VISN 19 MIRECC Specialties: Post Traumatic Stress Disorder (PTSD)

Research, Education and Clinical Care Related to
Post Traumatic Stress Disorder (PTSD)

Research Projects

Differentiating Between Mild Traumatic Brain Injury And Behavioral Health Conditions: The Role Of The Neurobehavioral Symptom Inventory

Research Team: Nancy Cutter PhD, Lisa A. Brenner PhD, Gina M Signoracci PhD, Bryan Alvarez, MD, Melissa McHarg BA 

The purpose of this retrospective chart review study is to examine differences in post-concussive (PC) symptom endorsement among four groups of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) Veterans: those with a history of target, service-related, mild traumatic brain injury (mTBI) and co-occurring posttraumatic stress disorder (PTSD) (Group 1); those with a history of target, service-related, mTBI only (Group 2); those with PTSD only (Group 3); and those with no history of target, service-related, mTBI or PTSD (Group 4).

Keywords: Assessment, PTSD, Traumatic Brain Injury (TBI)

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Effects of mild TBI and PTSD on Executive Functioning in OEF/OIF Veterans

Research Team: Marie Banich PhD, Lisa A. Brenner PhD, Jennifer Olson-Madden PhD, Brendan Depue PhD, Herbert Nagamoto MD, Elissa Roesch BA, Brooke Holliman MA, Melodi Billera MSW LSW

This project will determine whether methods drawn from basic science can robustly detect the effects of traumatic brain injury (TBI) and/or post traumatic stress disorder (PTSD) on executive function. Although TBI often occurs in the context of a traumatic event, very little research has attempted to disentangle the effects of TBI from PTSD, which also compromises executive function.

Keywords: Suicide Prevention, Post Traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI)

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Experiential avoidance in combat Veterans with and without posttraumatic stress disorder (PTSD)

Research Team: Nazanin H. Bahraini PhD, Lisa A. Brenner PhD, Marie Devore MS

This study is designed to test a novel method of measuring avoidance of trauma-related material in combat Veterans with and without PTSD, and to compare this novel behavioral measure of avoidance with other traditional self report measures of avoidance.

Keywords: Suicide Prevention, Post Traumatic Stress Disorder (PTSD)

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Lithium Augmentation for Hyperarousal Symptoms of PTSD: Pilot Study

Research Team: Hal S. Wortzel MD, Thomas Beresford MD, Lisa A. Brenner PhD, Peter M. Gutierrez PhD, Jeri E.Forster PhD, Jeffrey Rings PhD, Latoya Conner BA

The proposed investigation is a pilot study intended to establish the safety and tolerability of lithium augmentation of standard psychopharmacological treatment of PTSD for combat veterans seeking treatment at the Denver VA Medical Center.

Keywords: Evidence-Based Treatments, Post Traumatic Stress Disorder (PTSD)

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Recent Presentations Related to Post Traumatic Stress Disorder (PTSD)

Does a history of mild traumatic brain injury increase suicide risk in Veterans with PTSD?

3/14/2012

Sean M. Barnes PhD

University of Colorado, Department of Psychiatry Junior Faculty Poster Session

Keywords: PTSD, Suicide Prevention, TBI

PowerPoint | PDF

Traumatic Brain Injury and Post Traumatic Stress Disorder: Current State of the Science, Diagnostic Challenges, and Best Clinical Practices

10/28/11

Lisa A. Brenner PhD 

Fort Carson, CO

Keywords: Assessment, Post Traumatic Stress Disorder (PTSD), TBI 

PowerPoint | PDF 

PTSD and Suicide in Veterans and Military Personnel

9/6/11

Bridget B. Matarazzo PsyD 

Northern California Healthcare System

Keywords: Post Traumatic Stress Disorder (PTSD), Suicide Prevention

PDF 

PTSD and Suicide Risk: Assessment and Intervention

12/15/10

Pamela J. Staves RN MS NP

Boulder Mental Health Center

Keywords: Assessment, Post Traumatic Stress Disorder (PTSD), Suicide Prevention

PowerPoint | PDF 

Risk of TBI, PTSD & Suicide in OEF/OIF Veterans

11/1/10

Hal S. Wortzel, MD

29th Annual Conference of the Brain Injury Association of Ohio: “Building Community: Recognition, Response, Resilience”, Columbus, OH

Keywords: OEF/OIF/OND Veterans, Post Traumatic Stress Disorder (PTSD), Suicide Prevention, TBI

PowerPoint | PDF

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Recent Publications (since 2009)

Bahraini, N. H., Brenner, L. A., Harwood, J. E. F., Homaifar, B. Y., Ladley-O’Brien, S. E., Filley, C. M., et al. (Adler, L. E.). (2009). Utility of the Trauma Symptom Inventory for the assessment of posttraumatic stress symptoms in veterans with a history of psychological trauma and/or brain injury. Military Medicine, Oct;174(10):1005-9.

