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8
Co-Occurring Psychiatric
and Medical Conditions and
Psychosocial Complexities
M
any service members and veterans who have posttraumatic stress
disorder (PTSD) have other conditions that require treatment
and rehabilitation with treatment for PTSD—such psychiatric
and medical conditions as depression, anxiety, substance abuse, chronic
pain, and traumatic brain injury (TBI) and psychosocial conditions such as
relationship problems, unemployment or underemployment, intimate part-
ner violence (IPV), homelessness, and incarceration. This chapter focuses
on co-occurring conditions that are most likely to interfere with effective
PTSD-specific treatments (which themselves are discussed in Chapter 7)
and whose treatment should be integrated into a comprehensive treatment
program for PTSD. Three major categories of co-occurring conditions are
considered: psychiatric (including depression and substance use disorders),
medical (including chronic pain, TBI, and spinal cord injury), and psycho-
social (including IPV, child maltreatment, homelessness, and incarceration).
Discussion of each category includes a brief overview of the conditions and
their co-occurrence with PTSD in military and veteran populations fol-
lowed by a presentation of how to integrate their treatment into treatment
for PTSD. The committee notes that evidence of the effectiveness of these
approaches, as part of a broad overall rehabilitation program for service
members or veterans who have PTSD, is sparse.
The committee recognizes that the prevalence of co-occurring psychiat-
ric and medical conditions and psychosocial issues differs among the varied
cohorts and subpopulations of service members and veterans (for example
between women and men) and that the treatment needs of different groups
will be different. For example, homelessness and vocational training are
293
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294 PTSD IN MILITARY AND VETERAN POPULATIONS
issues for veteran populations but not for active-duty service members.
Among current service members, the needs of active-duty personnel differ
from those of National Guard and reserve members and may vary accord-
ing to service branch. Within veteran populations, the most important co-
occurring medical and psychosocial treatment needs for patients who have
PTSD may vary according to era and location of service. Dementia and
other neurologic conditions that occur more frequently in aging popula-
tions, for example, constitute important comorbidity issues for veterans of
World War II and Vietnam, but not for veterans of more recent conflicts.
CO-OCCURRING PSYCHIATRIC CONDITIONS AND PTSD
Comorbid conditions that include symptoms of depressive or anxiety
disorders, substance use disorders, and high-risk behaviors appear to af-
fect at least as many veterans returning from Operation Enduring Freedom
(OEF) and Operation Iraqi Freedom (OIF) as PTSD alone (Hoge et al.,
2004; Santiago et al., 2010). A large body of literature on trauma-exposed
veteran and civilian populations supports the frequent co-occurrence of
PTSD symptoms with depression (Erickson et al., 2001; Freuh et al., 2000;
O’Donnell et al., 2004; Perlman et al., 2011; Shalev et al., 1998), traumatic
grief (Prigerson, 2009; Shear, 2001, 2005), and alcohol use and drug use
problems (Cerda et al., 2008; Cisler et al., 2011; Kulka, 1990; Zatzick and
Galea, 2007) that may lead affected people to engage in high-risk behaviors
that, in turn, are associated with exposure to additional traumatic events
(Hearst et al., 1986; Kulka, 1990; Pat-Horenczyk et al., 2007). High rates
of moral injury (defined as the perpetration of or failure to prevent atroci-
ties or the witnessing of acts that transgress moral beliefs) (Litz et al., 2009)
have been documented in active-duty military personnel deployed in the
OEF and OIF theaters of war (MHAT IV, 2006).
The National Vietnam Veterans Readjustment Study, one of the first
major epidemiologic investigations of Vietnam veterans, documented high
rates of co-occurrence of PTSD and psychiatric disorders (Kulka, 1990).
