance of change) were negatively related to suicidal ideation. Moderator analysis revealed that a positive screen for depression or PTSD significantly diminished the protective effect of postdeployment social support on suicidal ideation.

Conclusions

1 in 5 treatment-seeking OEF-OIF Veterans may contemplate suicide. Interventions to reduce depressive symptoms, and maladaptive cognitive-behavioral coping strategies of self-punishment and cognitive social avoidance, and to bolster psychological resilience may help mitigate suicidality in this population.     

Neuropsychological Effects of Self-Reported Deployment-Related Mild TBI and Current PTSD in OIF/OEF Veterans

Current combat veterans are exposed to many incidents that may result in mild traumatic brain injury (mTBI) and/or posttraumatic stress disorder (PTSD). While there is literature on the neuropsychological consequences of PTSD only (PTSD-o) and mTBI alone (mTBI-o), less has been done to explore their combined (mTBI+PTSD) effect. The goal of this study was to determine whether Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans with mTBI+PTSD have poorer cognitive and psychological outcomes than veterans with PTSD-o, mTBI-o, or combat exposure-only. The final sample included 20 OIF/OEF veterans with histories of self-reported deployment mTBI (mTBI-o), 19 with current PTSD (PTSD-o), 21 with PTSD and self-reported mTBI (mTBI+PTSD), and 21 combat controls (CC) (no PTSD and no reported mTBI). Groups were formed using structured interviews for mTBI and PTSD. All participants underwent comprehensive neuropsychological testing, including neurocognitive and psychiatric feigning tests. Results of cognitive tests revealed significant differences in performance in the mTBI+PTSD and PTSD-o groups relative to mTBI-o and CC. Consistent with previous PTSD literature, significant differences were found on executive (switching) tasks, verbal fluency, and verbal memory. Effect sizes tended to be large in both groups with PTSD. Thus, PTSD seems to be an important variable affecting neuropsychological profiles in the post-deployment time period. Consistent with literature on civilian mTBI, the current study did not find evidence that combat-related mTBI in and of itself contributes to objective cognitive impairment in the late stage of injury.     

Suicidal ideation among National Guard troops deployed to Iraq: the association with postdeployment readjustment problems

Despite well-documented postdeployment readjustment problems affecting veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF), few studies have explored the possible relationship of readjustment stressors to the recent increase in military suicide. This study examined associations between suicidal ideation and postdeployment readjustment problems using cross-sectional population-based survey data from 1665 National Guard members who recently returned from Iraq. The findings suggested that readjustment problems are widespread, with 45% of veterans endorsing one or more financial or family problems 3 months postdeployment. After adjusting for mental health and combat exposure, veterans with the highest number of readjustment stressors were at 5? times greater risk of suicidal ideation than those with no stressors. In a psychiatrically impaired subsample, the high stressor group experienced a fourfold risk of suicide ideation compared with those with no stressors. The findings argue for suicide prevention efforts that more directly target readjustment problems in returning OEF/OIF veterans.     

Accelerated longitudinal cortical atrophy in OEF/OIF/OND veterans with severe PTSD and the impact of comorbid TBI

Veterans who deployed in support of Operation Enduring Freedom (OEF), Iraqi Freedom (OIF), and New Dawn (OND) commonly experience severe psychological trauma, often accompanied by physical brain trauma resulting in mild traumatic brain injury (mTBI). Prior studies of individuals with posttraumatic stress disorder (PTSD) have revealed alterations in brain structure, accelerated cellular aging, and impacts on cognition following exposure to severe psychological trauma and potential interactive effects of military‐related mTBI. To date, however, little is known how such deployment‐related trauma changes with time and age of injury of the affected veteran. In this study, we explored changes in cortical thickness, volume, and surface area after an average interval of approximately 2 years in a cohort of 254 OEF/OIF/OND Veterans ranging in age from 19 to 67 years. Whole‐brain vertex‐wise analyses revealed that veterans who met criteria for severe PTSD (Clinician‐Administered PTSD Scale ≥60) at baseline showed greater negative longitudinal changes in cortical thickness, volume, and area over time. Analyses also revealed a significant severe‐PTSD by age interaction on cortical measures with severe‐PTSD individuals exhibiting accelerated cortical degeneration with increasing age. Interaction effects of comorbid military‐related mTBI within the severe‐PTSD group were also observed in several cortical regions. These results suggest that those exhibiting severe PTSD symptomatology have accelerated atrophy that is exacerbated with increasing age and history of mTBI.     

