AllenKelly_Thesis

Allen

Self-Reported Cognitive Symptoms in Military Veteran College Students

By

Kelly Allen

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Abstract:

An increasing number of military veterans are enrolling in college, primarily due

to the Post-9/11 GI Bill, which provides educational benefits to veterans who served on

active duty since September 11, 2001. With rigorous training, active combat situations,

and exposure to unexpected situations, the veteran population is at a higher risk for

traumatic brain injury (TBI), Post Traumatic Stress Disorder (PTSD), and depression. All

of these conditions are associated with cognitive consequences, including attention

deficits, working memory problems, and episodic memory impairments. Some

conditions, particularly mild TBI, are not diagnosed or treated until long after the injury

when the person realizes they have cognitive difficulties. Even mild cognitive problems

can hinder learning in an academic setting, but there is little data on the frequency and

severity of cognitive deficits in veteran college students. The current study examines self-

reported cognitive symptoms in veteran students compared to civilian students and how

those symptoms relate to service-related conditions. A better understanding of the pattern

of self-reported symptoms will help researchers and clinicians determine the veterans

who are at higher risk for cognitive and academic difficulties.

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Introduction

Due to the post 9/11 GI Bill, which covers the full cost of undergraduate

education to veterans who have served three years on active duty since September 11,

2001, there has been an increase in veterans returning to college (The Post-9/11 GI Bill).

The veteran population is at a higher risk for service related conditions, such as

Traumatic Brain Injury (TBI), Post Traumatic Stress Disorder (PTSD), and social anxiety

(Kennedy, Jaffee, Leskin, Stokes, Leal, & Fitzpatrick, 2007). These complications can be

caused by unique blast explosion related to burns and injury or inhalation of toxic fumes.

In addition to blast injuries, services members are at risk of injury from projectiles,

accidents during transportation, and other combat hazards.

Mild TBI is often undiagnosed, and those affected might not seek medical help

due to the “tough it out” mentality associated with trauma in the military (Schumm

Schumm, Koucky, & Bartel, 2014). Common problems associated with mild TBI include

attention deficits, working memory problems, and episodic memory problems (Kennedy

et. al, 2007). These problems can lead to a difficulty in learning in an academic setting.

The current study examines self-reported cognitive symptoms in veteran students

compared to civilian students and how those symptoms relate to service-related

conditions. A better understanding of the pattern of self-reported symptoms will help

researchers and clinicians determine the veterans who are at higher risk for cognitive and

academic difficulties.

Traumatic Brain Injury is a nondegenerative alteration in the brain that could be

caused by external force, a penetrating head injury, or an altered state of consciousness at

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the time of an injury (Hyatt, 2014). There are three parts of mTBI (Mild Traumatic Brain

Injury) or concussion diagnosis, including an altered state of consciousness,

posttraumatic amnesia (trouble storing or retrieving new information) for less than 24

hours and a Glasgow Coma Scale Score of level 13 of consciousness (Kennedy et. al,

2007).

Certain parts of the brain are most affected in mTBI. For example, the prefrontal

cortex is often involved in mTBI, particularly the dorsolateral prefrontal cortex (DLPFC)

(Bitonte, Tribuzio, Hecht & DeSanto). A study found people with mTBI showed poor

performance in executive functions related to decreased fractional anisotropy in the

DLPFC two weeks after their injury (Bitonte et. al). Additionally, studies have found that

patients with damage to the DLPFC also have difficulty with working memory, attention,

and executive function. Executive functions are neurological-based skills, such as being

able to control attention and behavior (Diamond, 2013). Furthermore, transmitted waves

or rotational-translational acceleration (or blast injuries) can result in axonal shearing

injuries that damage the neural pathways into the frontal lobe (Magnuson, Leonessa &

Ling, 2012).

More than 300,000 U.S. veterans of the wars in Iraq and Afghanistan have

sustained a mTBI, with many going untreated (Hoge, Goldberg, & Castro, 2009).

Unreported and untreated mTBI is even more of a concern for veterans than for civilians

due to military culture expectations and the emphasis placed on American individualism

(Schumm, et. al, 2014). Military values and belief systems based on traditional masculine

roles can act as a barrier to support and resources. For example, a veteran may fear being

perceived as weak when family or friends express their concern or sympathy, as the

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military places an emphasis on strength in times of suffering or difficulty. Military

members may also worry health problems could negatively impact their career, as they

will be perceived as weak or undependable (Held & Owens, 2013). Veterans may be

reluctant to report anything if they do not have visible injuries or if others around them

have visible injuries. Additionally, a veteran may be reluctant if reporting the injury may

delay their release back to the base or home.