Three-fourths of male Vietnam veterans who had PTSD also had a lifetime
diagnosis of alcohol abuse or dependence, 44% had a lifetime diagnosis
of generalized anxiety disorder, and at least 20% had a lifetime diagnosis
of depression or dysthymia. Of female Vietnam veterans who had PTSD,
44% had a lifetime diagnosis of depression and 23% had current depres-
sion. Research conducted in the 1980s also suggested that men who served
in Vietnam were at increased risk for trauma, including fatal motor vehicle
crashes and completed suicide (Hearst et al., 1986).
Stepped-care approaches begin with lower-intensity treatments, such as
support groups, and phase in more intensive procedures, such as evidence-
based interventions—such as cognitive behavioral therapy (CBT) and
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CO-OCCURRING CONDITIONS AND COMPLEXITIES
pharmacotherapy—for patients who have recalcitrant or recurrent symp-
toms of PTSD and related comorbidities (Engel and Katon, 1999). Col-
laborative stepped-care approaches and rehabilitative interventions that
simultaneously target PTSD and comorbid conditions and psychosocial
complexities have been proposed as an essential treatment delivery model
for active-duty military and veteran populations (Engel and Katon, 1999;
Engel et al., 2008; Gilbody et al., 2006; Zatzick et al., 2004, 2011, 2012).
Collaborative stepped-care interventions are implemented by interdisciplin-
ary teams of medical and mental health providers. Central to stepped-care
approaches is regular assessment of PTSD symptoms and related comorbid-
ities, coincident with evidence-based treatments. Collaborative stepped-care
interventions that include care management and motivational interviewing
can enhance a patient’s initial engagement with treatment and diminish
high-risk behaviors, such as binge drinking, and thereby optimize entry into
and completion of evidence-based psychotherapy and pharmacotherapy for
PTSD (Geiss Trusz et al., 2011; Zatzick et al., 2011). Those interventions
can also incorporate emergency evaluations and treatments to target im-
mediate and critical problems (such as suicide and interpersonal violence)
directly.
Established treatments for PTSD, such as prolonged exposure (PE)
therapy, can also address comorbid conditions, such as depression, anger,
guilt, and general anxiety symptoms (Foa, 2011). Additional support for a
stepped-care treatment approach comes from studies of veterans who have
received multiple treatments that targeted their comorbidities before being
randomized into efficacy trials of PTSD-targeted interventions. For exam-
ple, a review of two major CBT efficacy trials found that many veterans in
the studies received treatment for comorbid psychiatric and substance use
conditions before their enrollment in the PTSD-specific treatment protocol,
and following CBT treatment they had significant improvements in their
PTSD and comorbid symptoms (Monson et al., 2006; Schnurr et al., 2007).
Combat experience is a known risk factor for both PTSD and sub-
stance use disorders (Jacobsen et al., 2001, 2008; Norman et al., 2010). In
one study of OEF and OIF veterans who were treated in a Department of
Veterans Affairs (VA) facility, 17% had co-occurring PTSD and a substance
use disorder (Norman et al., 2010). One widely used treatment model is
Seeking Safety, a manualized CBT program used to treat co-occurring
PTSD and substance use disorder (Najavitz, 2009). A VA consensus con-
ference noted that although there have been no randomized controlled
trials (RCTs) of Seeking Safety, it may be an option for patients who are
not ready for evidence-based treatment for PTSD (VA, 2010b). Central
principles of the model include safety, both physically and psychologi-
cally in one’s internal and external worlds; integrated treatment of PTSD
and substance abuse; a focus on ideas and a search for meaning; and case
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296 PTSD IN MILITARY AND VETERAN POPULATIONS
management with an emphasis on cognitive, behavioral, and interpersonal
domains (Najavitz, 2002). Several studies have evaluated the effectiveness
of Seeking Safety in different populations and settings, including several
veteran populations (Boden et al., 2012; Cook et al., 2006; Desai et al.,
2008, 2009; Norman et al., 2010; Weaver et al., 2007; Weller, 2005); the
results have been mixed.