Sleep quality in treatment-seeking veterans of Operations Enduring Freedom and Iraqi Freedom: the role of cognitive coping strategies and unit cohesion

Objective

Sleep difficulties are common in individuals exposed to stress or trauma, and maladaptive cognitive coping strategies, such as worry and fear of losing vigilance, as well as low social support, may further impair sleep quality. This study examined the severity and correlates of sleep difficulties in a sample of treatment-seeking veterans of Operations Enduring Freedom and Iraqi Freedom (OEF-OIF).

Method

A total of 167 OEF-OIF veterans seeking behavioral or primary care services completed a questionnaire containing measures of sleep quality, combat exposure, psychopathology, fear of loss of vigilance, cognitive coping strategies, and unit and postdeployment social support within 1 year of returning from deployment.

Results

Mean Pittsburgh Sleep Quality Inventory scores in the full sample were indicative of severely impaired sleep. Posttraumatic stress disorder (PTSD) was associated with increased sleep difficulties, most notably sleep disturbances, daytime dysfunction, and sleep quality. Hierarchical regression analysis in the full sample revealed that PTSD symptoms and scores on measures of worry and fear of loss of vigilance were positively associated with sleep difficulties and that scores on a measure of unit member support were negatively associated with sleep difficulties. Among veterans with PTSD, fear of loss of vigilance was positively associated with sleep difficulties and cognitive distraction and unit member support were negatively associated with sleep difficulties.

Conclusions

Treatment-seeking OEF-OIF veterans report severe sleep difficulties, with more pronounced impairment in veterans with PTSD. The results of this study suggest that interventions to mitigate worry and fear of loss of vigilance and to enhance perceived unit member support may be helpful in reducing sleep difficulties following return from deployment in this population.     

An examination of the relation between combat experiences and combat-related posttraumatic stress disorder in a sample of Connecticut OEF-OIF Veterans

Background

Combat exposure is an important risk factor for posttraumatic stress disorder (PTSD). However, little research has examined specific combat experiences associated with PTSD and confirmatory factor analytically (CFA)-derived re-experiencing, avoidance, dysphoria, and hyperarousal symptom clusters.

Methods

A total of 285 predominantly older National Guard/Reservist OEF–OIF Veterans completed an anonymous mail survey that assessed demographics and deployment history, a broad range of combat experiences, PTSD, and unit and postdeployment social support.

Results

Personally witnessing someone from one’s unit or an ally unit being seriously wounded or killed (β = 0.22), and being exposed to “friendly” fire (β = 0.14) and land mines/traps (β = 0.13) were the only three combat experiences associated with severity of combat-related PTSD symptoms, after adjustment for age, relationship status, unit support, postdeployment social support, and other combat experiences. Differential patterns of associations were observed for specific combat experiences in relation to CFA-derived symptom clusters (e.g., experiencing “friendly” fire was associated with re-experiencing and dysphoria symptoms, but not avoidance and hyperarousal symptoms). Personally witnessing someone from one’s unit or an ally unit being seriously wounded or killed (odds ratio [OR] = 4.34; 95% confidence interval [CI] = 1.62–11.61) and being exposed to “friendly” fire (OR = 2.94; 95%CI = 1.16–7.47) emerged as independent predictors of a positive screen for probable PTSD.

Conclusions

Results of this study suggest that witnessing someone in one’s unit or ally unit being seriously wounded or killed while in a combat zone and being exposed to “friendly” fire are most strongly associated with combat-related PTSD in this sample of OEF/OIF Veterans. Examination of the relation between specific combat experiences and combat-related PTSD in OEF/OIF Veterans may help inform etiologic models of PTSD, and guide prevention and treatment approaches in this population.     

Postconcussion symptoms reported by Operation Enduring Freedom/Operation Iraqi Freedom veterans with and without blast exposure,mild traumatic brain injury,and posttraumatic stress disorder