Another reason mTBI goes untreated is because many people do not experience

symptoms immediately following their mTBI. Since mTBI does not always cause loss of

consciousness and does not produce visual structural damage on magnetic resonance

imaging, many people do not seek help or are misdiagnosed (Hyatt, 2014). Mild

traumatic brain injury may appear normal on computed tomography (CT) and magnetic

resonance imaging (MRI) scans because these machines do not identify diffuse axonal

injuries (DAI) (Shenton et. al). Additionally, 15 to 30% of those diagnosed based on

clinical evaluations have persisting symptoms 3 months after their injury, some instances

leading to a long-term disability. Therefore, the number of veterans sustaining mTBI

could be considerably higher.

Mild Traumatic Brain Injury also presents multiple diagnostic challenges, such as

the reliance on patient self-report accounts that are imprecise and unreliable (Chapman,

2014). Symptoms of mTBI could be attributed to multiple causes. These challenges stress

the importance for objective methods that would improve diagnostic accuracy. The lack

of objective and precise measures to diagnose mTBI could also mean there are a larger

number of veterans sustaining mTBI that are not accounted for.

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There are physical and cognitive consequences that may follow mTBI. Symptoms

of mTBI vary, but the most frequently reported symptoms immediately following the

mTBI include, “headaches, nausea, vomiting, dizziness, blurred vision, and tinnitus”

where as the delayed symptoms include, “confusion, irritation, anxiety, fatigue or

lethargy, sleep pattern changes, behavioral or mood changes, and impaired memory or

concentration” (Hyatt, 2014). There are also cognitive symptoms, the most common

including, “impaired memory, attention, concentration, and executive functioning”

(Hyatt, 2014). Qualitative analysis of episodic detail and coherency of autobiographical

memory in veterans with and without mTBI were evaluated on their ability to recall a

blast event in Operation Enduring Freedom and Operation Iraqi Freedom (Palombo,

Kapson, Lafleche, Vasterling, Marx, Franz & Verfaellie, 2015). The study found that the

mTBI group produced narratives that were less coherent than the group with mTBI.

However, the mTBI group produced narratives with more episodic details than the group

without mTBI. The researchers find that this suggests that mTBI effects the

organizational aspect of memory (Palombo et al., 2015).

A patient may experience psychological disorders such as depression and anxiety

following a mTBI. TBI, postconcussive symptoms, PTSD, and depression were assessed

in a study with their relationship among symptoms of PTSD and depression among

returning veterans. The veterans completed an interview examining their TBI and

postconcussive symptoms in addition to completing a self-report measure of their time in

combat and any symptoms of depression and PTSD (Morissette, Woodward, Kimbrel,

Meyer, Kruse, Dolan & Gulliver, 2011). The study found 85% of the sampled veterans

reported at least one post concussion syndrome (PCS). The study also found veterans

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with a deployment-related TBI reported higher levels of symptoms of PTSD and

depression. These results suggest the need to address PCS to ensure the recovery of

veterans. In another study, 53% of patients reported having anxiety and 45% reported

depression two years after their TBI (Hyatt, 2014). After 5 years, 49% of patients

reported anxiety and 44% reported depression. This implies psychological changes can

have an impact on mental well-being years after an injury and emphasizes the importance

of long-term support for brain injury patients.

A military mTBI is different from civilian mTBI in significant ways. Military

service members who experience mTBI may also be under high stress and sleep deprived

from the combat environment, which can impede their ability to recognize symptoms

(Chapman, 2014). A military mTBI is also different in the type of injury. For example,

pure blast force mTBI may have greater post-concussive consequences as opposed to

blunt mTBI (Mendez, Owens, Berenji, Peppers, Liang & Licht, 2013). The study

examined PCS, health, cognitive, and positron emission tomography (PET) on veterans

who sustained a blast-force mTBI and group who sustained blunt-force mTBI. The

results from the study showed that both groups had significantly lower scores on the Post-

Concussion Questionnaire and the Health Survey. However, the Blast Group had worse

scores on the Auditory Serial Addition Test and greater PET hypometabolism in the right

superior parietal region (Mendez et al., 2013). The researchers find that these results

suggest that pure blast force mTBI may have greater post-concussive consequences than

those who sustained a blunt mTBI.