In a recent RCT of 98 male veterans who had both substance use dis-
order and PTSD symptoms and who were recruited from an outpatient VA
substance use disorders clinic, substituting Seeking Safety for part of the
usual treatment was associated with better drug use outcomes than in the
controls. However, alcohol use and PTSD severity decreased equally under
both treatments (Boden et al., 2012). Findings of a pilot study of 14 male
OEF and OIF veterans suggest that Seeking Safety may help to reduce alco-
hol use, depression, and PTSD in some participants at clinically significant
levels. The investigators identified several features of the model that are
especially helpful with combat veterans, including the case management
component that helps persons to engage in other mental health and sub-
stance use disorder services. Veterans identified reintegration into civilian
life and peer connections with other veterans as central to their recovery
(Norman et al., 2010).
In another study, two nonequivalent cohorts of homeless female vet-
erans who had psychiatric and substance abuse problems were recruited
from VA homelessness programs. Seeking Safety appeared to have a mod-
erately beneficial effect over 1 year on several clinical outcomes, including
employment, social support, general symptoms of psychiatric distress, and
symptoms of PTSD (Desai et al., 2008). In an uncontrolled pilot study of
18 male and female veterans in a VA setting, efficacy data on Seeking Safety
indicated significant reduction in PTSD and substance use disorder symp-
toms, but in the absence of a randomized controlled condition it is unclear
whether the reduction in symptoms was due to Safety Seeking or to other
factors (Cook et al., 2006).
CO-OCCURING MEDICAL CONDITIONS AND PTSD
This section examines the treatment needs of people who have PTSD
and co-occurring medical conditions. Chronic pain, TBI, amputation,
spinal-cord injury, and severe burns—which may also result from the same
trauma as that underlying PTSD—are each discussed. The section then
examines the effect of PTSD on long-term health outcomes, including car-
diovascular disease, inflammatory and autoimmune diseases, and diabetes
mellitus.
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CO-OCCURRING CONDITIONS AND COMPLEXITIES
Chronic Pain
Chronic pain is defined as pain that persists for at least 3 months after
the resolution of a physical injury or disease process (Merskey and Bogduk,
1994). Such pain can affect social, occupational, and recreational function
and can lead to problems of motivation, mood, social isolation, and esti-
mates of self-worth.
The occurrence of physical injury that results in chronic pain is rel-
atively common in the military, occurring from basic training to after
discharge. Some 25% of male recruits and 50% of female recruits are pre-
dicted to experience at least one pain-related injury during basic combat
training (McGeary et al., 2011). Chronic pain is the primary reason that
OIF service members are evacuated from the theater of war (Harman et al.,
2005), and combat-related orthopedic pain and musculoskeletal pain are
the primary causes of disability (Masini et al., 2009). A review of medi-
cal records of OEF and OIF veterans who were seeking treatment at a VA
polytrauma clinic found that 82% of them had documented chronic pain
(Lew et al., 2009). Other studies of veterans have found that 50% of men
and up to 78% of women report regular pain (Haskell et al., 2006; Kerns
et al., 2003).
Chronic pain has adverse consequences on the cardiovascular, pulmo-
nary, gastrointestinal, immunologic, and muscular systems. It also has been
associated with increased anxiety, fear, anger, and depression and with a
reduction in patient satisfaction and slower recovery from injury (Joshi and
Ogunnaike, 2005). Starr et al. (2004) estimated the comorbidity of pain
and PTSD to be greater than 50% for persons who sustained an orthopedic
traumatic injury, and McGeary et al. (2011) report significantly higher rates
of health care use by and poorer prognoses in patients who have comorbid
PTSD and pain than those who have either diagnosis alone.
Treatment for Chronic Pain
Improvements in battlefield medicine practices and protective gear
(body armor and helmet design) have led to increased survival of severely
injured service members. Service members are also at risk for PTSD stem-
ming from their physical injuries and the context in which they occurred.
