Objective: Over the past two decades, there has been much research on measures of response bias and myriad measures have been validated in a variety of clinical and research samples. This critical ...review aims to guide clinicians through the use of performance validity tests (PVTs) from test selection and administration through test interpretation and feedback. Method/results: Recommended cutoffs and relevant test operating characteristics are presented. Other important issues to consider during test selection, administration, interpretation, and feedback are discussed including order effects, coaching, impact on test data, and methods to combine measures and improve predictive power. When interpreting performance validity measures, neuropsychologists must use particular caution in cases of dementia, low intelligence, English as a second language/minority cultures, or low education. Conclusions: PVTs provide valuable information regarding response bias and, under the right circumstances, can provide excellent evidence of response bias. Only after consideration of the entire clinical picture, including validity test performance, can concrete determinations regarding the validity of test data be made.
Purpose
This study examined the clinical utility of post-traumatic stress disorder (PTSD), low resilience, poor sleep, and lifetime blast exposure as risk factors for predicting future ...neurobehavioral outcome following traumatic brain injury (TBI).
Methods
Participants were 591 U.S. military service members and veterans who had sustained a TBI (
n
= 419) or orthopedic injury without TBI (
n
= 172). Participants completed the Neurobehavioral Symptom Inventory, PTSD Checklist, and the TBI-Quality of Life (TBI-QOL) scale at baseline and follow-up.
Results
Using the four risk factors at baseline, 15 risk factor combinations were examined by calculating odds ratios to predict poor neurobehavioral outcome at follow-up (i.e., number of abnormal scores across five TBI-QOL scales e.g., Fatigue, Depression). The vast majority of risk factor combinations resulted in odds ratios that were considered to be clinically meaningful (i.e., ≥ 2.5) for predicting poor outcome. The risk factor combinations with the highest odds ratios included PTSD singularly, or in combination with poor sleep and/or low resilience (odds ratios = 4.3–72.4). However, poor sleep and low resilience were also strong predictors in the absence of PTSD (odds ratios = 3.1–29.8).
Conclusion
PTSD, poor sleep, and low resilience, singularly or in combination, may be valuable risk factors that can be used clinically for targeted early interventions.
Sub-concussive injuries have emerged as an important factor in the long-term brain health of athletes and military personnel. The objective of this study was to explore the relationship between ...service member and veterans (SMVs) lifetime blast exposure and recovery from a traumatic brain injury (TBI). A total of 558 SMVs with a history of TBI were examined. Lifetime blast exposure (LBE) was based on self-report (M = 79.4, standard deviation = 392.6; range = 0-7500) categorized into three groups: Blast Naive (
= 121), Low LBE (
= 223; LBE range 1-9), and High LBE (
= 214; LBE >10). Dependent variables were the Neurobehavioral Symptom Inventory (NSI) and Post-traumatic Stress Disorder Checklist-Civilian (PCL-C) and the Traumatic Brain Injury Quality of Life (TBI-QOL). Analyses controlled for demographic factors (age, gender, and race) as well as TBI factors (months since index TBI, index TBI severity, and total number lifetime TBIs). The Blast Naive group had significantly lower NSI and PCL-C scores compared with the Low LBE group and High LBE group, with small to medium effect sizes. On the TBI-QOL, the Blast Naïve group had better quality life on 10 of the 14 scales examined. The Low LBE did not differ from the High LBE group on the PCL-C, NSI, or TBI-QOL. Blast exposure over an SMV's career was associated with increased neurobehavioral and post-traumatic stress symptoms following a TBI. The influence of psychological trauma associated with blasts may be an important factor influencing symptoms as well as the accuracy of self-reported estimates of LBE.
To determine whether neurofilament light (NfL), glial fibrillary acidic protein (GFAP), tau, and ubiquitin C-terminal hydrolase-L1 (UCH-L1) measured in serum relate to traumatic brain injury (TBI) ...diagnosis, injury severity, brain volume, and diffusion tensor imaging (DTI) measures of traumatic axonal injury (TAI) in patients with TBI.
