The purpose of this study was to examine the clinical utility of three recently developed validity scales (Validity-10, NIM5, and LOW6) designed to screen for symptom exaggeration using the ...Neurobehavioral Symptom Inventory (NSI). Participants were 272 U.S. military service members who sustained a mild, moderate, severe, or penetrating traumatic brain injury (TBI) and who were evaluated by the neuropsychology service at Walter Reed Army Medical Center within 199 weeks post injury. Participants were divided into two groups based on the Negative Impression Management scale of the Personality Assessment Inventory: (a) those who failed symptom validity testing (SVT-fail; n = 27) and (b) those who passed symptom validity testing (SVT-pass; n = 245). Participants in the SVT-fail group had significantly higher scores (p<.001) on the Validity-10, NIM5, LOW6, NSI total, and Personality Assessment Inventory (PAI) clinical scales (range: d = 0.76 to 2.34). Similarly high sensitivity, specificity, positive predictive power (PPP), and negative predictive (NPP) values were found when using all three validity scales to differentiate SVT-fail versus SVT-pass groups. However, the Validity-10 scale consistently had the highest overall values. The optimal cutoff score for the Validity-10 scale to identify possible symptom exaggeration was ≥19 (sensitivity = .59, specificity = .89, PPP = .74, NPP = .80). For the majority of people, these findings provide support for the use of the Validity-10 scale as a screening tool for possible symptom exaggeration. When scores on the Validity-10 exceed the cutoff score, it is recommended that (a) researchers and clinicians do not interpret responses on the NSI, and (b) clinicians follow up with a more detailed evaluation, using well-validated symptom validity measures (e.g., Minnesota Multiphasic Personality Inventory-2 Restructured Form, MMPI-2-RF, validity scales), to seek confirmatory evidence to support an hypothesis of symptom exaggeration.
To examine the reliability and validity of the short form (SF) and computer adaptive test (CAT) versions of the Patient-Reported Outcomes Measurement Information System (PROMIS) measures of social ...health of caregivers of civilians and service members/veterans (SMVs) with traumatic brain injury (TBI).
Self-report questionnaires administered through an online data collection platform.
Hospital and community-based outreach at 3 TBI Model Systems rehabilitation hospitals, an academic medical center, and a military medical treatment facility.
Caregivers (N=560) (344 civilians and 216 military) of individuals with a documented TBI.
Not applicable.
A total of 5 PROMIS social health measures.
All 5 PROMIS social health measures exceeded the a priori criterion for internal consistency reliability (≥0.70); most PROMIS measures met the criterion for test-retest reliability (≥0.70) in the civilian sample; in the SMV sample, test-retest reliability was generally below this criterion, except for social isolation. For both samples, convergent validity was supported by moderate correlations between the 5 PROMIS social health measures and related measures, and discriminant validity was supported by low correlations between PROMIS social health measures and measures of dissimilar constructs. Most PROMIS scores indicated significantly worse social health in both samples of those caring for individuals who were low functioning. Finally, impairment rates in social health were elevated for those caring for low-functioning individuals, especially in the SMV sample.
The PROMIS CAT and SF social health measures have potential clinical utility for use in caregivers of civilians and SMVs with TBI.
To examine the influence of different performance validity test (PVT) cutoffs on neuropsychological performance, post-concussion symptoms, and rates of neurocognitive disorder and postconcussional ...syndrome following mild traumatic brain injury (MTBI) in active duty service members.
Participants were 164 service members (Age: M = 28.1 years SD = 7.3) evaluated on average 4.1 months (SD = 5.0) following injury. Participants were divided into three mutually exclusive groups using original and alternative cutoff scores on the Test of Memory Malingering (TOMM) and the Effort Index (EI) from the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS): (a) PVT-Pass, n = 85; (b) Alternative PVT-Fail, n = 53; and (c) Original PVT-Fail, n = 26. Participants also completed the Neurobehavioral Symptom Inventory.
