Brain Imaging and Behavior DOI 10.1007/s11682-015-9391-7
MILITARY/VETERAN TBI
Personality Assessment Inventory profiles of veterans: Differential effects of mild traumatic brain injury and psychopathology Holly M. Miskey 1,2 & Robert D. Shura 1,2 & Ruth E. Yoash-Gantz 1,2 & Jared A. Rowland 2,3
# Springer Science+Business Media New York (outside the USA) 2015
Abstract 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.
* Holly M. Miskey [email protected] 1
Mental Health & Behavioral Sciences Service Line, W.G. (Bill) Hefner Veteran’s Affairs Medical Center, 11-M2/MH&BS, 1601 Brenner Ave, Salisbury, NC 28144, USA
2
Mid-Atlantic Mental Illness Research Education and Clinical Centers (MIRECC), Durham, NC, USA
3
Research and Education Service Line, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC, USA
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. Keywords PTSD . mTBI . Posttraumatic . Postconcussive . Veteran A diagnosis of traumatic brain injury (TBI) was reported in over 200,000 Veterans enrolled in care at Veteran’s Affairs Medical Centers between 2008 and 2012 (Bagalman 2013), with the vast majority of reported injuries qualifying as mild in severity. In the seminal article, Hoge et al. (2008) found that approximately 44 % of Iraq Veterans who experienced a TBI with loss of consciousness also met criteria for posttraumatic stress disorder (PTSD). The authors also found that PTSD and depression accounted for the majority of negative health outcomes related to TBI, suggesting that persisting psychiatric complaints following mild TBI (mTBI) are complex but clinically relevant. Thus, it is imperative that clinicians evaluating returning Veterans have the ability to measure psychological distress and to understand how psychiatric diagnoses and mTBI history potentially affect the results. This is difficult to accomplish with disorder specific questionnaires and may be best addressed using larger, comprehensive assessments. The Personality Assessment Inventory (PAI; Morey 1991) is an ideal tool to examine post-deployment psychiatric distress in Veterans reporting a history of mTBI. The PAI is a multi-scale self-report personality inventory that permits a more complete picture of clinical presentation than one or two self-report inventories devoted to a specific cluster of symptoms. Clinicians using the PAI are able to assess a
Brain Imaging and Behavior
multitude of psychiatric, somatic, and cognitive complaints sometimes voiced by individuals following TBI. The PAI is available in VA medical centers and many clinical settings, and psychologists are generally trained in interpretation of the measure. Strengths of the PAI include the minimal reading ability required (4th grade), the non-overlapping and contentderived clinical scales, and inclusion of numerous validity scales and indices. The elimination of invalid profiles is important as these profiles may inaccurately inflate levels of reported distress and further contribute to inconsistent findings. Few studies are available on the use of the PAI with mTBI, and several confounding issues complicate the literature such as inclusion of forensic participants, varying severity of TBI, and comorbid psychopathology. Litigation has consistently been shown to account for a significant amount of variance for persisting post-mTBI complaints (Bay and Donders 2008; Belanger et al. 2005; Carroll et al. 2004; Mooney and Speed 2001), which may affect PAI profiles due to the incentive to portray one’s symptoms as more severe than as actually experienced. For example, Kurtz et al. (2007) compared the PAI profiles of individuals referred for a neuropsychological evaluation following an accident with claimed TBI. Compared with the moderate-to-severe sample, the mTBI sample, 72 % of whom were compensation seeking, reported higher scores on the Somatization (72T vs. 66T) and Depression scales (71T vs. 63T) while moderate-to-severe TBI participants reported comparatively higher scores on Antisocial Features (46T vs. 51T) and Alcohol Problems scales (46T vs. 51T). Results initially appear to suggest different PAI profiles may be associated with different TBI severity levels. However, the