Correspondence of three core Trauma Symptom Inventory (TSI) posttraumatic stress disorder (PTSD) scales (Intrusive Experiences, Defensive Avoidance, and Anxious Arousal) and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-IV) PTSD module were examined among 72 veterans with traumatic brain injury (TBI), PTSD, or both conditions. Subjects were classified into PTSD only, TBI only, or co-occurring PTSD and TBI groups based on TBI assessment and SCID-IV PTSD diagnosis. Linear regression was used to model TSI T-Scores as a function of group. Scores on all three scales significantly differed between the TBI and PTSD groups (PTSD only and co-occurring PTSD and TBI) in the expected direction. Study findings indicate that despite the potential overlap of symptoms between PTSD and TBI, the TSI appears to be a useful measure of trauma-related symptoms in veterans who may also have a TBI, particularly mild TBI. Limitations and areas for future research are discussed.

Keywords: PTSD, Traumatic Brain Injury (TBI)

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Barnes, S.M., Walter, K.H., & Chard, K.M. (2012). Does a history of mild traumatic brain injury increase suicide risk in veterans with PTSD? Rehabilitation Psychology, 57, 18-26.

Objective: Research shows that posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) independently increase suicide risk; however, scant research has investigated whether mTBI increases suicide risk above and beyond the risk associated with PTSD alone. Design: The current research compared suicide risk factors among a matched sample of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) military personnel and veterans with PTSD alone or PTSD and a history of an mTBI. Results: Differences in the assessed risk factors were small and suggest that if PTSD and mTBI are associated with elevations in suicide risk relative to PTSD alone, the added risk is likely mediated or confounded by PTSD symptom severity. Conclusion: This finding highlights the importance of screening and treating military personnel and veterans for PTSD. Future explication of the impact of TBI-related impairments on suicide risk will be critical as we strive to ensure safety and optimize care for our military personnel and veterans.

Keywords: PTSD, Suicide, Traumatic Brain Injury (TBI)

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Betthauser LM, Bahraini N, Krengel MH, Brenner LA. 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). Neuropsychol Rev. 2012 Feb 19.

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: OEF/OIF/OND, PTSD, Traumatic Brain Injury (TBI)

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Brenner LA. Neuropsychological and neuroimaging findings in traumatic brain injury and post-traumatic stress disorder. Dialogues Clin Neurosci. 2011;13(3):311-23. Review.

Advances in imaging technology, coupled with military personnel returning home from Iraq and Afghanistan with traumatic brain injury (TBI) and/or post-traumatic stress disorder (PTSD), have increased interest in the neuropsychology and neurobiology of these two conditions. There has been a particular focus on differential diagnosis. This paper provides an overviev of findings regarding the neuropsychological and neurobiological underpinnings of TBI and for PTSD. A specific focus is on assessment using neuropsychological measures and imaging techniques. Challenges associated with the assessment of individuals with one or both conditions are also discussed. Although use of neuropsychological and neuroimaging test results may assist with diagnosis and treatment planning, further work is needed to identify objective biomarkers for each condition. Such advances would be expected to facilitate differential diagnosis and implementation of best treatment practices.

Keywords: Brain & Biology, PTSD, Traumatic Brain Injury (TBI)

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Brenner L, Bahraini N and Hernández TD (2012). Perspectives on creating clinically relevant blast models for mild traumatic brain injury and post traumatic stress disorder symptoms. Front. Neur. 3:31.

Military personnel are returning from Iraq and Afghanistan and reporting non-specific physical (somatic), behavioral, psychological, and cognitive symptoms. Many of these symptoms are frequently associated with mild traumatic brain injury (mTBI) and/or post traumatic stress disorder (PTSD). Despite significant attention and advances in assessment and intervention for these two conditions, challenges persist. To address this, clinically relevant blast models are essential in the full characterization of this type of injury, as well as in the testing and identification of potential treatment strategies. In this publication, existing diagnostic challenges and current treatment practices for mTBI and/or PTSD will be summarized, along with suggestions regarding how what has been learned from existing models of PTSD and traditional mechanism (e.g., non-blast) TBI can be used to facilitate the development of clinically relevant blast models.