The PVT-Pass group performed better on cognitive testing and reported fewer symptoms than the two PVT-Fail groups. The Original PVT-Fail group performed more poorly on cognitive testing and reported more symptoms than the Alternative PVT-Fail group. Both PVT-Fail groups were more likely to meet DSM-5 Category A criteria for mild and major neurocognitive disorder and symptom reporting criteria for postconcussional syndrome than the PVT-Pass group. When alternative PVT cutoffs were used instead of original PVT cutoffs, the number of participants with valid data meeting cognitive testing criteria for neurocognitive disorder or postconcussional syndrome decreased dramatically.
PVT performance is significantly and meaningfully related to overall neuropsychological outcome. By using only original cutoffs, clinicians and researchers may miss people with invalid performances.
The purpose of this study was to examine individual postconcussion symptom PCSx trajectories following mild traumatic brain injury (MTBI), and to examine risk factors for persistent PCSx reporting.
...Participants were 138 U.S. military service members and veterans (SMVs) prospectively enrolled in the Defense and Veterans Brain Injury Center, 15-Year Longitudinal TBI study. Participants were classified into three groups: uncomplicated MTBI (n = 54), injured controls (IC, n = 26), and non-injured controls (NIC, n = 58). Participants completed the Neurobehavioral Symptom Inventory, PTSD Checklist, and Traumatic Brain Injury Quality of Life at baseline (<8 months post-injury) and at follow-up (2-4 years post-injury).
The prevalence of those who met DSM-IV-TR symptom criteria for Postconcussional Disorder (PCD) was high in all three groups (e.g., 44.8-63.0%) and did not significantly change from baseline to follow-up (all ps>.05). However, there was substantial variability in individual symptom trajectories over time. The majority of participants had symptom trajectories classified as either 'persistent' (∼32-55%) or 'asymptomatic' (∼30-36%), with a substantial minority classified as 'improved' (∼7-12%) or 'developed' (∼7-19%). Factors associated with 'persistent' PCD trajectories included cognitive complaints, PTSD, depression, anxiety, pain, and headaches at baseline; but not the presence/absence of MTBI. Factors associated with 'developed' PCD trajectories included PTSD and the number of lifetime exposures to blast.
Conclusions: Reporting of 'new' PCSx over time was common in individuals with and without MTBI. It would be erroneous to assume uncritically that PCSx reported many years post-injury reflect only persistent symptomatology, or can be solely attributable to the direct consequences of a brain injury.
The purpose of this study was to examine the relationship between resilience and self-reported neurobehavioral functioning following traumatic brain injury (TBI) in U.S. military service members and ...veterans (SMVs). A secondary objective was to examine the interaction between resilience and posttraumatic stress disorder (PTSD) on neurobehavioral functioning.
Participants included 795 SMVs classified into four groups: Uncomplicated Mild TBI (MTBI; n=300); Complicated Mild, Moderate, Severe, or Penetrating TBI (STBI, n 162); Injured Controls (IC, n=185); and Non-injured Controls (NIC, n=148). Two independent cohorts were evaluated - those assessed within 1-year of injury and those assessed 10-years post-injury. SMVs completed self-report measures including the PTSD Checklist-Civilian version, Neurobehavioral Symptom Inventory, and TBI-Quality of Life.
Results showed that (1) lower resilience was strongly associated with poorer neurobehavioral functioning across all groups at 1-year and 10-years post-injury, and (2) PTSD and resilience had a robust influence on neurobehavioral functioning at both time periods post-injury, such that SMVs with PTSD and low resilience displayed the poorest neurobehavioral functioning.
Results suggest that regardless of injury group and time since injury, resilience and PTSD strongly influence neurobehavioral functioning following TBI among SMVs. Future research evaluating interventions designed to enhance resilience in this population is indicated.