effect of compensation seeking was not examined and elevations cannot be attributed solely to mTBI. In an effort to clarify this issue, Whiteside et al. (2012) combined data from nonforensic mTBI participants with Kurtz et al.’s (2007) mTBI sample. The forensic mTBI sample reported significantly higher elevations than the non-forensic sample on Somatization (71.71T vs. 63.25T), Anxiety (66.29T vs. 56.14T), and Depression (70.51T vs. 63.63T). Notably, these represent three of the four elevated scales reported by Kurtz et al. (2007). Thus, inclusion of compensation seeking individuals in mTBI samples may artificially inflate clinical scale elevations. This is an important consideration when using clinical Veteran samples who may be receiving compensation for mental health disorders and supports the use of measures with embedded validity scales. No studies using the PAI with mTBI samples have controlled for psychopathology, an important aspect of the clinical picture in post-deployment samples. Clinical profile elevations on the PAI are affected by the presence and number of psychiatric disorders. When compared with healthy controls, participants diagnosed with PTSD only scored significantly higher on 4 scales/subscales, participants with comorbid
PTSD and major depressive disorder (MDD) scored higher on 16 scales/subscales, and participants with PTSD, MDD, and other Axis I disorders scored higher on 29 scales/ subscales (Drury et al. 2009). The number and magnitude of moderately (60T) and clinically (70T) significant elevations also increased with the complexity of the presentation from 2 subscales over 60T (ARD-T, DEP-P) in the PTSD group to 20 scale/subscale elevations over 60T and 8 over 70T in the PTSD/MDD/Axis I group. Similarly, a psychologically complex community sample (100 % PTSD, 29 % specific phobia, 21 % MDD, 21 % obsessive compulsive personality disorder, and 21 % depressive personality disorder) demonstrated 2 subscales elevated over 70T (ARD-T, DEP-P) and another 13 subscales elevated above 60T (McDevitt-Murphy et al. 2005). However, invalid profiles were not excluded. In a study of valid profiles produced by psychology undergraduates (82 % female) diagnosed with PTSD (83 % met criteria for an additional mood disorder), 1 subscale (ARD-T) was elevated above 70T and 17 subscales were elevated above 60T (McDevitt-Murphy et al. 2007). Given the sensitivity of the PAI to increasing psychopathology, research that examines the potential persisting effects of mTBI on PAI profiles should assess comorbid psychopathology.
Specific aims The purpose of this study was to examine how mTBI and diagnosable psychiatric conditions affect the PAI symptom profiles of OEF/OIF Veterans, and to evaluate whether the PAI can be used by clinicians to evaluate psychopathology in the presence of mTBI. The current study improved upon previous research in a number of ways: no forensic participants were included, only valid PAI profiles were included in analyses, participants were assessed for psychopathology using a structured clinical interview, a healthy control group was included, and the sample was limited to OEF/OIF Veterans. Additionally, we did not combine varying severities of TBI as mild, moderate, and severe TBI may present differently and confound results. Veterans were divided into one of five groups based on combinations of presence/absence of mTBI and/or psychiatric status (described in the BParticipants^ section). We hypothesized that: (1) the mean scores of PAI subscales would increase with increasing psychopathology regardless of mTBI status, (2) the number of PAI subscales greater than 60T would increase with increasing psychopathology regardless of mTBI status, (3) the number of PAI subscales greater than 70T would increase with increasing psychopathology regardless of mTBI, (4) groups with psychopathology would report significantly higher subscale scores than controls and those with mTBI only, and (5) PTSD and other psychiatric diagnoses, but not mTBI, would explain a
Brain Imaging and Behavior
significant amount of variance in PAI mean score, number of elevations over 60T and number of elevations over 70T.
