Neuropsychology Review

, Volume 22, Issue 1, pp 35–53 | Cite as

Self-Report Measures to Identify Post Traumatic Stress Disorder and/or Mild Traumatic Brain Injury and Associated Symptoms in Military Veterans of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)

  • Lisa M. Betthauser
  • Nazanin Bahraini
  • Maxine H. Krengel
  • Lisa A. Brenner
Review

Abstract

Individuals serving in Iraq and Afghanistan sustain injuries associated with physical and psychological trauma. Among such injuries, mild traumatic brain injury (mTBI) and post traumatic stress disorder (PTSD) are common. Self-report measures are frequently used to identify mTBI and/or PTSD and symptoms associated with these conditions. In addition to providing information regarding mTBI and PTSD, the goal of this literature review was to identify and present information on the psychometric properties of measures used to obtain information regarding these common conditions among Veterans who have returned from Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF). A comprehensive review of studies in which self-report measures were used to evaluate mTBI, PTSD, and associated symptoms among OEF/OIF Veterans is presented. Findings suggest that additional work is needed to identify psychometrically sound and clinically useful self-report measures that assess mTBI and PTSD and associated symptoms among OEF/OIF Veterans.

Keywords

Operation Enduring Freedom Operation Iraqi Freedom Traumatic Brain Injury Post Traumatic Stress Disorder Assessment Self-report measures 

Abbreviations

mTBI

Mild traumatic brain injury

PTSD

Post traumatic stress disorder

OEF

Operation Enduring Freedom

OIF

Operation Iraqi freedom

TBI

Traumatic brain injury

AOC

Alteration in consciousness

LOC

Loss of consciousness

PTA

Post-traumatic amnesia

MOS

Military occupation specialty

PC

Post-concussive

PCS

Post concussive syndrome

ICD-10

International classification of diseases (10th edition)

DSM-IV

Diagnostic and statistical manual of mental disorders (4th edition)

DSM-IV TR

Diagnostic and statistical manual of mental disorders (4th edition), text revision

PCL

Posttraumatic Stress Disorder Checklist

BTBIS

Brief Traumatic Brain Injury Screen

TSI

Trauma Symptom Inventory

NSI

Neurobehavioral Symptom Inventory

PILOTS

Published International Literature On Traumatic Stress

MeSH

Medical Subject Headings

CAPS

Clinician Administered PTSD Scale

OSU TBI-ID

Ohio State University Traumatic Brain Injury Identification

PCL-C

PTSD Checklist-Civilian

Since 2001, over 2.3 million individuals have been deployed as part of the Global War on Terror (Environmental Health Strategic Healthcare Group 2011). While serving, military personnel have been exposed to physical and/or psychological traumas that may result in mild traumatic brain injury (mTBI) and/or post traumatic stress disorder (PTSD). The vast majority of these individuals are eligible to receive care within the Veterans Health Administration (VHA). Since 2002, 711,986 new Veterans have sought such services (Environmental Health Strategic Healthcare Group 2011). To meet the needs of these individuals, self-report measures are commonly used in clinical practice to screen for conditions of interest and augment neuropsychological assessment procedures. Self-report measures can assist in the process of efficiently identifying diagnostic criteria or symptoms of interest. This paper provides background information regarding mTBI and PTSD, along with a general discussion regarding the strengths and weaknesses of self-report measures. A review and critique of existing research articles in which self-report measures were used in cases of mTBI or PTSD among OEF/OIF Veterans will follow, as will recommendations regarding future research and current practice.

Mild Traumatic Brain Injury (mTBI)

To have sustained a traumatic brain injury (TBI) an individual must have experienced an external physical force that resulted in a traumatically-induced structural injury to the brain, a physiological disruption of brain function as indicated by medical findings (e.g., neuroimaging findings such as white matter signal abnormalities), or an acute alteration in consciousness (AOC). The AOC may range from immediate confusion and disorientation to unconsciousness. TBI severity is classified according to the extent of injury to the brain or AOC post-injury (Table 1). According to criteria outlined, by the Departments of Veterans Affairs and Defense (2009), TBI is an injurious historical event and severity of sequelae reported is not used in diagnostic determination. In terms of mTBI, the American Congress of Rehabilitation Medicine (ACRM) diagnostic criteria requires a traumatically induced physiological disruption of brain function as manifested by at least one of the following: 1) any period of loss of consciousness; 2) any loss of memory for events immediately before or after the injury; 3) any alteration in mental state at the time of the injury (e.g., feeling dazed, disoriented and confused); and/or 4) focal neurological deficits that may or may not be transient (Kay et al. 1993). In addition, the following must not be exceeded: 1) 30 min loss of consciousness (LOC); 2) after 30 min, Glasgow Coma Scale score of 13–15; and/or 3) post-traumatic amnesia (PTA) of 24 h (Kay et al. 1993).
Table 1

Departments of Defense and Veterans Affairs Consensus based classification of closed Traumatic Brain Injury (TBI) severity (Department of Veterans Affairs and Department of Defense 2009)

 

Mild TBI/Concussion

Moderate TBI

Severe TBI

Structural Imaging Results

Normal

Normal or abnormal

Normal or abnormal

AOC (time)

A moment to 24 h

Greater than 24 h

Greater than 24 h

LOC (time)

0–30 min

> 30 min but <24 h

> 24 h

PTA (time)

0-1 day

> 1 but <7 days

> 7 days

AOC Alteration of Consciousness

LOC Loss of Consciousness

PTA Post Traumatic Amnesia

Although TBI acquired in civilian settings are frequently caused by a bump, blow, or jolt to the head that disrupts brain functioning (e.g., alteration in or LOC) (National Center for Injury Prevention and Control 2003), the majority of TBIs being sustained by military personnel are blast-related (Terrio et al. 2009). A blast associated with the detonation of munitions can be deleterious to the brain (Cernak et al. 1999; Cernak et al. 2001). Such barotrauma is frequently referred to as primary blast injury. Military personnel can also sustain TBIs secondary to objects being thrown off explosives (secondary injury) and bodily displacement (tertiary injury) (Centers for Disease Control and Prevention 2006). Reported rates of military personnel sustaining mTBI has varied widely (8% to 23%) and are dependent on multiple factors (e.g., time served, Military Occupation Specialty [MOS]) (Terrio et al. 2009; Vasterling et al. 2006).

Military personnel returning from OEF/OIF with a history of mTBI are reporting a range of post-concussive (PC) symptoms, including headaches, dizziness, memory problems, balance problems, and irritability (Terrio et al. 2009). Terrio and colleagues (2009) reported that the rate of symptoms markedly decreased between the time of injury and assessment post-deployment. Whereas 33.4% of soldiers with TBI reported three or more symptoms immediately post-TBI, 7.5% noted such symptoms at post-deployment. For at least some of these individuals it is expected that the decrease is associated with recovery from their acute injury. These non-specific symptoms have also been associated with mental health conditions including depression and PTSD, which are prevalent among military personnel with mTBI (Brenner, Ivins et al. 2010; Brenner, Terrio et al. 2010; Hoge et al. 2008; Schneiderman et al. 2008). In addition, there is some indication that women report distinct symptoms and are diagnosed with different conditions than their male counterparts (Iverson et al. 2011). In specific, women were less likely to be diagnosed with PTSD and more likely to be diagnosed with depression, non-PTSD anxiety disorder, or PTSD with co-morbid depression compared with men; indeed, women reported more severe symptoms across neurobehavioral categories (Iverson et al. 2011).

