8

Co-Occurring Psychiatric and Medical Conditions and Psychosocial Complexities

Many 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 partner 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 followed 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 psychiatric 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



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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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295 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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297 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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299 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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301 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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303 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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