Research has found in cases of military mTBI, detection and treatment may be

delayed, possibly due to stigma surrounding military culture or because common

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symptoms of mTBI can resemble a multitude of causes. Additionally, there is a lack of

objective measures to assess mTBI due to the unreliability of veteran accounts and

inability to identify on CT and MRI scans. However, there is little data on the frequency

and severity of cognitive deficits in veteran college students. This study addresses how

service-related conditions affect different aspects of academic performance. Veterans and

civilians completed a 99 multiple online survey involving questions on their personal,

military, and medical background as well as questions relating to their memory, attention,

and anxiety in academic settings and overall.

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Method

Participants

137 military veterans and 212 civilian students enrolled at Arizona State University,

community college, or college preparatory programs, participated in this study. The

veteran participants were recruited through the ASU Pat Tillman Veterans Center

and civilian participants were recruited from undergraduate classes. The

participants received partial course credit or were entered into a drawing for a gift

card for their participation. All participants spoke English fluently and provided

informed consent prior to participating.

Table 1: Demographic Information for Civilians and Veteran Students

Civilian Students Veteran Students

Male 56 (26.3%) 116 (84.7%)Female 156 (73.2%) 21 (15.3%)

Age (in yrs) 20.39 (SD 4.5) 33.12 (SD 8.0)

First Enrolled University 151 (70.9%) 53 (38.7%) Com. College 59 (27.7%) 83 (60.6%)

Mean College GPA 3.48 (SD=.49) 3.32 (SD=.47)

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Table 2. Frequency of Conditions in the Civilian and Veteran Groups

Civilian Students Veteran Students

Depression 15.0% 24.8%

PTSD 1.4% 11.7%

TBI Diagnosed 14.1% 13.9%

TBI Suspect 16.0% 16.8%

ANY TBI 24.9% 24.8%

TBI and PTSD 0% 29.40%

TBI and Depression 9.40% 32.40%

TBI, Depression, &

PTSD 0% 17.60%

Procedure

Following informed consent, participants completed an online survey. The survey

contained sections consisting of questions about the participant’s demographic

information, developmental and educational history, military or work background,

and medical history(including history of depression, PTSD, and concussion/head

injuries).The self-assessment questions related to their memory, attention, and

anxiety levels in academic and daily life contexts. The entire survey contained 99

multiple choice and short answer questions. The participants completed the online

survey on a computer at home and had as much time as they needed to complete the

survey. The survey generally took 30-45 minutes to complete.

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Results

Figure 1 shows the response proportion for civilians and veterans on

questions related to their overall level of anxiety and test anxiety. For overall

anxiety self-ratings, a similar proportion of civilians and veterans reported anxiety

(moderate and severe) (23% versus 19% respectively). A higher proportion of

civilians reported higher levels of test anxiety (moderate and severe) related to

veterans (34% versus 28% respectively).

Figure 2 shows the response proportion of civilians and veterans on

questions related to their general memory and to their memory for class material.

For overall memory ability, a higher proportion of veterans reported having worse

or somewhat worse memory relative to the proportion of civilians (35% versus

15% respectively). A higher proportion of veterans reported having worse or

somewhat worse class memory relative to the proportion of civilians (23% versus

10% respectively).

The following responses were related to self-perceived changes in memory,

attention, and anxiety. Figure 3 shows the proportion of veterans and civilians who

reported changes in their memory over time. For reported memory changes over

time more veteran students reported that their memory had gotten worse relative

to civilian students (43% versus 25%). Most civilian students reported no change in

their memory (53%).

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8%

30%

39%

20%

3%

Civilian Overall Anxiety

NoneSomeModerateFairly SevereVery Severe

9%

29%

43%

18%

1%

Veteran Overall Anxiety


Figure 1. Proportion of Civilian and Veteran Groups Self-Reporting Overall Anxiety Levels (top) and Test Anxiety Levels (bottom) 12

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7%

34%

31%

23%

4%

Veteran Test Anxiety


9%

23%

34%

26%

8%

Civilian Test Anxiety


1%

14%

37%

38%

10%

Civilian Overall Memory

Much WorseSomewhat WorseThe SameSomewhat BetterMuch Better

9%

26%

24%

28%

13%

Veteran Overall Memory


Figure 2. Proportion of Civilian and Veteran Groups Self-Reporting Overall Memory (top) and Class Memory (bottom)13

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Figure 4 shows the proportion of veterans and civilians who reported

changes in their attention over time. Most civilians reported no change in their

attention (69%). There were a higher proportion of veteran students reported their

attention is worse relative to civilian students (40% versus 13%). Figure 5 shows

the proportion of veterans and civilians who reported changes in their anxiety over

time. Overall, both of the civilians and the veterans reported their anxiety is worse

(civilians 44% and veterans 54%).