Method Data used in the current project were drawn from a larger study that was reviewed and approved by the W.G. (Bill) Hefner VA Medical Center (Hefner VAMC) Institutional Review Board. Informed consent was obtained from all individual participants included in the study. Welfare and privacy of human subjects were protected and maintained. Participants Participants were sampled from a larger study being conducted by the Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC) investigating postdeployment mental health in Veterans who have served since September 2001. Procedures included self-report and clinician administered interviews of psychological and physical health (for a description, see Dedert et al. 2009). Veterans who completed this initial study and met eligibility criteria were invited to complete an additional study of neuropsychological functioning. Exclusion criteria for participation in the neuropsychological study included current substance abuse/ dependence or psychosis, combat prior to 1985, selfreported moderate or severe TBI, and non-military PTSD with onset prior to military deployment (determined by the Structured Clinical Interview for DSM-IV Diagnosis; First et al. 2002). All participants were research volunteers and the consent process included a thorough explanation that results would only be available to the research team and could not be used for compensation purposes. Participants for the present study were drawn from this existing data set based on production of a valid PAI profile defined by T-scores less than 92 on Negative Impression Management (NIM), 68 on Positive Impression Management (PIM), 73 on Inconsistency (ICN), and 75 on Infrequency (INF) according to cutoffs recommended by the test author (Morey 1991). In addition, participants were required to meet criteria for one of the research groups based on mTBI status and current psychiatric diagnoses (described below). Of the 212 Veterans completing the larger neuropsychological battery, 180 produced valid PAI profiles indicating a failure rate of 15 %. This rate is slightly lower than the 22 % failure rate found by Braxton and colleagues (2007) in their study of outpatient Veterans. Of the 180 participants, 145 met diagnostic criteria for inclusion in one of the five groups described below. One participant in the control group was deleted as an outlier due to multiple subscales in excess of three standard deviations above the group mean leaving a total of 144 participants. On average, participants were 35.29 years of age (SD=8.94, range 21 to
59), male (89.6 %), and married (66.0 %) with an average of 13.92 years of education (SD=1.88, range 10 to 19 years). Participants were divided into five groups based on presence/absence of mTBI and current psychological diagnoses: 1) no history of TBI and no current psychological diagnoses (control group, n=40); 2) presence of mTBI consistent with American Congress of Rehabilitation Medicine (ACRM) criteria (Ruff et al. 2009) and no current psychopathology (mTBI group, n=31); 3) presence of mTBI and a current diagnosis of PTSD only (mTBI/PTSD group, n=23); 4) presence of mTBI, PTSD and at least one additional current diagnosis (mTBI/PTSD/MDD+ group, n=25); and 5) no TBI history and presence of one or more current mental health diagnoses (MH group, n=25). Although not required for group assignment, all participants in the mTBI/PTSD/MDD+ were discovered to have comorbid PTSD and MDD; to promote clarity for the reader, BMDD^ was therefore included in the group name. In this group, 17 Veterans met criteria for two diagnoses (PTSD and MDD), 5 met criteria for three diagnoses, 2 met criteria for four diagnoses, and 1 met criteria for five diagnoses. In comparison, 19 Veterans in the MH group met criteria for one diagnosis, 5 met criteria for two diagnoses, and 1 met criteria for three diagnoses. Table 1 provides a listing of current diagnoses for both groups. There were not sufficient participants who met criteria for PTSD without mTBI history (see Table 1, description of MH group diagnoses) to support an independent group for statistical comparisons. We maintained the mTBI/PTSD group rather than collapsing it with the mTBI/PTSD/MDD+ group as it is relevant for clinicians working with this population. Table 1
List of current diagnoses
mTBI/PTSD/MDD+ group
MH group
Diagnosis
n (%)
Diagnosis
n (%)
PTSD MDD Social phobia Specific phobia Adjustment D/O Panic D/O Binge eating D/O
25 (100) 25 (100) 2 (8) 1 (4) 1 (4) 1 (4) 2 (8)
PTSD MDD Social phobia Specific phobia Adjustment D/O Panic D/O Binge eating D/O
12 (48) 4 (16) 2 (4) 1 (4) 2 (8) 1 (4) 1 (4)
Bulimia OCD
1 (4) 2 (8)
Bipolar II D/O Dysthymic D/O GAD Anxiety NOS
1 (4) 2 (8) 4 (16) 2 (8)