A percentage of individuals with mTBI report persistent and disabling symptoms, often described as post-concussive syndrome (PCS). Commonly used criteria for PCS include the 10th edition of the International Classification of Diseases (ICD-10; World Health Organization 2007) and the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association 1994). Both criteria require a history of head trauma that precedes the onset of symptoms. Within the ICD-10 criteria a LOC is required, along with symptoms in three or more categories. The onset of symptoms must be no more than 4 weeks post-injury. ICD-10 PC symptoms fall into six categories: 1) somatic (i.e., headaches, dizziness, malaise, fatigue, noise tolerance); 2) psychiatric (i.e., irritability, depression, anxiety, emotional lability); 3) cognitive (i.e., subjective concentration, memory, or intellectual difficulties without neuropsychological evidence of marked impairment); 4) insomnia; 5) reduced alcohol tolerance; and 6) preoccupation with the above symptoms and fear of brain damage with hypochondriacal concern and adoption of sick role.

In contrast to the ICD-10, DSM-IV criteria require evidence from formal testing of difficulty in attention or memory along with three or more symptoms that occur shortly after the trauma and last at least 3 months. DSM-IV symptoms of interest include becoming easily fatigued, disordered sleep, headache, vertigo or dizziness, irritability or aggression on little or no provocation, anxiety, depression, or affective instability, changes in personality, and/or apathy or lack of spontaneity. If symptoms predated the injury, symptoms must be substantially worsened following the head trauma. The disturbance must also cause significant impairment in social or occupational functioning that represents a significant functional decline. Increased understanding of symptoms may inform neuropsychological assessment procedures or interpretation of results. For example, for an individual with cognitive complaints it may be important to focus on specific areas of functioning (e.g., memory) to objectively highlight strengths and weaknesses. If the individual is reporting emotional dysregulation (e.g., irritability, depressed mood), evaluating if and how such symptoms alter performance could affect result interpretation.

Within the VA system, initial screening and follow-up evaluations are conducted to determine who is “at risk” for PCS. This process is meant to be inclusive so as to minimize the risk of false negatives. A screening questionnaire regarding TBI history similar to the Brief Traumatic Brain Injury Screen (BTBIS; Schwab et al. 2007—see below) has been used routinely since 2007 and several researchers have used similar tools to document the extent to which individuals meet criteria for mTBI. The measurement scales described below have not been extensively evaluated in terms of their psychometric properties for use with this population consisting of individuals with multiple traumas (physical and psychological) and potential concussive events.

The BTBIS (Schwab et al. 2007) was developed by Defense and Veterans Brain Injury Center (DVBIC) to determine the extent to which individuals require further clinician assessment of TBI. This three-item screen queries regarding type of injury, alteration of consciousness and current difficulties. Once a Veteran enters the VA system they are evaluated with a 4 item screening tool adapted from the BTBIS (Schwab et al. 2007). This screening tool is also meant to provide information regarding who should be referred for a clinician administered detailed diagnostic screening, the second level screen. This detailed screening includes measures to assess for TBI and PTSD symptoms.

The Neurobehavioral Symptom Inventory-22 (NSI-22) is an instrument developed originally for the civilian population (Cicerone and Kalmar 1995). Initial factor analytic study revealed 4 factors relating to head trauma and 5 additional items not related to any of these 4 factors (Cicerone and Kalmar 1995). This measure has only recently been studied in terms of psychometrics among the Veteran population. Meterko et al. (2012) used aggregate data from a national database and found that, as in Cicerone’s original work, 4 factors emerged from the 22 items, including somatosensory, affective, cognitive and vestibular. This measure is also used within the VA to assess for PCS.

Post Traumatic Stress Disorder (PTSD)

PTSD is an anxiety disorder that develops following exposure to a traumatic event (American Psychiatric Association 2000).Whereas criteria for diagnosis of TBI does not include post-injury sequelae, symptom endorsement is integral to the diagnosis of PTSD. PTSD is characterized by three distinct symptom clusters: (1) re-experiencing of the traumatic event; (2) avoidance of trauma-related stimuli and emotional numbing; and (3) persistent hyperarousal. Re-experiencing symptoms may consist of intrusive thoughts and memories of the trauma, flashbacks, or nightmares. Avoidance may include both effortful avoidance and as emotional numbing. Finally, hyperarousal represents a range of symptoms from irritability and difficulty concentrating to hypervigilance and exaggerated startle response.

There are a number of inherent challenges when assessing PTSD symptomatology. First, PTSD is a complex and multifaceted disorder with a broad range of symptoms, some of which are vaguely defined in the diagnostic criteria (Weathers et al. 2009). For example, some symptoms such as sense of foreshortened future are not well explored within the literature, and others (e.g., difficulty remembering certain aspects of the trauma) may be misattributed to psychological trauma even though they may be a direct consequence of some other aspect of the event (e.g., LOC or AOC secondary to TBI). In addition, some symptoms overlap across clusters (e.g., nightmares and sleep disturbance), which can lead to double coding and overall inflation of PTSD symptom severity (Weathers et al. 2009). Finally, the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV TR; American Psychiatric Association 2000) criteria rely heavily on items that require verbal descriptions of internal experiences and states. This can be particularly challenging as the prominence of avoidance related processes in PTSD may affect individuals’ abilities to report adequate information to substantiate symptoms.

The screening tools most commonly used for diagnostics of PTSD include the Posttraumatic Stress Disorder Checklist (PCL)-civilian or military version which assesses PTSD symptoms that correspond with the DSM-IV criteria and the Davidson Trauma Scale (DTS) which assesses the frequency and severity of each of the PTSD DSM-IV symptoms. These scales have been researched and validated for use in non-OEF/OIF Veteran populations. See Table 2 for a detailed description of mTBI and PTSD self-report measures.
Table 2

Frequently used measures - mild traumatic brain injury and post traumatic stress disorder

Measure

Domains Assessed

Background Information

Approximate Administration Time

Brief Traumatic Brain Injury Screen (BTBIS) (Schwab et al. 2007)/VA Traumatic Brain Injury (TBI) Screening Tool (Department of Veterans Affairs VHA 2010)

TBI screen

The BTBIS is a 4-item self-report survey that queries history of deployment-related TBI and associated symptoms. The BTBIS has demonstrated adequate concurrent validity (Schwab et al. 2007). The VA TBI Screening Tool, implemented by the Department of Veterans Affairs, is a screening measure consistent with the BTBIS. Questions include: 1) During any of your OIF/OEF deployment(s) did you experience any of the following events? (Blast or Explosion, Vehicular accident/crash, Fragment wound or bullet wound above the shoulders, Fall); 2) Did you have any of these immediately afterwards? (Losing consciousness/“knocked out”, Being dazed, confused or “seeing stars”, Not remembering the event, Concussion, Head injury); 3) Did any of the following problems begin or get worse afterwards? (Memory problems or lapses, Balance problems or Dizziness, Sensitivity to bright light, Irritability, Headaches, Sleep problems); 4) In the past week, have you had any of the symptoms from question 3?

