Jared A. Rowland

White matter compromise in veterans exposed to primary blast forces.

Objective:Use diffusion tensor imaging to investigate white matter alterations associated with blast exposure with or without acute symptoms of traumatic brain injury (TBI). Participants:Forty-five veterans of the recent military conflicts included 23 exposed to primary blast without TBI symptoms, 6 having primary blast with mild TBI, and 16 unexposed to blast. Design:Cross-sectional case-control study. Main Measures:Neuropsychological testing and diffusion tensor imaging metrics that quantified the number of voxel clusters with altered fractional anisotropy (FA) radial diffusivity, and axial diffusivity, regardless of their spatial location. Results:Significantly lower FA and higher radial diffusivity were observed in veterans exposed to primary blast with and without mild TBI relative to blast-unexposed veterans. Voxel clusters of lower FA were spatially dispersed and heterogeneous across affected individuals. Conclusion:These results suggest that lack of clear TBI symptoms following primary blast exposure may not accurately reflect the extent of brain injury. If confirmed, our findings would argue for supplementing the established approach of making diagnoses based purely on clinical history and observable acute symptoms with novel neuroimaging-based diagnostic criteria that “look below the surface” for pathology.

The Post-Deployment Mental Health (PDMH) study and repository: A multi-site study of US Afghanistan and Iraq era veterans.

The United States (US) Department of Veterans Affairs (VA) Mid‐Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) Post‐Deployment Mental Health (PDMH) multi‐site study examines post‐deployment mental health in US military Afghanistan/Iraq‐era veterans. The study includes the comprehensive behavioral health characterization of over 3600 study participants and the genetic, metabolomic, neurocognitive, and neuroimaging data for many of the participants. The study design also incorporates an infrastructure for a data repository to re‐contact participants for follow‐up studies. The overwhelming majority (94%) of participants consented to be re‐contacted for future studies, and our recently completed feasibility study indicates that 73–83% of these participants could be reached successfully for enrollment into longitudinal follow‐up investigations. Longitudinal concurrent cohort follow‐up studies will be conducted (5–10+ years post‐baseline) to examine predictors of illness chronicity, resilience, recovery, functional outcome, and other variables, and will include neuroimaging, genetic/epigenetic, serum biomarker, and neurocognitive studies, among others. To date, the PDMH study has generated more than 35 publications from the baseline data and the repository has been leveraged in over 20 publications from follow‐up studies drawing from this cohort. Limitations that may affect data collection for a longitudinal follow‐up study are also presented.

Embedded Performance Validity Measures with Postdeployment Veterans: Cross-Validation and Efficiency with Multiple Measures

Embedded validity measures support comprehensive assessment of performance validity. The purpose of this study was to evaluate the accuracy of individual embedded measures and to reduce them to the most efficient combination. The sample included 212 postdeployment veterans (average age = 35 years, average education = 14 years). Thirty embedded measures were initially identified as predictors of Green’s Word Memory Test (WMT) and were derived from the California Verbal Learning Test-Second Edition (CVLT-II), Conners’ Continuous Performance Test-Second Edition (CPT-II), Trail Making Test, Stroop, Wisconsin Card Sorting Test-64, the Wechsler Adult Intelligence Scale-Third Edition Letter-Number Sequencing, Rey Complex Figure Test (RCFT), Brief Visuospatial Memory Test-Revised, and the Finger Tapping Test. Eight nonoverlapping measures with the highest area-under-the-curve (AUC) values were retained for entry into a logistic regression analysis. Embedded measure accuracy was also compared to cutoffs found in the existing literature. Twenty-one percent of the sample failed the WMT. Previously developed cutoffs for individual measures showed poor sensitivity (SN) in the current sample except for the CPT-II (Total Errors, SN = .41). The CVLT-II (Trials 1–5 Total) showed the best overall accuracy (AUC = .80). After redundant measures were statistically eliminated, the model included the RCFT (Recognition True Positives), CPT-II (Total Errors), and CVLT-II (Trials 1–5 Total) and increased overall accuracy compared with the CVLT-II alone (AUC = .87). The combination of just 3 measures from the CPT-II, CVLT-II, and RCFT was the most accurate/efficient in predicting WMT performance.