Objective: This study examined symptom reporting related to the 10th Edition of the International Statistical Classification of Diseases and Related Health Problems (ICD–10) criteria for postconcussional syndrome (PCS) in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans. Our aims were to: (a) examine relationships among PCS symptoms by identifying potential subscales of the British Columbia Postconcussion Symptom Inventory (BC-PSI); and (b) examine group differences in BC-PSI items and subscales in Veterans with and without blast exposure, mild traumatic brain injury (mTBI), and posttraumatic stress disorder (PTSD). Method: Our sample included Veterans with blast-related mTBI history (n = 47), with blast exposure but no mTBI history (n = 20), and without blast exposure (n = 23). Overall, 37 Veterans had PTSD, and 53 did not. We conducted an exploratory factor analysis (EFA) of the BC-PSI followed by multivariate analysis of variance to examine differences in BC-PSI subscale scores by blast exposure, mTBI history, and PTSD. Results: BC-PSI factors were interpreted as cognitive, vestibular, affective, anger, and somatic. Items and factor scores were highest for Veterans with blast exposure plus mTBI, and lowest for controls. Vestibular, affective, and somatic factors were significantly higher for Veterans with blast exposure plus mTBI than for controls, but not significantly different for those with blast exposure but no mTBI. These results remained significant when PTSD symptom severity was included as a covariate. Cognitive, anger, and somatic subscales were significantly higher for Veterans with PTSD, though there was no interaction effect of PTSD and mTBI or blast history. Conclusions: EFA-derived subscales of the BC-PSI differentiated Veterans based on blast exposure, mTBI history, and PTSD.     

Poor Performance Validity Predicts Clinical Characteristics and Cognitive Test Performance of OEF/OIF/OND Veterans in a Research Setting

This study examined the performance of 198 Veteran research participants deployed during Operation Enduring Freedom, Operation Iraqi Freedom, and/or Operation New Dawn (OEF/OIF/OND) on four measures of performance validity: the Medical Symptom Validity Test (MSVT), California Verbal Learning Test: Forced Choice Recognition (FCR), Reliable Digit Span (RDS), and TOVA Symptom Exaggeration Index (SEI). Failure on these performance validity tests (PVTs) ranged from 4% to 9%. The overall base rate of poor performance validity, as measured by failure of the MSVT in conjunction with an embedded PVT (FCR, RDS, SEI), was 5.6%. Regression analyses revealed that poor performance validity predicted cognitive test performance and self-reported psychological symptom severity. Furthermore, a greater prevalence of traumatic brain injury (TBI), Post-Traumatic Stress Disorder (PTSD), co-morbid TBI/PTSD, and other Axis I diagnoses, was observed among participants with poor effort. Although poor performance validity is relatively uncommon in a research setting, these findings demonstrate that clinicians should be cautious when interpreting psychological symptoms and neuropsychological test performance of Veteran participants who fail effort measures.     

Variables associated with subjective cognitive change among Iraq and Afghanistan war Veterans with blast-related mild traumatic brain injury

Introduction: This study investigated variables associated with subjective decline in executive function among Veterans of Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND) following a history of blast-related mild traumatic brain injury (mTBI).

Method: Fifty-six male U.S. Veterans (M_Age = 35.3 ± 8.8 years) with a history of blast-related mTBI (6.6 ± 3.2 years post injury) completed a battery of self-report questionnaires and neuropsychological measures. Participants rated current and retrospectively estimated pre-mTBI executive function difficulties on the Frontal Systems Behavior Scale (FrSBe). A difference score (post- minus pre-mTBI ratings) was the dependent variable (?FrSBe). Linear regression models examined variables predicting ?FrSBe, including: pre-injury characteristics (education, premorbid intelligence), injury-related characteristics (number of blast exposures, losses of consciousness), post-injury clinical symptoms (PTSD Checklist–Military version; Pittsburgh Sleep Quality Index), and post-injury neuropsychological performances on executive function measures (Trail Making Test Part B; Controlled Oral Word Association Test; Auditory Consonant Trigrams; Wisconsin Card Sorting Test).

Results: While 11% of participants had a clinically elevated pre-injury FrSBe total score, 82% had a clinically elevated post-injury FrSBe total score. Only self-reported PTSD symptom severity independently predicted perceived change in executive function.

Conclusions: Many OEF/OIF/OND Veterans with a history of blast-related mTBI experience subjective decline in executive function following injury. Perceived executive function decline was associated with higher PTSD symptom severity, aligning with previous research associating PTSD with cognitive complaints. Results did not support a correspondence between perceived cognitive change and neuropsychological performances.     

Hysterical Psychosis in the New Guinea Highlands: A Bena Bena Example†

Objective: Posttraumatic stress disorder (PTSD) results from exposure to traumatic events. Social support is negatively related to PTSD symptoms in cross-sectional and longitudinal studies. It is unclear, however, if social support is associated with treatment response for PTSD. The current study evaluated the extent to which social support was associated with PTSD treatment response among treatment-seeking veterans receiving prolonged exposure (PE). It was hypothesized that social support would improve PTSD treatment response and that PTSD symptom reduction would improve social support. Method: A total of 123 veterans were recruited from a Veterans Affairs Medical Center and evaluated for PTSD, diagnostic-related symptoms, and social support. All participants received PE. Data were analyzed using mixed-effects models. Results: Findings suggested that elevated social support during treatment was associated with greater reductions in PTSD symptoms during treatment. Social support also increased during treatment. Increases in social support were not moderated by PTSD symptoms during treatment. Conclusions: These findings suggest that social support and PTSD symptoms are related throughout treatment. Social support moderated the change in PTSD symptoms, whereas PTSD symptoms did not moderate changes in social support.     