The symptoms that characterize chronic pain (for example, headache, ir-
ritability, sleep disturbance, and memory impairments) overlap with many
symptoms of PTSD, and this complicates the diagnosis of, appropriate
treatment for, and management of both conditions. The U.S. Army Surgeon
General Pain Management Task Force Report (U.S. Army, 2010b) suggested
the absence of pain-management practice guidelines in the theater of war
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298 PTSD IN MILITARY AND VETERAN POPULATIONS
has resulted in an “overreliance on opioid-based pain solutions, from point
of injury throughout the care continuum.”
Although a systematic literature review of treatments that targeted
both chronic pain and PTSD symptoms found no combined treatment
protocols, there is empirical evidence on the treatment of chronic pain in
civilian and military populations with CBT and rehabilitation programs
to restore function. Interdisciplinary chronic pain rehabilitation programs
have empirical support for reducing pain and improving function in civil-
ian populations (Gatchel et al., 2009; Gatchel and Okifuji, 2006; Guzman
et al., 2001; Turk and Okifuji, 2002). Components of this approach typi-
cally include physical therapy, occupational therapy, CBT—including re-
laxation and biofeedback—and self-managed physical exercise. The U.S.
Army Surgeon General Pain Management Task Force Report (U.S. Army,
2010b) made several recommendations for a comprehensive DoD and VA
pain-management strategy that acknowledges the importance of treating
pain. A number of studies have found CBT to be efficacious in reducing
lower back pain (Hoffman et al., 2007), back and neck pain (Linton and
Ryberg, 2001), osteoarthritis (Heinrich et al., 1985), and tension headache
(Holroyd et al., 2001) and in improving function (Van Tulder et al., 2000).
Key components of CBT pain programs include cognitive restructuring,
relaxation training, time-based activity pacing, and graded homework as-
signments designed to target activity avoidance and improve engagement
in an active lifestyle (Otis et al., 2011).
The functional-restoration approach is one example of an interdis-
ciplinary program. Originally developed for use in sports medicine, this
musculoskeletal pain management approach is individually tailored to the
patient (on the basis of self-reported pain, medical history, structural mea-
sures, and functional-capacity measurements) with the goal of returning
him or her to activity rather than focusing on pain symptoms (Mayer et al.,
2003). Program components include objective and physical evaluation of
physical and functional capacity, psychosocial assessment, identification of
potential socioeconomic barriers to recovery, physician-directed treatment,
and an interdisciplinary treatment-team approach. Evidence of the efficacy
and robustness of functional-restoration approaches has been reported in
several international populations (Gatchel and Okifuji, 2006).
The DoD Functional and Occupational Rehabilitation Treatment
(FORT) program began in 2003 and uses a functional-restoration approach
to decrease chronic musculoskeletal pain and increase functioning in service
members (Gatchel et al., 2009). An RCT compared the FORT program
with the usual treatment, standard anesthesia. The study used repeated
measures in a treatment design that compared both groups immediately
after and 6 and 12 months after treatment. The FORT participants had
significantly better improvements in both psychosocial and physical out-
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CO-OCCURRING CONDITIONS AND COMPLEXITIES
comes immediately after treatment and at the 12-month follow-up than the
treatment-as-usual group. The FORT group also had significant improve-
ments in self-reported pain severity and intensity, perceived disability, pain-
related concerns about physical activity and quality of life, sleep problems,
emotional distress (depression and fear avoidance), functional lifting capac-
ity (both floor-to-waist and waist-to-eye level), and lumbar active range of
motion. At the 12-month follow-up, FORT participants were significantly
less likely to seek high levels of treatment for pain, significantly less likely
to rely on multiple pain medications, and twice as likely to remain on active
duty. The DoD endorsed the functional-restoration approach in 2009 with
a call for physical therapists to implement principles of sports medicine on
the battlefield by 2013 (DoD, 2009).