Patients with TBI (n = 162) and controls (n = 68) were prospectively enrolled between 2011 and 2019. Patients with TBI also underwent serum, functional outcome, and imaging assessments at 30 (n = 30), 90 (n = 48), and 180 (n = 59) days, and 1 (n = 84), 2 (n = 57), 3 (n = 46), 4 (n = 38), and 5 (n = 29) years after injury.
At enrollment, patients with TBI had increased serum NfL compared to controls (
0.0001). Serum NfL decreased over the course of 5 years but remained significantly elevated compared to controls. Serum NfL at 30 days distinguished patients with mild, moderate, and severe TBI from controls with an area under the receiver-operating characteristic curve (AUROC) of 0.84, 0.92, and 0.92, respectively. At enrollment, serum GFAP was elevated in patients with TBI compared to controls (
0.001). GFAP showed a biphasic release in serum, with levels decreasing during the first 6 months of injury but increasing over the subsequent study visits. The highest AUROC for GFAP was measured at 30 days, distinguishing patients with moderate and severe TBI from controls (both 0.89). Serum tau and UCH-L1 showed weak associations with TBI severity and neuroimaging measures. Longitudinally, serum NfL was the only biomarker that was associated with the likely rate of MRI brain atrophy and DTI measures of progression of TAI.
Serum NfL shows greater diagnostic and prognostic utility than GFAP, tau, and UCH-L1 for subacute and chronic TBI.
This study provides Class III evidence that serum NfL distinguishes patients with mild TBI from healthy controls.
Concurrent posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) is common in military populations. The purpose of this study was to examine long‐term neurobehavioral outcomes in ...service members and veterans (SMVs) with versus without PTSD symptoms following TBI of all severities. Participants were 536 SMVs prospectively enrolled from three military medical treatment facilities who were recruited into three experimental groups: TBI, injured controls (IC), and noninjured controls (NIC). Participants completed the PTSD Checklist, Neurobehavioral Symptom Inventory, and the TBI–Quality of Life (TBI‐QOL) and were divided into six subgroups based on the three experimental categories, two PTSD categories (i.e., present vs. absent), and two broad TBI severity categories (unMTBI, which included uncomplicated mild TBI; and smcTBI, which included severe TBI, moderate TBI, and complicated mild TBI): (a) NIC/PTSD‐absent, (b) IC/PTSD‐absent, (c) unMTBI/PTSD‐absent, (d) unMTBI/PTSD‐present, (e) smcTBI/PTSD‐absent, and (f) smcTBI/PTSD‐present. There were significant main effects across the six groups for all TBI‐QOL measures, ps < .001. Select pairwise comparisons revealed significantly lower scores, p < .001, on all TBI‐QOL measures in the PTSD‐present groups when compared to the PTSD‐absent groups within the same TBI severity classification, ds = 0.90–2.11. In contrast, when controlling for PTSD, there were no significant differences among the TBI severity groups for any TBI‐QOL measures. These results provide support for the strong influence of PTSD but not TBI severity on neurobehavioral outcomes following TBI. Concurrent PTSD and TBI of all severities should be considered a risk factor for poor long‐term neurobehavioral outcomes that require ongoing monitoring.
The present study aimed to examine the impact of lifetime blast exposure (LBE) on neuropsychological functioning in service members and veterans (SMVs).
Participants were 282 SMVs, with and without ...history of traumatic brain injury (TBI), who were prospectively enrolled in a Defense and Veterans Brain Injury Center (DVBIC)-Traumatic Brain Injury Center of Excellence (TBICoE) Longitudinal TBI Study. A cross-sectional analysis of baseline data was conducted. LBE was based on two factors: Military Occupational Speciality (MOS) and SMV self-report. Participants were divided into three groups based on LBE: Blast Naive (
= 61), Blast + Low Risk MOS (
= 96), Blast + High Risk MOS (
= 125). Multivariate analysis of variance (MANOVA) was used to examine group differences on neurocognitive domains and the Minnesota Multiphasic Personality Inventory-2 Restructured Form.