Post-Traumatic Epilepsy: Review of Risks, Pathophysiology, and Potential Biomarkers

Post-traumatic epilepsy (PTE) is a recurrent seizure disorder secondary to traumatic brain injury. Five percent of all epilepsy and 20% of structural epilepsy in the general population is PTE. PTE is also the most common cause of new-onset epilepsy in young adults.

Sleep quality affects cognitive functioning in returning combat veterans beyond combat exposure, PTSD, and mild TBI history.

Objective: The purpose of this study was to determine how sleep quality affects cognitive functioning in returning combat veterans after accounting for effects of combat exposure, posttraumatic stress disorder (PTSD), and mild traumatic brain injury (mTBI) history. Method: This was a cross-sectional assessment study evaluating combat exposure, PTSD, mTBI history, sleep quality, and neuropsychological functioning. One hundred and nine eligible male Iraq/Afghanistan combat veterans completed an assessment consisting of a structured clinical interview, neuropsychological battery, and self-report measures. Results: Using partial least squares structural equation modeling, combat experiences and mTBI history were not directly associated with sleep quality. PTSD was directly associated with sleep quality, which contributed to deficits in neuropsychological functioning independently of and in addition to combat experiences, PTSD, and mTBI history. Combat experiences and PTSD were differentially associated with motor speed. Conclusions: Sleep affected cognitive function independently of combat experiences, PTSD, and mTBI history. Sleep quality also contributed to cognitive deficits beyond effects of PTSD. An evaluation of sleep quality may be a useful point of clinical intervention in combat veterans with cognitive complaints. Improving sleep quality could alleviate cognitive complaints, improving veterans’ ability to engage in treatment.

Neuropsychological Test Administration by Videoconference: A Systematic Review and Meta-Analysis

The purpose of the current systematic review and meta-analysis was to assess the effect of videoconference administration on adult neurocognitive tests. We investigated whether the scores acquired during a videoconference administration were different from those acquired during on-site administration. Relevant counterbalanced crossover studies were identified according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twelve studies met criteria for analysis. Included samples consisted of healthy adults as well as those with psychiatric or neurocognitive disorders, with mean ages ranging from 34 to 88 years. Heterogenous data precluded the interpretation of a summary effect for videoconference administration. Studies including particpants with a mean age of 65–75, as well as studies that utilized a high speed network connection, indicated consistent performance across videoconference and on-site conditions, however studies with older participants and slower connections were more variable. Subgroup analyses indicated that videoconference scores for untimed tasks and those allowing for repetition fell 1/10th of a standard deviation below on-site scores. Test specific analyses indicated that verbally-mediated tasks including digit span, verbal fluency, and list learning were not affected by videoconference administration. Scores for the Boston Naming Test fell 1/10th of a standard deviation below on-site scores. Heterogenous data precluded meaningful interpretation of tasks with a motor component. The administration of verbally-mediated tasks by qualified professionals using existing norms was supported, and the use of visually-dependent tasks may also be considered. Variability in previous studies indicates a need for further investigation of motor-dependent tasks. We recommend the development of clinical best practices for conducting neuropsychological assessments via videoconference, and advocate for reimbursement structures that allow consumers to benefit from the increased access, convenience, and cost-savings that remote assessment provides.

The Behavioral Dyscontrol Scale-II with Non-Elderly Veterans

The Behavioral Dyscontrol Scale-II (BDS-II) is a unique test of frontal lobe function. Although the test was created for use in geriatric populations, it can add useful data to assessments of non-elderly patients. The original scoring system for the BDS was characterized by a low ceiling, limiting its use with higher functioning populations. The BDS-II scoring system was created to address this issue; however, new normative data were not published. This study used a non-elderly Veteran sample to compare the psychometric properties of the BDS and BDS-II scoring systems. The BDS-II showed improved psychometric properties (reductions in skewness and kurtosis) and was significantly more reliable than the BDS. Normative data using both the total sample, as well as the subsample of healthy individuals, are provided for clinical use.