4 min

Davidson Trauma Scale (DTS; Davidson et al. 1997)

PTSD Symptoms

The DTS is a 17-item self report measure that assesses both the frequency and severity of each of the DSM-IV symptoms of PTSD. When rating each of the 17 items, respondents are asked to refer to a particular traumatic event and specific time frame (i.e., during the past week). The DTS yields a total score, combining both frequency and severity ratings for all 17 items as well as separate ratings for the total frequency and total severity of all 17 items. Additionally, separate scores for the three symptom clusters (i.e., Intrusive, Avoidance/Numbing, and Hyperarousal) can be obtained.

20 min

Neurobehavioral Symptom Inventory (NSI; Cicerone and Kalmar 1995)

Post Concussive Symptoms

The NSI is a 22-item measure used to assess symptoms often reported post- mTBI. Items are scored on a 0 to 4 scale; 0 = none and 4 = very severe. The measure total score ranges from 0 to 88. The severity of each symptom is assessed using the above stated 5-item scale which asks participants to indicate the extent to which each symptom has disturbed them in the previous 2 weeks. The NSI total score is the sum of severity ratings of the 22 symptoms. Cluster scores (domains: physical, cognitive, affective, and sensory) were derived (Cicerone and Kalmar 1995): Affective Cluster - Irritability, Poor Frustration Tolerance, Anxiety, and Depression (4 items; 0–16); Cognitive Cluster- Fatigue/Loss of Energy, Difficulty Making Decisions, Slowed Thinking, Poor Concentration, Forgetfulness (5 items; 0–20); Somatic Cluster—Poor Coordination/Clumsy, Feeling Dizzy, Loss of Balance, Nausea, Vision Problems/Blurring, Loss of/Increased Appetite (6 items;0–24); and Sensory Cluster- Sensitivity to Noise, Sensitivity to Light (2 items; 0–8). Caplan and colleagues (2010) used data from three military samples to evaluate alternative symptom cluster models. Whereas the 9 cluster model provided a valid description of the relationship between items, a 3 factor model (i.e., somatic/sensory, affective, cognitive) provided nearly as good a fit and greater parsimony.

10 min

Primary Care PTSD Screen (PC-PTSD; Prins et al. 2003)

PTSD screen

The PC-PTSD screen is a brief, 4-item, yes/no screen for PTSD in primary care. The items reflect four factors of PTSD including re-experiencing, numbing, avoidance, and hyperarousal. The PC-PTSD has demonstrated good psychometric properties when compared with the PCL and the CAPS (Prins et al. 2003). Questions ask about experiences had in the past month related to a traumatic event including: 1) had nightmares or thought about it when you did not want to; 2) Tried hard not to think about it or went out of your way to avoid situations that remind you of it; 3) Were constantly on guard, watchful, or easily startled; 4) Felt numb or detached from others, activities, or your surroundings.

4 min

PTSD Checklist-Civilian, Military, and Specific Trauma (PCL; Weathers et al. 1993)

PTSD symptoms

The PCL is a 17-item questionnaire that corresponds to the 17 PTSD symptom criteria listed in the DSM-IV. Support for the reliability and validity of the PCL has been shown among different trauma populations, such as high correlations with the CAPS (overall r = .93; Blanchard et al. 1996) as well as high internal consistency and convergent validity (Ruggiero et al. 2003). Three versions of the PCL are available: the PCL-C (for civilians), the PCL-S (for addressing a specific stressful experience), and the PCL-M (for military).

10 min

Trauma Symptom Inventory (TSI; Briere 1995)

Trauma sequelae

The TSI is a global measure of trauma sequelae. The TSl is a 100-item self-report measure that was created to assess PTSD symptoms and a variety of other related sequelae. The TSI is composed of 3 validity scales and 10 clinical scales, 3 of which are closely related to the symptom clusters presented in DSM-IV criteria for PTSD. The TSI includes scales that measure response validity, core PTSD symptoms, and broader symptoms related to trauma (e.g., tension-reducing behaviors). The TSI has demonstrated good internal consistency and construct validity in samples of university students (0.84; Runtz and Roche 1999), psychiatric inpatients and outpatients (0.87; Briere et al. 1995), and Navy recruits (0.85; Merrill 2001). Furthermore, Bahraini et al. (2009) demonstrated that despite the potential overlap of symptoms between PTSD and TBI, the TSI appears to be a useful measure of symptoms of psychological trauma in Veterans who may also have a TBI, particularly mTBI.

30 min

Self-Report Measures

Although self-report measures should not be used as the sole source of information for clinical assessment and diagnosis of mTBI and/or PTSD, they are an efficient means of obtaining useful idiosyncratic information regarding symptoms and severity (Kazdin 2003). Self-report measures can also be used to obtain information regarding an individual’s daily functioning and potential environmental barriers and facilitators (Kazdin 2003). While evidence-based treatments in mental health have received considerable attention, the topic of evidence-based assessment has only recently gained interest among researchers and practitioners (Hunsley and Mash 2008). As such, clinicians often use measures that have little or no supporting evidence regarding their reliability or validity (Hunsley et al. 2003). Given the emerging interest in this area, guidelines for evidence-based assessment of psychological disorders have been recommended (Hunsley and Mash 2008). These guidelines can apply directly to the assessment of mTBI and/or PTSD (U.S. Department of Veterans Affairs Office of Research 2008; Department of Veterans Affairs and Department of Defense 2009) including selecting measures that are: 1) appropriate for the targeted disorder or condition, 2) psychometrically sound (e.g., have established adequate reliability, validity, sensitivity, specificity in the population of interest), and 3) clinically useful. Taking these guidelines into consideration, benefits and limitations of self-report measures are discussed below.

In evaluating self-report measures information concerning reliability, validity, positive predictive value and negative predictive value is imperative (Table 3). Ideally, self-report measures are studied across a variety of relevant clinical populations; however, knowledge pertaining to the specific population of interest is vital. For example, although the PCL is often discussed as a valid measure (see Keane et al. 2008; McDonald and Calhoun 2010), work by McDonald and Calhoun (2010) demonstrates that the measure’s operating characteristics varied across populations and settings. Less work has been conducted to establish the psychometric properties of mTBI related self-report measures (e.g., Cicerone and Kalmar 1995; Schwab et al. 2007).
Table 3

Psychometric properties (Kaplan and Saccuzzo 2009)

Term

Definition

Reliability

The consistency of the measure to assess the construct of interest consistently. Classes of reliability estimates include: inter-rater, test-retest, inter-method, and internal consistency.