Keywords: PTSD, Traumatic Brain Injury (TBI)

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Brenner, L. A., Betthauser, L.M., Homaifar, B. Y., Villarreal, E., Harwood, J. E., Staves, P. J., & Huggins, J. A. (2011). Posttraumatic stress disorder, traumatic brain injury, and suicide attempt history among Veterans receiving mental health services. Suicide & Life Threatening Behavior, 41, 416-423.

History of posttraumatic stress disorder (PTSD) or traumatic brain injury (TBI) has been found to increase risk of suicidal behavior. The association between suicide attempt history among veterans with PTSD and/or TBI was explored. Cases (N = 81) and 2:1 matched controls (N = 160) were randomly selected from a Veterans Affairs Medical Center clinical database. PTSD history was associated with an increased risk for a suicide attempt (OR = 2.8; 95% CI: 1.5, 5.1). This increased risk was present for those with and without a history of TBI. Results support incorporating PTSD history when assessing suicide risk among veterans with and without TBI.

Keywords: Suicide, PTSD, Traumatic Brain Injury (TBI)

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Brenner, L. A., Ivins, B. J., Schwab, K., Warden, D., Nelson, L. A., Jaffee, M., et al. (2009). Traumatic brain injury, post traumatic stress disorder, and post concussive symptom reporting among troops returning from Iraq. Journal of Head Trauma Rehabilitation, 25(5), 307-312.

OBJECTIVES: Analyze the contribution of mild traumatic brain injury (mTBI) and/or posttraumatic stress disorder (PTSD) to the endorsement of postconcussive (PC) symptoms during Post Deployment Health Assessment. Determine whether a combination of mTBI and PTSD was more strongly associated with symptoms than either condition alone. METHODS: Cross-sectional study design where both the exposure, mTBI and/or PTSD, and the outcomes of interest, PC symptoms, were ascertained after return from deployment. Subjects were injured soldiers (n = 1247) from one Fort Carson Brigade Combat Team (n = 3973). MAIN OUTCOME MEASURES: Positive history of PC symptoms. RESULTS: PTSD and mTBI together were more strongly associated with having PC symptoms (adjusted prevalence ratio 6.27; 95% CI: 4.13-9.43) than either mTBI alone (adjusted prevalence ratio = 4.03; 95% CI: 2.67-6.07) or PTSD alone (adjusted prevalence ratio = 2.74; 95% CI: 1.58-4.74) after adjusting for age, gender, education, rank, and Military Occupational Specialty. CONCLUSIONS: In soldiers with histories of physical injury, mTBI and PTSD were independently associated with PC symptom reporting. Those with both conditions were at greater risk for PC symptoms than those with either PTSD, mTBI, or neither. Findings support the importance of continued screening for both conditions with the aim of early identification and intervention.

Keywords: Suicide, PTSD, Traumatic Brain Injury (TBI), OEF/OIF/OND

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Brenner, L. A., Ladley-O'Brien, S. E., Harwood, J. E. F., Filley, C. M., Kelly, J. P., Homaifar, B. Y., et al. (Adler, L. E.). (2009). An exploratory study of neuroimaging, neurological, and neuropsychological findings in traumatic brain injury and post traumatic stress disorder. Military Medicine, 174(4), 347-352.

Seventy-two veterans with traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), or both participated in assessment procedures to evaluate between group differences. Half the sample was randomly selected for magnetic resonance imaging (MRI). Neurologic examinations were conducted using the Neurologic Rating Scale (NRS). Neuropsychological measures included the Paced Auditory Serial Addition Test (PASAT), Rey Auditory Verbal Learning Test (RAVLT), Conners' Continuous Performance Test II (CPT II), and Halstead Impairment Index (HII) including the Booklet Category Test (BCT). Data were analyzed using linear regression. Participants with moderate/ severe TBI were significantly more likely to have trauma-related imaging findings, and more severe TBI predicted lower scores on the NRS. No significant between-group differences were identified on the HII, PASAT, RAVLT, or CPT II. TBI group performance was significantly better on the BCT. More severe TBI predicted abnormal imaging findings and lower NRS scores. Hypothesized between-group differences on neuropsychological measures were not supported.