Auditory Consonant Trigrams: A Psychometric Update†.

The Auditory Consonant Trigrams (ACT) test was developed to evaluate immediate memory in the absence of rehearsal. There are few psychometric studies of the measure and a lack of normative data using samples from the United States or Veterans. ACT data were examined for 184 participants who passed the Word Memory Test, denied a history of moderate to severe traumatic brain injury (TBI), and consented for research purposes only. Reliability and construct validity were examined and normative data developed using a healthy subsample. Cronbachs α for the ACT total score was 0.79. Regression analyses suggested that years of education, estimated premorbid IQ, psychomotor speed, working memory, and impulsivity had the strongest relationships with performance on the ACT. Performance was unrelated to posttraumatic stress disorder and remote mild TBI, but the presence of major depressive disorder was associated with lower total scores. These results demonstrate the ACT has adequate psychometric properties.

Factor structure and construct validity of the Behavioral Dyscontrol Scale-II

The Behavioral Dyscontrol Scale-II (BDS-II) was developed as an improved scoring method to the original BDS, which was designed to evaluate the capacity for independent regulation of behavior and attention. The purpose of this study was to evaluate the factor structure and construct validity of the BDS-II, which had not been adequately re-examined since the development of the new scoring system. In a sample of 164 Veterans with a mean age of 35 years, exploratory factor analysis was used to evaluate BDS-II latent factor structure. Correlations and regressions were used to explore validity against 22 psychometrically sound neurocognitive measures across seven neurocognitive domains of sensation, motor output, processing speed, attention, visual-spatial reasoning, memory, and executive functions. Factor analysis found a two-factor solution for this sample which explained 41% of the variance in the model. Validity analyses found significant correlations among the BDS-II scores and all other cognitive domains except sensation and language (which was not evaluated). Hierarchical regressions revealed that PASAT performance was strongly associated with all three BDS-II scores; dominant hand Finger Tapping Test was also associated with the Total score and Factor 1, and CPT-II Commissions was also associated with Factor 2. These results suggest the BDS-II is both a general test of cerebral functioning, and a more specific test of working memory, motor output, and impulsivity. The BDS-II may therefore show utility with younger populations for measuring frontal lobe abilities and might be very sensitive to neurological injury.

Personality Assessment Inventory profiles of veterans: Differential effects of mild traumatic brain injury and psychopathology

Objective: Neuropsychiatric complaints often accompany mild traumatic brain injury (mTBI), a common condition in post-deployed Veterans. Self-report, multi-scale personality inventories may elucidate the pattern of psychiatric distress in this cohort. This study investigated valid Personality Assessment Inventory (PAI) profiles in post-deployed Veterans. Method: Measures of psychopathology and mTBI were examined in a sample of 144 post-deployed Veterans divided into groups: healthy controls (n = 40), mTBI only (n = 31), any mental health diagnosis only (MH; n = 25), comorbid mTBI and Posttraumatic Stress Disorder (mTBI/PTSD; n = 23), and comorbid mTBI, PTSD, and other psychological diagnoses (mTBI/PTSD/MDD+; n = 25). Results: There were no significant differences between the mTBI and the control group on mean PAI subscale elevation, or number of subscale elevations above 60T or 70T. The other three groups had significantly higher overall mean scores, and more elevations above 60 and 70T compared to both controls and mTBI only. The mTBI/PTSD/MDD+ group showed the highest and most elevations. After entering demographics, PTSD, and number of other psychological diagnoses into hierarchical regressions using the entire sample, mTBI history did not predict mean PAI subscale score or number of elevations above 60T or 70T. PTSD was the only significant predictor. There were no interaction effects between mTBI and presence of PTSD, or between mTBI and total number of diagnoses. Conclusions: This study suggests that mTBI alone is not uniquely related to psychiatric distress in Veterans, but that PTSD accounts for self-reported symptom distress.