Validity

The ability of the measurement tool to assess what it claims to measure. In psychometrics, test validity refers to the evidence and theory that supports the interpretation of the measurement score. Types of validity include: construct, convergent, discriminant, content, face, criterion, concurrent, and predictive validity.

Positive Predictive Value (PPV)

The proportion of individuals that meet a set criterion for a condition who are correctly diagnosed with the condition. The value depends upon the prevalence of the outcome of interest, which may not be known for the target population.

PPV = Number of True Positives/(Number of True Positives + Number of False Positives)

Negative Predictive Value (NPV)

The proportion of individuals who do not meet a set criterion for a condition (negative for condition), but who are correctly diagnosed with the condition.

NPV = Number of True Negatives/(Number of True Negatives + Number of False Negatives)

Although there are benefits to self-report questionnaires, there are also serious limitations. Responses may be influenced by psychological and/or contextual variables and the accuracy of information obtained may be questionable and susceptible to response bias and distortion (Harrison et al. 1996; Lanyon and Goodstein 1997). Additionally, responses may be influenced by individuals’ motivational needs, such as self-interest or secondary gain. Most self-report measures have not been developed to account for possible exaggeration or under-reporting of symptom severity.

Self-report instruments are also limited with respect to diagnostic utility. There are no “gold standard” diagnostic self-report measures for either mTBI or PTSD. Moreover, self-report measures have limited utility in terms of differential diagnosis, and in fact may contribute to symptom misattribution. Given that researchers and clinicians alike have been using self-report measures for diagnostic and evaluation purposes in the OEF/OIF Veteran cohort, it is essential to review the literature on these assessment tools to assist in policy making, clinician diagnostic accuracy and development of “gold-standard” criteria. To our knowledge no previous reviews have examined the use of self-report mTBI and PTSD measures among returning OEF/OIF Veterans.

Search Strategy

In September 2011, four electronic databases (Journals at OVID, MEDLINE, PsychINFO, and Published International Literature on Traumatic Stress [PILOTS]) were searched for terms (medical subject headings [MeSH]) similar to terms used by Brewin (2005). Combinations of the following keywords were used: Veteran, PTSD, posttraum*, TBI, brain inj*, postconcus*, symptoms, self-report, measure, and instrument. Key words with an asterisk (*) were entered as a wildcard search terms to capture all possible permutations. Veteran was defined as Service members discharged or separated from the military, or individuals who had received VA services. Peer-reviewed, English-only articles published between 2001 (start of OEF/OIF conflicts) and 2011 were included.

Results

The initial searches yielded 414 articles; after combining the search results and removing duplicates, 238 articles were allocated for review. Exclusion criteria narrowed full text review to 31 studies. Two articles were found in bibliographies after the initial search and two recent studies were identified by the authors and included in final the review. Thus, 35 studies were included in review (Tables 4 & 5). Studies were excluded from review as follows. The focus of this search was on military Veterans and in particular the populations of individuals seeking care post-service within the Veterans Health Administration (VHA), therefore studies which solely focused on individuals who had not yet separated or been discharged from the military were excluded. Studies were also excluded if TBI and/or PTSD were established by medical record review and/or diagnosis by a clinician, without the use of a related self-report measure. Studies were also excluded if neither mTBI nor PTSD were the focus of the study, or if the study only included an incidental mentioning of the conditions, the population of interest did not include U.S. OEF/OIF Veterans, or the literature was not original research.
Table 4

Mild traumatic brain injury & postconcussive symptom studies

Study

Measure as described in study

N (Sample/Recruited)

Gender (Male%)

Population

Mean Score

SD

Observed Prevalence

Summary of Findings

Setting of Administration

Afari et al. 2009b

Author-devised medical symptom checklist, including headache

308 (442)

88%

OEF/OIF Veterans

4.2% with serious head injury with LOC

Physical injury, PTSD and substance abuse were significant predictors of self-reported headache.

VA Health Care System (VAHCS)

Belanger et al. (2011)a, b

NSI

390

94%

13% of sample were OEF/OIF Veterans; met ACRM criteria for mTBI

Blast mechanism of brain injury does not differ from non-blast injury in terms of PCS complaints

VA Medical Center (VAMC), Army Medical Center

Benge et al. (2009) b

NSI

345 (529)

96.2%

OEF/OIF Veterans

53.5

15.6

Posttraumatic stress explained 5–38% of the variance in individual postconcussive symptoms.

VAMC

Hill et al. (2009)

VA TBI screening tool

115

96%

OEF/OIF Veterans

81.7% answered “yes” to the screening questions; 85% of the positive TBI screens met ACRM criteria for probable mild TBI (mTBI)

Veterans with and without mTBI demonstrated similar symptom reporting. Veterans with mTBI and chart-review diagnosis of PTSD reported more exposures and symptoms compared with those with a history of TBI only.

Retrospective chart review at a VAMC

Iverson et al. (2011)

VA TBI screening tool

12,605 (327,633)

94.8%

OEF/OIF Veterans

NSI-22 Mean scale score ≥3

 

Based on the TBI screen, using the initial sample: 10.5% of women and 21.3% of men screened positive for TBI

Results showed that women were less likely to have a PTSD diagnosis than men. Women were twice as likely to have a depression diagnosis, and were more likely to have a non-PTSD anxiety disorder and PTSD with comorbid depression as compared to men. Also, women were more likely to endorse severe or very severe somatosensory, cognitive, and vestibular neurobehavioral symptoms.

VA National Patient Care Database

Severe/Very Severe Group Affective

34.6%

Somato-sensory

4.6%

NSI

Cognitive

28.6%

Vestibular

5.0%

Levin et al. (2010)a, b

NSI

52 (236)a 37 TBI group; 15 comparison group

OEF/OIF Veterans

Scores on measures of PC symptoms, PTSD, and global distress and dysfunction worse among those with TBI than the comparison group. Diffusion tensor imaging showed no group differences in white matter. Correlations of imaging and symptom measures were inconsistent and not significant.

VAMC

Lippa et al. (2010) b

VA TBI screening tool

370 (529)

96.2%

OEF/OIF Veterans

100% of the Veterans included in analysis met mTBI criteria.