White matter abnormalities are associated with chronic postconcussion symptoms in blast‐related mild traumatic brain injury

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 nonspecific 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 comorbid 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 Operation Enduring Freedom/Operation Iraqi Freedom (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. Hum Brain Mapp 37:220–229, 2016. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.     

Demographics of and diagnoses in Operation Enduring Freedom and Operation Iraqi Freedom personnel who were psychiatrically evacuated from the theater of operations

OBJECTIVE: The objective of this study was to characterize the demographic and clinical information of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) military personnel who were psychiatrically evacuated from the theater of operations. METHOD: Records of 1264 consecutive OEF/OIF patients who were medically evacuated for primarily psychiatric reasons between November 4, 2001, and July 30, 2004, were reviewed to collect demographic information and psychiatric diagnoses. RESULTS: When compared with all returned OEF/OIF veterans (N=213,150), psychiatric evacuees were more likely to be: female, under the age of 31 years, African-American or Hispanic, enlisted and National Guard/Reserve. Over 80% of patients were evacuated during the first 6 months, compared with 17% during the second 6 months of deployment. The most common diagnostic categories were adjustment disorders (37.6%), mood disorders (22.1%), personality disorders (15.7%) and anxiety disorders (15.4%); 16.5% received no psychiatric diagnosis. Only 5% of evacuees were returned to OEF/OIF duty. CONCLUSION: Almost half of evacuated patients received no diagnosis or no adjustment disorder diagnosis, suggesting clinical improvement since a decision for evacuation was made. Potential areas of focus for preventing psychiatric evacuations are identifying service members who are at risk during early stages of deployment and studying whether there are gender-specific deployment stressors.     

Military Psychodynamics

High rates of attrition occur in outpatient and inpatient evidence-based treatments (EBTs) targeting newly returning veterans from Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) with posttraumatic stress disorder (PTSD). Traditionally, research has examined attrition as a dichotomous variable (i.e., noncompleters vs. completers) and focused almost exclusively on outpatient EBTs for PTSD. These studies have provided little information to inpatient psychiatric providers about timing-related predictors of treatment discontinuation. The present study attempted to mend these gaps by examining attrition as a continuous variable and investigated predictors of length of stay (LOS) among 282 OEF/OIF/OND male veterans, 69 of which did not complete the full 25-day intensive, multimodal inpatient PTSD EBT program. At admission, participants completed a series of clinician-rated, biological, and self-report assessments. Linear regression analyses were used to identify predictors of shorter LOS. The results demonstrated that less improvement in symptom reduction, overall functioning, and greater number of drugs used at admission were significant and unique predictors of shorter LOS. Overall, these findings reveal clinically relevant, timing-related predictors of attrition and provide generalizable clinical information to inpatient psychiatric providers.     

The contributions of self-reported injury characteristics and psychiatric symptoms to cognitive functioning in OEF/OIF veterans with mild traumatic brain injury

Mild traumatic brain injury (mTBI) affects a significant number of combat veterans returning from Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF). Although resolution of mTBI symptoms is expected over time, some individuals continue to report lingering cognitive difficulties. This study examined the contributions of self-reported mTBI injury characteristics (e.g., loss of consciousness, post-traumatic amnesia) and psychiatric symptoms to both subjective and objective cognitive functioning in a sample of 167 OEF/OIF veterans seen in a TBI clinic. Injury characteristics were not associated with performance on neuropsychological tests but were variably related to subjective ratings of cognitive functioning. Psychiatric symptoms were highly prevalent and fully mediated most of the relationships between injury characteristics and cognitive ratings. This indicates that mTBI characteristics such as longer time since injury and loss of consciousness or post-traumatic amnesia can lead to increased perceived cognitive deficits despite having no objective effects on cognitive performance. Psychiatric symptoms were associated with both cognitive ratings and neuropsychological performance, illustrating the important role that psychiatric treatment can potentially play in optimizing functioning. Finally, subjective cognitive ratings were not predictive of neuropsychological performance once psychiatric functioning was statistically controlled, suggesting that neuropsychological assessment provides valuable information that cannot be gleaned from self-report alone.