An RCT is being conducted by the South Texas Research Organiza-
tional Network Guiding Studies on Trauma and Resilience (STRONG
STAR) to evaluate the effectiveness of combined PE for PTSD and chronic
pain treatment in active-duty orthopedic-trauma patients. The STRONG
STAR RCT will compare outcomes in four study arms: a combined ab-
breviated PE and FORT-based pain approach, a PE group, a FORT group,
and a treatment-as-usual group assessed immediately after treatment and
at 6-month and 12-month follow-ups. This will be the first RCT to em-
pirically test an integrated PTSD and pain treatment approach to improve
functional outcomes in service members who have these co-occurring condi-
tions (STRONG STAR, 2012).
Treatment for Co-Occurring Chronic Pain and PTSD
Besides the occurrence of physical combat wounds, extended time in
service and multiple deployments have produced a population of active-
duty service members who have had substantial wear and tear on their
musculoskeletal systems. Because of concerns about stigma and appearing
weak, service members often ignore or self-manage their pain until their
condition impairs their ability to function and puts others at risk, at which
time they are most likely to seek care (McGeary et al., 2011).
High levels of PTSD symptoms immediately after an injury have been
shown to predict impairments in physical, role, and social functioning
(Holbrook et al., 2005; O’Donnell et al., 2005; Ramchand et al., 2008;
Zatzick et al., 2008a,b). Zatzick et al. (2008a) found that PTSD symp-
toms were independently associated with an inability to return to work
12 months after injury even after adjustment for all other relevant clinical,
injury, and demographic characteristics. PTSD has also been shown to af-
fect patient reports of physical symptoms and is a leading predictor of func-
tional outcome after injury, including physical limitations and inability to
return to work (Michaels et al., 1999). Co-occurring pain and PTSD from
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300 PTSD IN MILITARY AND VETERAN POPULATIONS
orthopedic trauma impede a patient’s ability to benefit from pain treatment;
such patients frequently have long periods of disability after trauma and
poorer outcomes (McGeary et al., 2011). In a retrospective study of severely
injured accident victims, Schnyder et al. (2001) found that PTSD predicted
“perceived general health” more than injury severity or degree of physical
functioning did. Thus, PTSD may lead to an increased focus on and per-
ception of pain or an increased likelihood of reporting of pain symptoms.
People who have PTSD also have a more negative perception of their gen-
eral health, and this may also lead to complications in pain assessment and
treatment. When chronic pain and PTSD are combined with a negative view
of the future, there may be less participation in pain management programs
that could lead to a reduction in symptoms.
Comorbid PTSD, depression, and chronic pain may interact to con-
found symptom presentation and treatment for each condition. PTSD
and depression work together to exacerbate pain symptoms (Ahman and
Stalnacke, 2008; Poundja et al., 2006; Roth et al., 2008). Several studies
have found that pain and depression severity are strong predictors of each
other and of functional status and quality of life (Bair, 2004; Kroenke et
al., 2011; Lin et al., 2006). Treating depression with a selective serotonin
reuptake inhibitor or other antidepressant or treating chronic pain with
CBT has been shown to improve outcomes of both conditions (Bair, 2004;
Institute for Clinical Systems Improvement, 2009; Kroenke et al., 2011).
Concurrent treatment for pain and the psychiatric condition may result
in greater improvement in both than sequential care. For example, when
either pain or depression is initially treated with the goal of maximizing its
treatment before addressing the comorbidity, neither is effectively treated,
and treatment effect decreases as symptom severity of both the pain and
the psychiatric condition increases (Kroenke et al., 2007, 2008, 2011; Lin
et al., 2003, 2006). Therefore, combining pharmacologic and psychologic
treatments for PTSD, depression, and chronic pain is likely to result in
improved outcomes.