Posttraumatic stress symptoms account for a large variance in PC symptom report.

two VAMCs

 

NSI

NSI Data Sample/Total Sample 339 (370)

    

Posttraumatic stress symptoms uniquely accounted for 46.6% of the variance in total PC symptom reporting. LOC uniquely accounted for 1.6% of this variance. PC symptom severity or cluster profile did not differ based on mechanism of TBI (blast vs. not blast)

  

Matthews et al. (2011)

BTBIS

22

100%

OEF/OIF Veterans

 

All subjects reported a history of at least 1 blast related mTBI; there were no significant differences on the number of mTBIs between the major depressive disorder (MDD) group and non-MDD group. LOC was more common in the MDD group (χ2 = 8.9, P <0.005)

VAMC

Meterko et al. (2012)

NSI

Derivation sample 6,001

Derivation sample 94.7%

OEF/OIF Veterans

 

Results confirmed original 4-factor model of the NSI-22 (Cicerone and Kalmar 1995), which include the four factors of somatosensory, affective, cognitive and vestibular symptoms. In addition, this study showed that Veterans with PTSD endorsed greater symptom severity on all factors compared to those without PTSD. Differences of level of symptom report were also noted for affective, cognitive somatosensory factors for individuals sustaining multiple TBIs (both blast and non-blast etiology). The exception was for vestibular symptom report.

VA national database

  

Validation sample 5,987 (36,919)

Validation sample 94.9%

      

Patil et al. (2011)

4 question mTBI screen

246 (250)

92.3%

OEF/OIF combat Veterans

100% of the 250 Veterans recruited were positive for mTBI based on screening questions & ACRM criteria

Results demonstrated an increased prevalence of headaches in Veterans with mTBI.

Retrospective chart review at a Veterans Health Administration Polytrauma Network Site

Pietrzak et al. (2009) b

4 question mTBI screen

277 (1000)

MTBI negative screen: 89.2% MTBI positive screen: 94.2%

OEF/OIF Veterans

18.8% screened positive for mTBI

Participants positive for mTBI were younger, more likely to have PTSD, report fair/poor overall health, unmet medical and psychological needs, and scored higher on psychosocial difficulties and perceived barriers to mental health care as compared to negative mTBI participants.

Surveys mailed to OEF/OIF Veterans from a VA database

Schneiderman et al. (2008) b

BTBIS

2,235 (7,259)

86%

OEF/OIF Veterans

Approx. 12% screened positive for mTBI

Mild TBI history was common among Veterans injured by a variety of mechanisms. Factors associated with PTSD included report of multiple injury mechanisms and combat mTBI. The strongest factor associated with PC symptoms was PTSD.

Mail questionnaire; addresses obtained by Department of Defense and National Change of Address database

Spencer et al. (2010)

NSI

105 (134)

OEF/OIF Veterans

52.4

15.0

Self-reported cognitive functioning was not significantly correlated with cognitive abilities as assessed by neuropsychological testing. Self-reported cognitive deficits were associated with depression, anxiety, and PTSD.

VAMC

Included if screened positive for possible head injury, excluded if moderate or severe TBI or demonstrated inconsistent effort on neuropsychological testing

Tan et al. (2009)

4-item screener: 1) exposure 2) presence of alteration in mental status 3) presence of immediate, and 4) residual PCS

28

57%

 

64% screened positive to all 4 items

This sample demonstrated depressed heart rate variability. Heart rate variability may be influenced by the effects of pain, PTSD and mTBI.

 
 

NSI (grouped by cluster)

  

Cluster

     
   

Physical

TBI Group: 1.33; Comparison Group: 0.72

TBI Group: 0.73; Comparison Group: 0.73

   
  

Cognitive

TBI Group: 2.23; Comparison Group: 1.43

TBI Group: 0.90; Comparison Group: 1.21

   
  

Affective

TBI Group: 2.24; Comparison Group: 1.38

TBI Group: 0.99; Comparison Group: 1.13

   
  

Sensory

TBI Group: 1.82; Comparison Group: 0.83

TBI Group: 1.05; Comparison Group: 1.06

   
  

Sum of mean cluster scores

TBI Group: 7.64; Comparison Group: 4.36

TBI Group: 3.02; Comparison Group: 3.69

   
  

Headache

2.3

1

   
  

Sleep disturbance

2.6

1.2

   

PCS 3+ (self-attribution of 3 or more current neuropsychiatric symptoms including headache, dizziness, memory problems, balance problems, ringing in the ears, irritability and sleep problems)

35% of within-theater mTBI reported persistent PCS3+

 

Zeber et al. (2010)a, b

Self-report of TBI (one item)

347

33.10%

OEF/OIF Veteran, active duty service-member or family member

1.1% self-reported TBI

Veterans and their loved ones reported serious social disruptions from military service, and a high prevalence of traumatic combat events.

Urban and suburban practice-based Ambulatory Research Network primary care clinics

aStudy included other era Veterans or Active Duty sample

bStudies included in both Tables 4 and 5

Table 5

Posttraumatic stress studies

Study

Measure as described in study

N (Sample/Recruited)

Gender (Male%)

Population

Mean Score

SD

Observed Prevalence

Summary of Findings

Setting of Administration

Afari et al. 2009b

DTS

308 (442)

88%

OEF/OIF Veterans

40% met criteria for PTSD

Veterans with PTSD and combat-related physical injury were more likely to report headaches. PTSD was found to be associated with both migraine and tension-type headache, while combat-related physical injury was primarily related to migraine headache.

VAHCS

Alvarez et al. (2011)

PCL

197

100%

aMale Veterans (15.3% served in Iraq/Afghanistan) assigned to Cognitive Processing Therapy group)

CPT at Intake: 64.05 CPT at Discharge: 55.50

CPT at Intake: 11.14 CPT at Discharge: 12.78

CPT participants’ demonstrated PC symptom improvement at time of discharge as compared to the treatment as usual group.

Veterans Health Administration Residential Treatment Program

Baker et al. 2009

DTS

339 (449)

89%

OEF/OIF Veterans & Reservists

36.9% if yes to emotional trauma item and DTS score ≥40

Most recent military branch and physical injury were significantly associated with screening positive for PTSD

VAHCS Member Services (initial registration)

Belanger et al. (2011)a, b

PCL

390

94%

13% of sample were OEF/OIF Veterans

Blast group: 41.5 Non-Blast: 37.3

Blast group: 17.4 Non-Blast group: 17.6

Mechanism of TBI and severity of mTBI did not significantly account for variance in PC symptom reporting. Symptom reporting was greater in individuals with PTSD.

VAMCs/WRAMC

Benge et al. (2009) b

PCL-C

345 (529)

96.2%

OEF/OIF Veterans

53.5

15.6

55.7% (PCL score ≥50)

Posttraumatic stress explained 5–38% of the variance in individual postconcussive symptoms.

VAMC

Burnett-Zeigler et al. 2011

PCL-M

562 (585)

87%

OEF/OIF National Guard demobilized

PTSD in the Alcohol Misuse group: 60%; PTSD in the non-Alcohol Misuse group: 40%

Rates of alcohol misuse in the National Guard sample was high and utilization of substance abuse treatment was low.