Objective: The current study examines health-related quality of life (HRQOL) and family functioning in a sample of spouse caregivers assisting post-9/11 service members and veterans (SMV) following ...traumatic brain injury (TBI). Method: Participants were 316 spouse (and partner) caregivers of SMVs following a mild, moderate, severe, or penetrating TBI. Caregivers completed the Family Assessment Device General Functioning subscale, 24 HRQOL questionnaires, and the Mayo-Portland Adaptability Inventory (4th ed.; MPAI-4). The sample was divided into two family functioning groups: Healthy Family Functioning (HFF; n = 162) and Unhealthy Family Functioning (UFF; n = 154). Scores on HRQOL measures that generate T scores using normative data were classified as "clinically elevated," using a cutoff of >60T. Results: Compared with the HFF group, caregivers in the UFF group reported worse scores on all HRQOL measures and worse SMV functional ability on the MPAI-4 Adjustment Index and Anxiety, Depression, and Irritability/Anger/Aggression items (all ps < .001, ds = .41-1.36). A significantly higher proportion of the UFF group had clinically elevated HRQOL scores compared with the HFF group on the majority of measures (Hs = .24-.75). When examining all HRQOL measures simultaneously, the UFF group consistently had a significantly higher cumulative percentage of clinically elevated scores compared with the HFF group (e.g., ≥5 clinically elevated scores: UFF = 53.9% vs. HFF = 22.2%; H = .68). Conclusions: Caring for a SMV following TBI with comorbid mental health problems may have negative implications for their family functioning and the caregiver's HRQOL. Family-centered interventions could be beneficial for military families experiencing distress following SMV TBI and mental health comorbidity.
Clinical Impact StatementClose to one in two spouse caregivers assisting service members and veterans (SMVs) following traumatic brain injury reported unhealthy family functioning. Unhealthy family functioning was related to worse caregiver health-related quality of life (HRQOL), whereas healthy family functioning was associated with factors that may mitigate poor HRQOL. Despite increasing evidence of the burden of caregiving, military policy continues to mandate that family services may only be provided in support of the SMV treatment plan. Money spent on caregiver and family-focused programs might improve outcomes for military families and could be achieved at a relatively modest cost with focused goals.
To provide important reliability and validity data to support the use of the Patient-Reported Outcomes Measurement Information System (PROMIS) mental health measures in caregivers of civilians or ...service members/veterans (SMVs) with traumatic brain injury (TBI).
Patient-reported outcome surveys administered through an electronic data collection platform.
Three TBI model systems rehabilitation hospitals, an academic medical center, and a military medical treatment facility.
Caregivers (N=560) of individuals with a documented TBI (344 civilians and 216 military).
Not applicable.
PROMIS anxiety, depression, and anger item banks.
Internal consistency for all the PROMIS Mental Health item banks was very good (all α>.86) and 3-week test-retest reliability was good to adequate (ranged from .65 to .85). Convergent validity and discriminant validity of the PROMIS measures were also supported. Caregivers of individuals who were low functioning had worse emotional health-related quality of life (HRQOL) (as measured by the 3 PROMIS measures) than caregivers of high-functioning individuals, supporting known groups validity. Finally, levels of distress, as measured by the PROMIS measures, were elevated for those caring for low-functioning individuals in both samples (rates ranged from 26.2% to 43.6% for caregivers of low-functioning individuals).
Results support the reliability and validity of the PROMIS anxiety, depression, and anger item banks in caregivers of civilians and SMVs with TBI. Ultimately, these measures can be used to provide a standardized assessment of HRQOL because it relates to mental health in these caregivers.
Background and Objectives
APOE e4 has been linked to poor outcome following traumatic brain injury (TBI); however, the mechanisms behind this relationship are unclear. Few studies have investigated ...the relationship between the APOE genotype and established brain related protein biomarkers following TBI. The purpose of this study was to examine this relationship in service members and veterans (SMVs) following TBI.