Traumatic Brain Injury
TBI is defined by the DoD and the VA (DCoE and DVBIC, 2009) as a
traumatically induced structural injury and/or physiological disruption of
brain function as a result of external force that is indicated by new onset
or worsening of at least one of the following clinical signs, immediately
following the event:
• Any period of loss of or a decreased level of consciousness;
• Any loss of memory for events immediately before or after the
injury;
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CO-OCCURRING CONDITIONS AND COMPLEXITIES
• Any alteration in mental state at the time of the injury (confusion,
disorientation, slowed thinking, etc.);
• Neurological deficits (weakness, loss of balance, change in vision,
praxis, paresis/plegia, sensory loss, aphasia, etc.) that may or may
not be transient; and
• Intracranial lesion.
From 2000 through the end of 2011, a total of 229,106 service members
in all services suffered TBI, of whom 77% experienced mild TBI (mTBI), as
shown in Table 8-1 (DVBIC, 2011). On the basis of data collected from the
postdeployment health questionnaires, 12% of returning service members
had experienced mTBI while deployed (Schneiderman et al., 2008); when a
structured interview was used, the prevalence of mTBI was almost twice as
high (23%) as the questionnaire rate (Terrio et al., 2009).
TBI may be caused by a bump, blow, or jolt to the head; by acceleration
or deceleration force without impact; or by penetration to the head that dis-
rupts the normal function of the brain (DVBIC, 2011). The primary cause
of TBI in OEF and OIF service members and veterans is an explosion or
blast injury (Owens et al., 2008); the majority are closed head injuries that
result from improvised explosive devices (IEDs) (Galarneau et al., 2008).
Falls, motor vehicle incidents, and assault also cause TBIs in this popula-
tion. However, blast-related TBI has been a focus of research because of its
frequency and the difficulties that it presents for diagnosis. For example,
concussive injuries associated with strong blasts may not be identified im-
mediately if they occurred at the same time as more life-threatening injuries
that dominate medical treatment. Additionally, mTBI resulting from a blast
may produce no outward sign of injury and leave service members reluctant
to report acute symptoms because they do not want to be medically evacu-
ated and separated from their units. Thus, mTBI may not be identified as
TABLE 8-1 Incidence of TBI by Severity in
All Armed Forces (Cumulative, 2000–2011)
TBI Severity Number
Penetrating 3,738
Severe 2,360
Moderate 38,235
Mild 175,674
Not classifiable 9,099
Total 229,106
SOURCE: DVBIC, 2011.
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302 PTSD IN MILITARY AND VETERAN POPULATIONS
a concern until a service member returns home from deployment (DVBIC,
2011).
The higher-level cognitive domains typically affected by TBI include
attention, speed of processing, working memory, visuospatial ability and
praxis, language and communication, and executive function. In the case of
mTBI, postconcussion syndrome is considered to have occurred when three
or more concussion symptoms persist for 3 months or more after injury
(APA, 2000). Symptoms of concussion include fatigue, disordered sleep,
headache, vertigo or dizziness, irritability or aggression with little or no
provocation, anxiety, depression or affective liability, changes in personal-
ity, and apathy or lack of spontaneity. Postconcussion syndrome has been
reported to occur in 10–20% of TBI cases (e.g., Ruff, 2005; Wood, 2004)
and as many as 44% of hospitalized mTBI cases (Dikmen et al., 2010). In
a U.S. Army brigade sample of clinically confirmed mTBI, memory deficits
(16%), headache (20%), and irritability (21%) were reported to be the
most frequent symptoms of postconcussion syndrome (Terrio et al., 2009).
Belanger et al. (2005) failed to show a difference in neuropsychologic per-
formance between blast and non-blast TBI, although anecdotal reports sug-
gest otherwise (no data were available to confirm this observation). Many
authors cite the need for more research to determine the effect of multiple
trauma because they suspect the brain may adapt to the first concussion
quickly but be more susceptible to injury with additional trauma owing to
residual effects of the first one (Bigler, 2008; Moser et al., 2005; Omalu et
al., 2005; Wall, 2006).