mTBI/PTSD/MDD+ mTBI, PTSD and other mental health diagnoses, MH Mental health only, PTSD Posttraumatic stress disorder, MDD Major depressive disorder, MH Mental health only, D/O Disorder, Panic D/O Panic disorder without agoraphobia, OCD Obsessive compulsive disorder, GAD Generalized anxiety disorder, NOS Not otherwise specified n=25 for both groups
Brain Imaging and Behavior
Measures The PAI is a 344-item, self-report measure of personality and psychopathology symptoms (Morey 1991). Items are rated on a four-point Likert-like scale from false to very true. The test includes 4 validity scales, 11 clinical scales, 31 subscales, 5 treatment scales, and 2 interpersonal scales. Scales were created by content validation and each item is contained in only one scale (i.e., non-overlapping). Raw scores are converted into T-scores with a mean of 50 and standard deviation of 10 based on gender, race, and age in comparison to the censusbased normative sample. For the present study, only symptom-based subscales were used, and higher scores reflect greater psychopathology. Scores of 60 or higher reflect moderate elevations and scores of 70 or higher a Bpronounced deviation from the typical responses of adults living in the community,^ (Morey 1991, p. 11). The presence of lifetime TBI was assessed using a semistructured interview querying history of TBI events. MTBI was defined according to ACRM criteria (Ruff et al. 2009); specifically, any injury to the head resulting in alteration in consciousness of up to 24 h, loss of consciousness up to 30 min, or posttraumatic amnesia of up to 24 h. Initial participants did not complete the TBI interview as it was added later in the study. For these participants (n=49), a self-report screen of TBI (Ivins et al. 2003; Schwab et al. 2007) completed during the study was used to identify a lifetime history of mTBI. For the screener, mTBI was defined as any head injury resulting in alteration of consciousness or PTA of less than 24 h and/or LOC 1 to 20 min, consistent with Lezak (1995). The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I; First et al. 2002) is an interview measure of psychopathology. The full research version was administered to all participants by a master’s or doctorate level researcher who underwent rigorous training on proper administration and diagnosis. Analyses All analyses were completed using SPSS 21. One-way analysis of variance (ANOVA) and chi-square analyses were used to evaluate possible differences between groups on demographic variables. Group differences for mean PAI score (average of all PAI subscales), number of subscales greater than 60T, and number of subscales greater than 70T were analyzed using ANOVAs with post-hoc Tukey or Games-Howell tests for significant results. Group differences on PAI subscale scores were analyzed using ANOVAs and post-hoc contrasts. Due to the large number of subscales, significance levels were adjusted using Bonferroni correction (p
MILITARY/VETERAN TBI
Personality Assessment Inventory profiles of veterans: Differential effects of mild traumatic brain injury and psychopathology Holly M. Miskey 1,2 & Robert D. Shura 1,2 & Ruth E. Yoash-Gantz 1,2 & Jared A. Rowland 2,3
# Springer Science+Business Media New York (outside the USA) 2015
Abstract 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.
* Holly M. Miskey [email protected] 1
Mental Health & Behavioral Sciences Service Line, W.G. (Bill) Hefner Veteran’s Affairs Medical Center, 11-M2/MH&BS, 1601 Brenner Ave, Salisbury, NC 28144, USA
2
Mid-Atlantic Mental Illness Research Education and Clinical Centers (MIRECC), Durham, NC, USA
3
Research and Education Service Line, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC, USA
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. Keywords PTSD . mTBI . Posttraumatic . Postconcussive . Veteran A diagnosis of traumatic brain injury (TBI) was reported in over 200,000 Veterans enrolled in care at Veteran’s Affairs Medical Centers between 2008 and 2012 (Bagalman 2013), with the vast majority of reported injuries qualifying as mild in severity. In the seminal article, Hoge et al. (2008) found that approximately 44 % of Iraq Veterans who experienced a TBI with loss of consciousness also met criteria for posttraumatic stress disorder (PTSD). The authors also found that PTSD and depression accounted for the majority of negative health outcomes related to TBI, suggesting that persisting psychiatric complaints following mild TBI (mTBI) are complex but clinically relevant. Thus, it is imperative that clinicians evaluating returning Veterans have the ability to measure psychological distress and to understand how psychiatric diagnoses and mTBI history potentially affect the results. This is difficult to accomplish with disorder specific questionnaires and may be best addressed using larger, comprehensive assessments. The Personality Assessment Inventory (PAI; Morey 1991) is an ideal tool to examine post-deployment psychiatric distress in Veterans reporting a history of mTBI. The PAI is a multi-scale self-report personality inventory that permits a more complete picture of clinical presentation than one or two self-report inventories devoted to a specific cluster of symptoms. Clinicians using the PAI are able to assess a