Keywords: Brain & Biology, PTSD, Traumatic Brain Injury (TBI)

Brenner, L. A., Terrio, H., Homaifar, B. Y., Gutierrez, P. M., Staves, P. J., Harwood, J. E. F., et al. (2010). Neuropsychological test performance in soldiers with blast-related mild TBI. Neuropsychology,24(2), 160-175.

This exploratory study was conducted to increase understanding of neuropsychological test performance in those with blast-related mild traumatic brain injury (mTBI). The two variables of interest for their impact on test performance were presence of mTBI symptoms and history of posttraumatic stress disorder (PTSD). Forty-five soldiers postblast mTBI, 27 with enduring mTBI symptoms and 18 without, completed a series of neuropsychological tests. Seventeen of the 45 met criteria for PTSD. The Paced Auditory Serial Addition Test (Frencham, Fox, & Mayberry, 2005; Spreen & Strauss, 1998) was the primary outcome measure. Two-sided, 2-sample t tests were used to compare scores between groups of interest. Presence of mTBI symptoms did not impact test performance. In addition, no significant differences between soldiers with and without PTSD were identified. Standard neuropsychological assessment may not increase understanding about impairment associated with mTBI symptoms. Further research in this area is indicated.

Keywords: PTSD, Traumatic Brain Injury (TBI)

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Brenner, L.A., Vanderploeg, R., Terrio, H. (2009). Assessment and Diagnosis of Mild Traumatic Brain Injury, Post Traumatic Stress Disorder, and Other Polytrauma Conditions: Burden of Adversity Hypothesis. Rehabilitation Psychology, Aug 54(3), 239-246.

OBJECTIVE/METHOD: Military personnel returning from Iraq and Afghanistan have been exposed to physical and emotional trauma. Challenges related to assessment and intervention for those with posttraumatic stress disorder (PTSD) and/or history of mild traumatic brain injury (TBI) with sequelae are discussed, with an emphasis on complicating factors if conditions are co-occurring. Existing literature regarding cumulative disadvantage is offered as a means of increasing understanding regarding the complex symptom patterns reported by those with a history of mild TBI with enduring symptoms and PTSD. IMPLICATIONS: The importance of early screening for both conditions is highlighted. In addition, the authors suggest that current best practices include treating symptoms regardless of etiology to decrease military personnel and veteran burden of adversity. (c) 2009 APA

Keywords: Suicide, Traumatic Brain Injury (TBI), PTSD

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Ribeiro JD, Pease JL, Gutierrez PM, Silva C, Bernert RA, Rudd MD, Joiner TE Jr. Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military. J Affect Disord. 2012 Feb;136(3):743-50.

Background: Sleep problems appear to represent an underappreciated and important warning sign and risk factor for suicidal behaviors. Given past research indicating that disturbed sleep may confer such risk independent of depressed mood, in the present report we compared self-reported insomnia symptoms to several more traditional, well-established suicide risk factors: depression severity, hopelessness, PTSD diagnosis, as well as anxiety, drug abuse, and alcohol abuse symptoms.

Methods: Using multiple regression, we examined the cross-sectional and longitudinal relationships between insomnia symptoms and suicidal ideation and behavior, controlling for depressive symptom severity, hopelessness, PTSD diagnosis, anxiety symptoms, and drug and alcohol abuse symptoms in a sample of military personnel (N=311).

Results: In support of a priori hypotheses, self-reported insomnia symptoms were crosssectionally associated with suicidal ideation, even after accounting for symptoms of depression, hopelessness, PTSD diagnosis, anxiety symptoms and drug and alcohol abuse. Selfreported insomnia symptoms also predicted suicide attempts prospectively at one-month follow up at the level of a non-significant trend, when controlling for baseline self-reported insomnia symptoms, depression, hopelessness, PTSD diagnosis and anxiety, drug and alcohol abuse symptoms. Insomnia symptoms were unique predictors of suicide attempt longitudinally when only baseline self-reported insomnia symptoms, depressive symptoms and hopelessness were controlled.

Limitations: The assessment of insomnia symptoms consisted of only three self-report items. Findings may not generalize outside of populations at severe suicide risk. Conclusions: These findings suggest that insomnia symptoms may be an important target for suicide risk assessment and the treatment development of interventions to prevent suicide.

Keywords: Suicide, PTSD, Substance Use Disorders (SUD) 

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