Mandatory National Guard Reintegration Reunion Workshop following demobilization from active duty deployment

Calhoun et al. (2010)

DTS

220 (241)

80%

OEF/OIF Veterans

24.5% PTSD; 29.6% with PTSD also met TBI criteria;

The DTS and SPAN (calculated from items on the DTS) were better predictors of PTSD than the PC-PTSD screen

VA MIRECC Registry

Carlson et al. (2011)

PC-PTSD screen; self-report health indicator of PTSD (item not listed)

742 (1500); Post-depoyment Injured: 348 Post-deployment Not injured: 394

Post-deployment Injured: 43.4% Post-deployment Not injured: 46.7%

OEF/OIF combat Veterans

PTSD Screen Positive Post-deployment Injured: 51.7% Post-deployment Not injured: 32.5%; Self-reported Diagnosis Post-deployment Injured: 41.8%, Post-deployment Not injured: 24.1%

Findings from the multivariate models indicate that Veterans with probable PTSD, self-reported diagnosed depression and anger problems had greater odds of post-deployment injury. Deployment-related injuries were associated with odds of post-deployment injury.

Survey mailed to Iraq/Afghanistan combat veterans who had accessed the VA between 2003 and 2007.

Erbes et al. (2009)

PCL-C

106 (212)a

95%

OEF/OIF Veterans

52.42

12.8

OEF/OIF Veterans showed lower rates of avoidance and higher rates of active alcohol problems than Vietnam Vets. OEF/OIF Veterans also showed less distress when compared to Vietnam Veterans.

VAMC aOEF/OIF sample compared to Vietnam sample

TSI

  

Anxious-Arousal

13.78

4.96

   
   

Depression

10.84

5.47

   
   

Anger/Irritability

17.32

6.09

   
   

Intrusive Experiences

11.72

5.81

   
   

Defensive Avoidance

11.57

6.18

   
   

Dissociation

11.19

5

   
   

Impaired Self-Reference

11.15

5.05

   
   

Tension Reduction Behavior

6.06

3.9

   

Garcia et al. (2011a)

PCL-M

69

100%

OEF/OIF Veterans

64.74

9.68

Masculine Behavior Scale scores were not correlated with overall PTSD severity.

VAMC

Garcia et al. (2011b)

PCL-M

117

95.70%

OEF/OIF Veterans

Tx Dropouts: 63.63 Tx Completers: 55.81

Tx Dropouts: 11.98 Tx Completers: 13.94

Veterans who dropped out of treatment differed significantly from those who did not in terms of MMPI-2 scale scores, PTSD symptom severity, and age.

VAMC

Gewirtz et al. (2010)

PCL-M

953 (2677)

100%

OIF National Guard Veterans (70.8% had received care from VA)

Time 1: 30.54 Time 2: 34.57

Time 1: 11.33 Time 2: 14.82

At time 2, increases in PTSD symptoms were associated with poorer couple adjustment and greater parenting challenges (p < .001).

Survey in-theater and 1 year postdeployment

Guerra et al. (2011)

DTS

393

82%

Veteran who served post- 9/11/2001

48.49

40.54

PTSD diagnosed participants with co-morbid major depressive disorder and alcohol use disorder were no more likely to endorse suicidal ideation than those PTSD participants without co-morbid conditions.

Recruited from VA MIRECC Registry; conducted at a VAMC

Helmer et al. (2009)

PC-PTSD screen

429

83.90%

OEF/OIF Veterans

2.4

1.6

53.4% screened positive for PTSD

Chronic widespread pain was common as were positive mental health screens (PTSD, depression, alcohol misuse).

War-Related Illness and Injury Study Center (WRIISC)

Jakupcak et al. (2010)

PCL-C

287 (336)

OEF/OIF Veterans

37.3% PTSD

Veterans positive for PTSD or depression were two times more likely to report alcohol misuse, compared to those without positive screens.

VAMC

Katz et al. (2009)

PCL-M

(215) 237

85.10%

OEF/OIF Veterans

43.3

20.2

The Post-Deployment Readjustment Inventory (PDRI) demonstrated excellent internal consistency and strong correlations with standardized measures.

VAMC

PDRI (PTSD symptoms)

  

22.4

9.13

  

Levin et al. (2010)a, b

PCL-C

52 (236)a 37 TBI group; 15 Comparison group

OEF/OIF Veterans

TBI Group: 55.57; Comparison Group: 40.07

TBI Group: 15.64; Comparison Group: 19.59

Scores on measures of PC symptoms, PTSD, and global distress and dysfunction worse among those with TBI than the comparison group. Diffusion tensor imaging showed no group differences in white matter. Correlations of imaging and symptom measures were inconsistent and not significant.

VAMC

Lippa et al. (2010) b

PCL

518 (529)

96.20%

OEF/OIF Veterans

54.61

15.52

61.4% of the participants with mTBI met PTSD cutoff score of ≥50

Posttraumatic stress symptoms account for a large variance in PC symptom reporting.

two VAMCs

McDonald et al. (2008)a

DTS

313 (629)a

80.20%

OEF/OIF Registry Veterans

51.9

38.2

Confirmatory Factor Analysis demonstrated that the 4-factor structural model of the DTS was superior to alternate models.

aStudy also included Vietnam Vets, data reported on OEF/OIF Vets only; VAMC, VA MIRECC Registry

McDevitt-Murphy et al. (2010)

PCL-M

151 (204 derived from info)

90.10%

OEF/OIF Veterans

42.9

18.6

39.1% screened positive for PTSD (PCL score >34)

PTSD symptoms and hazardous drinking were significantly correlated. Both were also significantly correlated with health functioning.

VAMC

Nelson et al. (2009)a

PCL-M

54 (70)

98%

OEF/OIF combat Veterans

35% PTSD (score >50)

Processing speed significantly contributes to performance on some executive functioning measures in a sample of TBI Veterans with and without PTSD.

VAMCs

Nunnink et al. (2010)

DTS

36

all female

OEF/OIF Veterans & Reservists

31% PTSD

A large percentage of a small sample of OEF/OIF female Veterans screened positive for PTSD symptoms. Almost half had a positive screen for high-risk drinking behaviors.

VAMC

Ouimette et al. (2011)a

IES-R

490 (500)

53%

19% OEF/OIF male Veterans; 33% OEF/OIF female Veterans

PTSD symptoms were associated with perceived barriers to care, with PTSD avoidance symptoms positively associated across all barriers to care scales. Individuals with more severe PTSD symptoms rated barriers to care as somewhat more important than individuals with lower severity of PTSD symptoms.

Mail survey to VA users

Pietrzak et al. (2009) b

PCL-M

277 (1000)

MTBI negative screen: 89.2% MTBI positive screen: 94.2%

OEF/OIF Veterans

MTBI negative screen, positive for PTSD: 24.4%; MTBI positive screen, positive for PTSD: 65.4%

Participants positive for mTBI were younger, more likely to have PTSD, and report fair/poor overall health, unmet medical and psychological needs, and score higher on measures of psychosocial difficulties and perceived barriers to mental health care as compared to negative mTBI participants.

Surveys mailed to OEF/OIF Veterans from a VA database

Pietrzak et al. (2010)

PCL-M

167

95.80%

OEF/OIF Veterans

65.6% PTSD

PTSD was associated with increased sleep difficulties, most notably sleep disturbances, daytime dysfunction, and sleep quality.