Brain Imaging and Behavior
multitude of psychiatric, somatic, and cognitive complaints sometimes voiced by individuals following TBI. The PAI is available in VA medical centers and many clinical settings, and psychologists are generally trained in interpretation of the measure. Strengths of the PAI include the minimal reading ability required (4th grade), the non-overlapping and contentderived clinical scales, and inclusion of numerous validity scales and indices. The elimination of invalid profiles is important as these profiles may inaccurately inflate levels of reported distress and further contribute to inconsistent findings. Few studies are available on the use of the PAI with mTBI, and several confounding issues complicate the literature such as inclusion of forensic participants, varying severity of TBI, and comorbid psychopathology. Litigation has consistently been shown to account for a significant amount of variance for persisting post-mTBI complaints (Bay and Donders 2008; Belanger et al. 2005; Carroll et al. 2004; Mooney and Speed 2001), which may affect PAI profiles due to the incentive to portray one’s symptoms as more severe than as actually experienced. For example, Kurtz et al. (2007) compared the PAI profiles of individuals referred for a neuropsychological evaluation following an accident with claimed TBI. Compared with the moderate-to-severe sample, the mTBI sample, 72 % of whom were compensation seeking, reported higher scores on the Somatization (72T vs. 66T) and Depression scales (71T vs. 63T) while moderate-to-severe TBI participants reported comparatively higher scores on Antisocial Features (46T vs. 51T) and Alcohol Problems scales (46T vs. 51T). Results initially appear to suggest different PAI profiles may be associated with different TBI severity levels. However, the effect of compensation seeking was not examined and elevations cannot be attributed solely to mTBI. In an effort to clarify this issue, Whiteside et al. (2012) combined data from nonforensic mTBI participants with Kurtz et al.’s (2007) mTBI sample. The forensic mTBI sample reported significantly higher elevations than the non-forensic sample on Somatization (71.71T vs. 63.25T), Anxiety (66.29T vs. 56.14T), and Depression (70.51T vs. 63.63T). Notably, these represent three of the four elevated scales reported by Kurtz et al. (2007). Thus, inclusion of compensation seeking individuals in mTBI samples may artificially inflate clinical scale elevations. This is an important consideration when using clinical Veteran samples who may be receiving compensation for mental health disorders and supports the use of measures with embedded validity scales. No studies using the PAI with mTBI samples have controlled for psychopathology, an important aspect of the clinical picture in post-deployment samples. Clinical profile elevations on the PAI are affected by the presence and number of psychiatric disorders. When compared with healthy controls, participants diagnosed with PTSD only scored significantly higher on 4 scales/subscales, participants with comorbid
PTSD and major depressive disorder (MDD) scored higher on 16 scales/subscales, and participants with PTSD, MDD, and other Axis I disorders scored higher on 29 scales/ subscales (Drury et al. 2009). The number and magnitude of moderately (60T) and clinically (70T) significant elevations also increased with the complexity of the presentation from 2 subscales over 60T (ARD-T, DEP-P) in the PTSD group to 20 scale/subscale elevations over 60T and 8 over 70T in the PTSD/MDD/Axis I group. Similarly, a psychologically complex community sample (100 % PTSD, 29 % specific phobia, 21 % MDD, 21 % obsessive compulsive personality disorder, and 21 % depressive personality disorder) demonstrated 2 subscales elevated over 70T (ARD-T, DEP-P) and another 13 subscales elevated above 60T (McDevitt-Murphy et al. 2005). However, invalid profiles were not excluded. In a study of valid profiles produced by psychology undergraduates (82 % female) diagnosed with PTSD (83 % met criteria for an additional mood disorder), 1 subscale (ARD-T) was elevated above 70T and 17 subscales were elevated above 60T (McDevitt-Murphy et al. 2007). Given the sensitivity of the PAI to increasing psychopathology, research that examines the potential persisting effects of mTBI on PAI profiles should assess comorbid psychopathology.