Co-Occurrence of TBI and PTSD
Symptoms of PTSD and mTBI may have considerable overlap, and this
presents a diagnostic challenge. Studies indicate that the co-occurrence of
TBI, pain, and psychosocial health problems is more common than is their
isolated occurrence in OEF and OIF service members and veterans. The
presence of PTSD after mTBI may prolong the duration of and potentially
exacerbate the mTBI symptoms (Brenner et al., 2010). A recent systematic
review found the frequency of comorbid probable PTSD in people who
had probable mTBI was 33–39% (Carlson et al., 2010). Sayer et al. (2009)
found there was a high comorbidity of pain, PTSD, and mTBI in patients
who were treated at VA level-1 polytrauma rehabilitation centers (treatment
facilities for the most-impaired veterans). Of 188 combat-injured service
members, 93% had incurred combat-related TBI, 81% reported a pain
problem, and 53% received some type of mental health service. A similar
study of 50 OEF and OIF veterans who were treated at a VA level-1 poly-
trauma rehabilitation center found that 80% reportedly incurred combat-
related TBI (58% were penetrating, 22% were closed), 96% reported at
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CO-OCCURRING CONDITIONS AND COMPLEXITIES
least one pain problem, and 44% reported experiencing PTSD (Clark et
al., 2007). Of 62 patients at a level-2 polytrauma network site, Lew et al.
(2007) found that 97% reported three or more postconcussive symptoms
(for example, headache, dizziness, and fatigue), 97% reported chronic pain,
and 71% met the criteria for PTSD. In a comprehensive review of medical
records of 340 OEF and OIF veterans seen at a level-2 polytrauma network
site, Lew et al. (2009) found that 82% had more than one diagnosis and
42% had three co-occurring diagnoses, including pain, PTSD, and post-
concussion syndrome. Veterans who had positive TBI screens were also
more likely to have a diagnosis of PTSD, depression, and substance abuse
disorder; these three conditions were present in isolation in only 5%, 10%,
and 3% of veterans, respectively—significantly lower frequencies than those
at which they were present in combination (Lew, 2009). In another study
by Ruff et al. (2008), approximately 66% of veterans who presented with
headache and TBI had cognitive deficits on examination, more severe and
more frequent headaches, more reports of pain, higher rates of PTSD, and
impaired sleep with nightmares than veterans with mTBI who did not have
a neurologic impairment.
A large study of approximately 3,000 hospitalized patients found
that those who had mild, moderate, or severe TBI and PTSD had sig-
nificantly worse physical, role, and social functioning than patients who
had TBI of any severity without PTSD. Regardless of TBI severity, pa-
tients who had PTSD had greater impairments in self-reported cognitive
functioning—including reasoning, memory, problem solving, concentration,
and thinking—than those who did not have PTSD. Patients who had severe
TBI had the highest cognitive impairments and had the least improvement
during the 12-month follow-up. Increasing severity of TBI (moderate and
severe) was associated with lower rates of PTSD symptoms in this popula-
tion than mTBI; this supports the theory that a more severe head injury may
disrupt memory consolidation and associated PTSD symptoms (Zatzick et
al., 2010).
Depression is frequently reported in people who have chronic postcon-
cussion syndrome (Hesdorffer et al., 2009). People who have mTBI and
experience depression after the injury report more symptoms and more
severe symptoms than those who have mTBI without depression (Lange
et al., 2010). People who have mTBI report more problems with cognitive
function if they have comorbid depression, anxiety, or PTSD than if they
do not have these conditions (Spencer et al., 2010). Depression after mTBI
has been associated with older age at time of injury and higher levels of
depressive symptoms in the week after injury (Bay, 2009).
When the Minneapolis VA Evidence Synthesis Program reviewed the
literature on patient care for TBI and PTSD from 1980 to April 2009 (VA,
2009), they had two key findings: the reported prevalence of comorbid
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328 PTSD IN MILITARY AND VETERAN POPULATIONS
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