Methods
Participants were 209 SMVs 124 uncomplicated mild TBI (mTBI); 85 complicated mild, moderate, severe, or penetrating TBI (mod-sev TBI) prospectively enrolled in the DVBIC-TBICoE 15-Year Longitudinal TBI Study. APOE genotyping was undertaken using non-fasting blood serum samples. Participants were divided into three groups: APOE e2+, APOE e3/e3, and APOE e4+.
Results
In participants with mTBI, those with the APOE e2 allele had significantly lower levels of tau than those with APOE e4 (
p
= 0.005,
r
= 0.43, medium-large effect size). Those with APOE e3/e3 trended toward having higher tau than those APOE e2+ (
p
= 0.076,
r
= 0.20, small-medium effect size) and lower tau than those with APOE e4+ (
p
= 0.062,
r
= 0.21, small-medium effect size). There were no significant differences in biomarkers based on APOE in the mod-sev TBI group.
Discussion
This study is the first to demonstrate APOE genotype is related to serum tau levels following a mTBI, extending prior findings to human serum following mTBI. In addition to higher serum tau levels in APOE e4 carriers, lower tau levels were observed in APOE e2 carriers, suggesting a possible protective effect.
This study aimed to identify risk factors predictive of the presence and persistence of posttraumatic stress disorder (PTSD) symptom reporting following traumatic brain injury (TBI). Participants ...were 1,301 U.S. service members and veterans (SMVs) divided into four groups: uncomplicated mild TBI (mTBI; n = 543); complicated mild, moderate, severe, and penetrating TBI (n = 230); injured controls (n = 340); and noninjured controls (n = 188). We examined 25 factors related to demographic, injury‐related, military‐specific, treatment/health care need, and mental health/social support variables. Seven factors were statistically associated with the presence of DSM‐IV‐TR symptom criteria for PTSD: premorbid IQ, combat exposure, depression, social participation, history of mTBI, need for managing mood and stress, and need for improving memory and attention, p < .001 (51.3% variance). When comparing the prevalence of these risk factors in a longitudinal cohort (n = 742) across four PTSD trajectory groups (i.e., asymptomatic, improved, developed, persistent), a higher proportion of participants in the persistent PTSD group reported worse depression, a lack of social participation, and history of mTBI. Additionally, a higher proportion of participants in the persistent and developed PTSD groups reported the need for managing mood/stress and improving memory/attention. When considered simultaneously, the presence of ≥ 1 or ≥ 2 risk factors was associated with a higher proportion of participants in the developed and persistent PTSD groups, ps < .001. These risk factors may be useful in identifying SMVs at risk for the development and/or persistence of PTSD symptoms who may need intervention.
To examine the reliability and validity of Patient-Reported Outcomes Measurement Information System (PROMIS) measures of sleep disturbance and fatigue in traumatic brain injury (TBI) caregivers and ...to determine the severity of fatigue and sleep disturbance in these caregivers.
Cross-sectional survey data collected through an online data capture platform.
A total of 4 rehabilitation hospitals and Walter Reed National Military Medical Center.
Caregivers (N=560) of civilians (n=344) and service member/veterans (SMVs) (n=216) with TBI.
Not applicable.
PROMIS sleep and fatigue measures administered as both computerized adaptive tests (CATs) and 4-item short forms (SFs).
For both samples, floor and ceiling effects for the PROMIS measures were low (<11%), internal consistency was very good (all α≥0.80), and test-retest reliability was acceptable (all r≥0.70 except for the fatigue CAT in the SMV sample r=0.63). Convergent validity was supported by moderate correlations between the PROMIS and related measures. Discriminant validity was supported by low correlations between PROMIS measures and measures of dissimilar constructs. PROMIS scores indicated significantly worse sleep and fatigue for those caring for someone with high levels versus low levels of impairment.
Findings support the reliability and validity of the PROMIS CAT and SF measures of sleep disturbance and fatigue in caregivers of civilians and SMVs with TBI.
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