Specific aims The purpose of this study was to examine how mTBI and diagnosable psychiatric conditions affect the PAI symptom profiles of OEF/OIF Veterans, and to evaluate whether the PAI can be used by clinicians to evaluate psychopathology in the presence of mTBI. The current study improved upon previous research in a number of ways: no forensic participants were included, only valid PAI profiles were included in analyses, participants were assessed for psychopathology using a structured clinical interview, a healthy control group was included, and the sample was limited to OEF/OIF Veterans. Additionally, we did not combine varying severities of TBI as mild, moderate, and severe TBI may present differently and confound results. Veterans were divided into one of five groups based on combinations of presence/absence of mTBI and/or psychiatric status (described in the BParticipants^ section). We hypothesized that: (1) the mean scores of PAI subscales would increase with increasing psychopathology regardless of mTBI status, (2) the number of PAI subscales greater than 60T would increase with increasing psychopathology regardless of mTBI status, (3) the number of PAI subscales greater than 70T would increase with increasing psychopathology regardless of mTBI, (4) groups with psychopathology would report significantly higher subscale scores than controls and those with mTBI only, and (5) PTSD and other psychiatric diagnoses, but not mTBI, would explain a
Brain Imaging and Behavior
significant amount of variance in PAI mean score, number of elevations over 60T and number of elevations over 70T.
Method Data used in the current project were drawn from a larger study that was reviewed and approved by the W.G. (Bill) Hefner VA Medical Center (Hefner VAMC) Institutional Review Board. Informed consent was obtained from all individual participants included in the study. Welfare and privacy of human subjects were protected and maintained. Participants Participants were sampled from a larger study being conducted by the Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC) investigating postdeployment mental health in Veterans who have served since September 2001. Procedures included self-report and clinician administered interviews of psychological and physical health (for a description, see Dedert et al. 2009). Veterans who completed this initial study and met eligibility criteria were invited to complete an additional study of neuropsychological functioning. Exclusion criteria for participation in the neuropsychological study included current substance abuse/ dependence or psychosis, combat prior to 1985, selfreported moderate or severe TBI, and non-military PTSD with onset prior to military deployment (determined by the Structured Clinical Interview for DSM-IV Diagnosis; First et al. 2002). All participants were research volunteers and the consent process included a thorough explanation that results would only be available to the research team and could not be used for compensation purposes. Participants for the present study were drawn from this existing data set based on production of a valid PAI profile defined by T-scores less than 92 on Negative Impression Management (NIM), 68 on Positive Impression Management (PIM), 73 on Inconsistency (ICN), and 75 on Infrequency (INF) according to cutoffs recommended by the test author (Morey 1991). In addition, participants were required to meet criteria for one of the research groups based on mTBI status and current psychiatric diagnoses (described below). Of the 212 Veterans completing the larger neuropsychological battery, 180 produced valid PAI profiles indicating a failure rate of 15 %. This rate is slightly lower than the 22 % failure rate found by Braxton and colleagues (2007) in their study of outpatient Veterans. Of the 180 participants, 145 met diagnostic criteria for inclusion in one of the five groups described below. One participant in the control group was deleted as an outlier due to multiple subscales in excess of three standard deviations above the group mean leaving a total of 144 participants. On average, participants were 35.29 years of age (SD=8.94, range 21 to