VAMC

Sayer et al. (2010)

PC-PTSD screen

754

45%

OEF/OIF combat Veterans

Diagnosis in VA records: PTSD 26%, TBI 4%; PC-PTSD screen 41%; PTSD and drug/alcohol problem 19%

Probable PTSD, as determined by the PC-PTSD screen, was associated with increased reports of readjustment difficulties and expressed interest in more types of services, including tradition mental health services.

Survey mailed to Iraq/Afghanistan combat Veterans who made at least one visit to a VA facility between 2003 and 2007

Schneiderman et al. (2008) b

PCL-17

2,235 (7,259)

86%

OEF/OIF Veterans

11% classified as having PTSD (PCL-17 score ≥50)

Mild TBI history was common among Veterans injured by a variety of mechanisms. Factors associated with PTSD included report of multiple injury mechanisms and combat mTBI. The strongest factor associated with PC symptoms was PTSD.

Mail questionnaire; addresses obtained by DoD and National Change of Address database

Spencer et al. (2010)

PCL-M

105 (134)

OEF/OIF Veterans

52.4

15.0

Self-reported cognitive functioning was not significantly correlated with cognitive abilities as assessed by neuropsychological testing. Self-reported cognitive deficits were associated with depression, anxiety, and PTSD.

VAMC

Included if screened positive for possible head injury, excluded if moderate or severe TBI or demonstrated inconsistent effort on neuropsychological testing

Zeber et al. (2010)a, b

Self-report of Depression or PTSD

347

33.10%

OEF/OIF Veteran, active duty service-member or family member

Self-report of Depression or PTSD of deployed individual prevalence was 12.7%

Veterans and their loved ones reported serious social disruptions from military service, and a high prevalence of traumatic combat events.

Urban and suburban practice-based Ambulatory Research Network primary care clinics

aStudy included other era Veterans or Active Duty sample

bStudies included in both Tables 4 and 5

The majority of the research articles focused on negative outcomes associated with PTSD or mTBI, including physical health, level of general functioning, social relationships, and health behaviors (e.g., substance abuse). Measures of interest were often used to identify symptoms or establish potential diagnoses and psychometric properties of these measures were frequently not presented. Limitations of a number of these studies included small sample size, use of mixed Veteran cohorts, non-random samples of Veterans seeking healthcare, limited attention to disability status, and limited enrollment of female participants.

mTBI Studies

The majority of mTBI studies recruited Veteran samples from VHA or military medical centers or associated databases and sample sizes ranged from 22 (Matthews et al. 2011) to 12,605 (Iverson et al. 2011) participants, with the majority of studies having very small sample sizes and few women. Only two studies examined neuropsychological (Levin et al. 2010; Spencer et al. 2010) and neuroimaging (Levin et al. 2010) findings associated with self-reported cognitive impairment. Spencer and colleagues (2010) examined the relationship between cognitive functions and self-reported cognitive symptoms, anxiety, depression and PTSD in an OEF/OIF Veteran cohort that met criteria for mTBI. A 22-item VA standardized checklist was used to assess subjective cognitive symptoms of concentration, memory, and thinking/organization (Spencer et al. 2010). Neuropsychological measures included the Digit Span subtest of the Wechsler Adult Intelligence Scale-IV, the Vocabulary subtest from the Shipley Institute of Living Scale, the Trail Making Test, Parts A and B, the Story Memory subtest from the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), and the Rey Complex Figure Test (Spencer et al. 2010). Spencer and colleagues (2010) found that self-reported memory concerns were significantly associated with the RBANS delayed story recall score. Neither attention nor thinking/organization self-reported impairment was significantly associated with cognitive abilities.

Levin and colleagues (2010) reported that the structure and integrity of brain white matter, assessed by magnetic resonance imaging and diffusion tensor imaging, in Veterans and Service members who reported mild to moderate TBI did not differ from control participants. PTSD was measured with the PCL-C, and post-concussion symptoms were measured with the NSI. Memory was assessed by the Verbal Selective Reminding Test and the Nonverbal Selective Reminding Test, and decision making was assessed with the Iowa Gambling Task. Results from the cognitive measures demonstrated verbal learning and memory and delayed recall of the word list was impaired in the TBI group compared with the control group.

Given the limitations mentioned above and the lack of consistency of measurement rating scales, it is difficult to make generalizations about outcomes. However, most common among the findings in these studies was that PCS symptoms were related to PTSD (Afari et al. 2009; Benge et al. 2009; Hill et al. 2009; Levin et al. 2010; Meterko et al. 2012; Pietrzak et al. 2009; Schneiderman et al. 2008) and depression (Iverson et al. 2011; Matthews et al. 2011). Two studies did not find significant differences in terms of symptom reporting when comparing Veterans with blast or non-blast mTBI (Belanger et al. 2011; Lippa et al. 2010). One study found higher levels of symptom severity were reported by individuals who sustained multiple TBIs (blast and non-blast) across affective, cognitive and somatosensory factors, as compared to those with only blast or non-blast TBI (Meterko et al. 2012).

PTSD Studies

The majority of studies used the PCL-military or civilian versions or the DTS, and most studies recruited their subjects from VA and military settings or associated databases. The smallest sample size was 36 (Nunnink et al. 2010) and the largest was 2,235 (Schneiderman et al. 2008), with the majority of studies having very small sample sizes and relatively few women in their samples.

Self-reported PTSD was associated with headache (Afari et al. 2009), increased symptom report of PCS (Afari et al. 2009; Belanger et al. 2011; Benge et al. 2009; Lippa et al. 2010; Schneiderman et al. 2008), increased post-deployment injury (Carlson et al. 2011), chronic pain (Helmer et al. 2009), and higher rates of alcohol use (Burnett-Zeigler et al. 2011; Erbes et al. 2009; Jakupcak et al. 2010; McDevitt-Murphy et al. 2010). In addition, studies found probable PTSD was associated with poorer adjustment (Sayer et al. 2010), distress and poorer health functioning (Levin et al. 2010; McDevitt-Murphy et al. 2010; Pietrzak et al. 2009), relationship status (Gewirtz et al. 2010; Pietrzak et al. 2009; Zeber et al. 2010) and self-report of cognitive impairment (Spencer et al. 2010). PTSD was also associated with a perception regarding increased barriers to care (Ouimette et al. 2011; Pietrzak et al. 2009).

Only three studies compared self-report measures of PTSD with neurocognitive (Nelson et al. 2009; Spencer et al. 2010) or neuroimaging (Levin et al. 2010) data. Nelson and colleagues (2009) assessed 53 OEF/OIF individuals with a history of mTBI using the Wechsler Adult Intelligence Scale-III Symbol Search and Digit Symbol-Coding subscales, Stroop Word, Color and Color-Word trials, and both Parts A and B of the Trail Making Test. Veterans with co-morbid PTSD and mTBI had significant differences in processing speed compared to Veterans with mTBI, but without PTSD (Nelson et al. 2009). In addition, Veterans with PTSD and mTBI scored significantly worse than the mTBI-only group. Spencer and colleagues (2010) examined neuropsychological testing and self-reported PTSD and indicated a positive association between the number of psychiatric symptoms (PTSD, anxiety, depression) reported and the degree of self-reported cognitive dysfunction. Levin and colleagues (2010) found that participants with TBI had higher mean total PTSD symptoms on the PCL-C, as compared to the control group. Neuroimaging results were not different between groups.