There were no statistically significant differences in attention/working memory, processing speed, executive functioning, and memory (
< 1.75, ps > .1, η
s < .032) or in General Cognition (
0.95, ps > .3, η
s < .008). Prior to correction for covariates, lifetime blast exposure was related to Restructured Clinical (
(18,542)
1.77,
= .026, η
= .055), Somatic/Cognitive (
(10,550)
1.99,
= .033, η
= .035), and Externalizing Scales (
(8,552)
2.17,
= .028, η
= .030); however, these relationships did not remain significant after correction for covariates (
1.53, ps > .145, η
s < .032).
We did not find evidence of a relationship between LBE and neurocognitive performance or psychiatric symptoms. This stands in contrast to prior studies demonstrating an association between lifetime blast exposure and highly sensitive blood biomarkers and/or neuroimaging. Overall, findings suggest the neuropsychological impact of lifetime blast exposure is minimal in individuals remaining in or recently retired from military service.
Purpose
To examine factors related to resilience in military caregivers across caregiver health-related quality of life (HRQOL), caregiver sociodemographic variables, and service member/veteran (SMV) ...injury and health status.
Methods
Caregivers (
N
= 346, Female = 96.2%; Spouse = 91.0%; Age:
M
= 40.6 years, SD = 9.3) of SMVs following a mild, moderate, severe, or penetrating TBI were recruited from U.S. military treatment facilities and via community outreach. Caregivers completed select TBI-CareQOL and NIH Toolbox scales, the Caregiver Appraisal Scale, Caregiver Questionnaire, and Mayo-Portland Adaptability Inventory-4. Caregivers were divided into three groups using the TBI-QOL Resilience scale: (1) Low-Moderate Resilience (
n
= 125), (2) Moderate Resilience (
n
= 122), and (3) Moderate-High Resilience (
n
= 99).
Results
Factors related to low caregiver resilience were strain on employment, financial burden from out-of-pocket expenses, caring for children, less personal time, caring for both verbal and physical irritability, anger, and aggression, and lower SMV functional ability (all
p
’s < .05). The Low-Moderate Resilience group had consistently worse HRQOL scores compared to the Moderate and Moderate-High Resilience groups (
p
s < .001;
d
= .50–1.60), with the exception of Caregiving Ideology.
Conclusion
Lower resilience among caregivers of SMVs following TBI is associated with poorer caregiver HRQOL. Programs aimed at promoting and maintaining resilience in military caregivers long-term is important for their own health, the health of the SMV, and the health of their children.
This study examined whether sleep disturbances were associated with neurobehavioral outcome following a traumatic brain injury (TBI) in a well characterized group of service members and veterans.
Six ...hundred and six participants were enrolled into the Defense and Veterans Brain Injury Center, 15-Year Longitudinal TBI study. All participants completed a battery of tests measuring self-reported sleep disturbances, neurobehavioral symptoms, and posttraumatic stress disorder symptoms. Data were analyzed using analysis of variance with post hoc comparisons. Four groups were analyzed separately: uncomplicated mild TBI; complicated mild, moderate, severe, or penetrating combined TBI; injured controls (ie, orthopedic or soft-tissue injury without TBI); and noninjured controls.
A higher proportion of the mild TBI group reported moderate-severe sleep disturbances (66.5%) compared to the injured control group (54.9%), combined TBI (47.5%), and noninjured control groups (34.3%). Participants classified as having Poor Sleep had significantly worse scores on the majority of TBI-Quality of Life scales compared to those classified as having Good Sleep, regardless of TBI severity or the presence of TBI. There was a significant interaction between sleep disturbances and posttraumatic stress disorder. While sleep disturbances and posttraumatic stress disorder by themselves were significant factors associated with worse outcome, both factors combined resulted in worse outcome than either singularly.
Regardless of group (injured or noninjured control), sleep disturbances were common and were associated with significantly worse neurobehavioral functioning. When experienced concurrently with posttraumatic stress disorder, sleep disturbances pose significant burden to service members and veterans.
Pattinson CL, Brickell TA, Bailie J, et al. Sleep disturbances following traumatic brain injury are associated with poor neurobehavioral outcomes in US military service members and veterans.
. 2021;17(12):2425-2438.
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.
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