59), male (89.6 %), and married (66.0 %) with an average of 13.92 years of education (SD=1.88, range 10 to 19 years). Participants were divided into five groups based on presence/absence of mTBI and current psychological diagnoses: 1) no history of TBI and no current psychological diagnoses (control group, n=40); 2) presence of mTBI consistent with American Congress of Rehabilitation Medicine (ACRM) criteria (Ruff et al. 2009) and no current psychopathology (mTBI group, n=31); 3) presence of mTBI and a current diagnosis of PTSD only (mTBI/PTSD group, n=23); 4) presence of mTBI, PTSD and at least one additional current diagnosis (mTBI/PTSD/MDD+ group, n=25); and 5) no TBI history and presence of one or more current mental health diagnoses (MH group, n=25). Although not required for group assignment, all participants in the mTBI/PTSD/MDD+ were discovered to have comorbid PTSD and MDD; to promote clarity for the reader, BMDD^ was therefore included in the group name. In this group, 17 Veterans met criteria for two diagnoses (PTSD and MDD), 5 met criteria for three diagnoses, 2 met criteria for four diagnoses, and 1 met criteria for five diagnoses. In comparison, 19 Veterans in the MH group met criteria for one diagnosis, 5 met criteria for two diagnoses, and 1 met criteria for three diagnoses. Table 1 provides a listing of current diagnoses for both groups. There were not sufficient participants who met criteria for PTSD without mTBI history (see Table 1, description of MH group diagnoses) to support an independent group for statistical comparisons. We maintained the mTBI/PTSD group rather than collapsing it with the mTBI/PTSD/MDD+ group as it is relevant for clinicians working with this population. Table 1
List of current diagnoses
mTBI/PTSD/MDD+ group
MH group
Diagnosis
n (%)
Diagnosis
n (%)
PTSD MDD Social phobia Specific phobia Adjustment D/O Panic D/O Binge eating D/O
25 (100) 25 (100) 2 (8) 1 (4) 1 (4) 1 (4) 2 (8)
PTSD MDD Social phobia Specific phobia Adjustment D/O Panic D/O Binge eating D/O
12 (48) 4 (16) 2 (4) 1 (4) 2 (8) 1 (4) 1 (4)
Bulimia OCD
1 (4) 2 (8)
Bipolar II D/O Dysthymic D/O GAD Anxiety NOS
1 (4) 2 (8) 4 (16) 2 (8)
mTBI/PTSD/MDD+ mTBI, PTSD and other mental health diagnoses, MH Mental health only, PTSD Posttraumatic stress disorder, MDD Major depressive disorder, MH Mental health only, D/O Disorder, Panic D/O Panic disorder without agoraphobia, OCD Obsessive compulsive disorder, GAD Generalized anxiety disorder, NOS Not otherwise specified n=25 for both groups
Brain Imaging and Behavior
Measures The PAI is a 344-item, self-report measure of personality and psychopathology symptoms (Morey 1991). Items are rated on a four-point Likert-like scale from false to very true. The test includes 4 validity scales, 11 clinical scales, 31 subscales, 5 treatment scales, and 2 interpersonal scales. Scales were created by content validation and each item is contained in only one scale (i.e., non-overlapping). Raw scores are converted into T-scores with a mean of 50 and standard deviation of 10 based on gender, race, and age in comparison to the censusbased normative sample. For the present study, only symptom-based subscales were used, and higher scores reflect greater psychopathology. Scores of 60 or higher reflect moderate elevations and scores of 70 or higher a Bpronounced deviation from the typical responses of adults living in the community,^ (Morey 1991, p. 11). The presence of lifetime TBI was assessed using a semistructured interview querying history of TBI events. MTBI was defined according to ACRM criteria (Ruff et al. 2009); specifically, any injury to the head resulting in alteration in consciousness of up to 24 h, loss of consciousness up to 30 min, or posttraumatic amnesia of up to 24 h. Initial participants did not complete the TBI interview as it was added later in the study. For these participants (n=49), a self-report screen of TBI (Ivins et al. 2003; Schwab et al. 2007) completed during the study was used to identify a lifetime history of mTBI. For the screener, mTBI was defined as any head injury resulting in alteration of consciousness or PTA of less than 24 h and/or LOC 1 to 20 min, consistent with Lezak (1995). The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I; First et al. 2002) is an interview measure of psychopathology. The full research version was administered to all participants by a master’s or doctorate level researcher who underwent rigorous training on proper administration and diagnosis. Analyses All analyses were completed using SPSS 21. One-way analysis of variance (ANOVA) and chi-square analyses were used to evaluate possible differences between groups on demographic variables. Group differences for mean PAI score (average of all PAI subscales), number of subscales greater than 60T, and number of subscales greater than 70T were analyzed using ANOVAs with post-hoc Tukey or Games-Howell tests for significant results. Group differences on PAI subscale scores were analyzed using ANOVAs and post-hoc contrasts. Due to the large number of subscales, significance levels were adjusted using Bonferroni correction (p