This review of self-report measures reveals the following commonalities and differences between mTBI and PTSD literatures. In the mTBI literature, most studies either used the NSI or one of the common mTBI screening tools (BTBIS, VA TBI-4 screening tool). By contrast, although the majority of PTSD studies used some version of the PCL, there tended to be more variability in the measures used (e.g., DTS, or the Primary Care–PTSD screen), and the measures were not consistently used for the same purposes (e.g., predictor, dependent, and/or control variables). While some studies across both domains yielded “observed prevalence” estimates, it was challenging to determine how the investigators calculated the prevalence, and what type of prevalence was used (point, period, or lifetime). Existing literature in which both self-report and neuropsychological or neuroimaging assessments were used was limited. The current literature review yielded three studies that compared or used both types of assessment. Two of these studies included both PTSD and mTBI self-report measures. In the third, only a PTSD measure was used despite the fact that the population was an mTBI Veteran cohort.

Conclusions

Despite the growing availability and widespread use of self-report measures for assessing mTBI or PTSD and associated symptoms among OEF/OIF Veterans, results from this literature review suggest a dearth of research aimed at establishing the psychometric properties of these frequently used measures. This finding is supported by the following assertion from McDonald and Calhoun (2010), “There is a critical lack of diagnostic accuracy studies [of the PCL] in several prominent populations such as Iraq and Afghanistan war Veterans” (p. 985). Moreover, results from the presented literature review also suggest that almost no research has been conducted to assess or report the psychometric proprieties of tools/measures designed to screen/assess for mTBI or PTSD in populations where conditions are co-occurring. Similarly, no self-report measures have been identified to reliably assess for both disorders or to assist in differential diagnosis. In light of the high rate of co-occurrence of these two conditions, particularly among returning OEF/OIF Veterans, this finding is particularly salient. These results support the use of clinical interviews, the current “gold standard” for mTBI and PTSD, when the goal of the evaluation is differential diagnosis. As the recent studies by Meterko et al. (2012) and Iverson et al. (2011) suggest, there is likely variability in severity and type of symptom report depending upon the mechanism of injury (blast versus non-blast TBI) and sex of the afflicted. Valid scales are essential to develop given their significance in clinical diagnoses and determination of disability status.

There is a gap in investigations of the combined use of neuropsychological or neuroimaging and self-report measures among Veterans with mTBI and/or PTSD. Integrated neuropsychological evaluation should include a thorough assessment of self-reported symptoms, including onset, frequency, duration, severity and report of changes over time (Groth-Marnat 2009). However, until data on the psychometric properties for populations of interest are available, there will be risk in interpretation of test scores. When using self-report measures to assess mTBI or PTSD and associated symptoms, it is important to consider the particular goals of the assessment. Many of the measures presented in Table 2 provide information regarding symptoms (i.e., PC or PTSD), but are less likely to be useful if the aim of the assessment is diagnostic in nature. For example, in the case of diagnostic screening, it is often necessary to determine if an individual’s description of a symptom meets diagnostic criterion (Weathers et al. 2009). Self-report measures do not allow individuals to provide examples or descriptive information related to specific symptom criteria. On the other hand, structured clinical interviews, such as the Clinician Administered PTSD Scale (CAPS; Blake et al. 1990) or Ohio State University TBI-ID (OSU TBI-ID; Corrigan and Bogner 2007), elicit such information and allow practitioners/researchers to assess whether an individual’s description accurately reflects the criterion in question. When assessing PC symptoms the link between injury event and symptom onset is imperative. Measures such as the NSI do not necessarily assist the examiner in this process. In terms of PTSD, it is essential to establish that all symptoms are tied to a single identified traumatic event (Briere 2004; Weathers et al. 2009). When selecting self-report measures, it is important to note that responses on some measures are not anchored to a specific traumatic event (e.g., PTSD Checklist-Civilian [PCL-C]). On other measures, such as the PTSD Checklist-Specific (PCL-S) or the DTS, the respondent is instructed to consider a specific stressor when rating symptoms.

Though not necessary to establish a diagnosis of mTBI or PTSD, quantifying PTSD or PC symptom severity allows clinicians and researchers to monitor changes in symptoms over time and assess treatment effects (Weathers et al. 2009). In this vein, self-report measures of symptoms may be useful in providing a continuous measure of symptom severity for the syndrome as well as symptom clusters (e.g., somatic, hypervigilance). Moreover, these measures may be used in conjunction with other diagnostic assessment tools to determine the extent of brain impairment and potential recovery rates.

The interplay between PC symptoms and PTSD is also important. Presence of PTSD can exacerbate cognitive and other post-concussive symptoms. In turn, the cognitive impairment and emotional difficulties associated with TBI may affect individuals’ ability to manage and effectively cope with PTSD symptoms. Self-report measures may help clinicians monitor such symptoms of interest regardless of their etiology.

Although the preponderance of clinical research in the past decade in both civilian and military populations has focused on identifying empirically supported treatments, more recently, researchers are emphasizing other types of evidence-based practices, including assessment. As a result, significant progress has been made in the last 5 years to establish guidelines for evaluating evidence-based assessment; however, more work is needed to ensure that the guidelines are applied to a variety of clinical conditions and populations to identify measures that are both psychometrically sound and clinically useful. In this vein, establishing evidence-based measures for mTBI and PTSD in OEF/OIF Veterans is pertinent to clinical decision making and will assist in developing and evaluating evidence-based treatments for these conditions.

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Copyright information

© Springer Science+Business Media, LLC (outside the USA) 2012

Authors and Affiliations

  • Lisa M. Betthauser
    • 1
    • 2
  • Nazanin Bahraini
    • 1
    • 3
  • Maxine H. Krengel
    • 4
    • 5
  • Lisa A. Brenner
    • 1
    • 3
    • 6
    • 7
  1. 1.Veterans Integrated Service Network 19, Mental Illness Research Education and Clinical CenterDenverUSA
  2. 2.Department of PsychologyUniversity of Colorado DenverDenverUSA
  3. 3.Department of PsychiatryUniversity of Colorado, Denver, School of MedicineDenverUSA
  4. 4.VA Boston Healthcare SystemBostonUSA
  5. 5.Department of NeurologyBoston University, School of MedicineBostonUSA
  6. 6.Department of NeurologyUniversity of Colorado, Denver, School of MedicineAuroraUSA
  7. 7.Department of Physical Medicine and RehabilitationUniversity of Colorado, Denver, School of MedicineAuroraUSA

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