Figures 3-5 show the mean self-ratings for memory, attention, and anxiety

for veterans and civilians with and without TBI, depression, and PTSD. For both

civilians and the veterans, the TBI and no TBI groups did not significantly differ in

self-ratings of college performance, class memory, test anxiety, or ability to attend.

In both the civilian and veteran groups, the TBI group reported significantly worse

overall memory compared to the No TBI group. Additionally, in the veteran group,

10%

39%41%

10%

Civilian Class Memory


6%

18%

42%

27%

8%

Veteran Class Memory


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the TBI group reported a significantly higher level of anxiety relative to the No TBI

group.

Table 3 shows the comparisons of self-rating across conditions for veteran

and civilian groups with and without TBI. In both the civilian and veteran groups

their TBI group reported significantly worse overall memory relative to the No TBI

group. Additionally, veterans with TBI also reported significantly worse overall

anxiety.

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Worse No Change Better0%

20%

40%

60%

80%Reported Memory Changes

Civilian StudentsVeteran Students

Pro

por

tion

Rep

orti

ng

Figure 3. Proportion of Civilian and Veteran Groups Self-Reporting Memory Changes over time

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20%

40%

60%

80%Reported Attention Changes


Pro

por

tion

Rep

orti

ng

Figure 4. Proportion of Civilian and Veteran Groups Self-Reporting Attention Changes over time

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20%

40%

60%

80%Reported Anxiety Changes


Pro

por

tion

Rep

orti

ng

Figure 5. Proportion of Civilian and Veteran Groups Self-Reporting Anxiety Changes over time

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Table 3. Comparisons of Self-Ratings Across Conditions for Veteran and Civilian Groups With and Without TBI

Civilian:No TBIN=159

Civilian:TBIN=53

Significance Veteran:No TBIN=103

Veteran:TBIN=34

Significance

College Performance

3.68 (.60) 3.62 (.63) t(211)=.61, p=.542

3.57 (.68) 2.65 (1.35) t(135)=1.39, p= .168

Overall Memory

3.53 (.86) 3.17 (.85) t(210)=2.68, p=.008

3.27 (1.10) 2.94 (1.15) t(135)=2.72, p=.007

Class Memory

3.58 (.82) 3.36 (.76) t(211)=1.69, p=.092

3.20 (.93) 2.03 (.72) t(134)= 1.3, p= .197

Overall Anxiety

1.82 (.93) 1.75 (1.04) t(210).41, p=.680

1.64 (.92) 2 (.95) t(72.1)= -2.56, p=.013

Test Anxiety 1.93 (1.04) 2.19 (1.19) t(210)=-1.52, p=131

1.77 (1.02) 2 (.95) t(135)= -1.17, p=.243

Ability Attend 1.44 (.92) 1.43 (.87) t(211)=.07, p=.946

1.62 (1.13) 1.97 (.97) t(65.0)= -1.75, p=.086

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Table 4 shows the comparisons of self-ratings across conditions for veteran

and civilian groups with and without depression. For both civilians and veterans,

the Depression and No Depression groups did not differ in college performance,

overall memory, or ability to attend. In the veteran group, the Depression group

reported a significantly higher level of anxiety. In both the civilian and veteran

groups their Depression group reported significantly worse overall anxiety relative

to the No Depression group. Additionally, in the civilian group the Depression group

reported a significantly higher level of anxiety.

Table 5 shows the comparisons of self-ratings across conditions for veteran

and civilian groups with and without PTSD. There was no significant difference

between the PTSD and No PTSD groups in college performance, class memory, test

anxiety, or ability to attend. The veteran PTSD group self-reported significantly

worse overall memory and anxiety relative to the No PTSD group. The veteran PTSD

group self-reported significantly worse overall memory and anxiety relative to the

No PTSD group.

Table 6 shows the results of multiple regression analyses that included TBI,

Depression, and PTSD as predictor variables and self-report ratings as the

dependent measures. Separate regression analyses were conducted on the data

from the veterans and civilians. For both veterans and civilians, the regression

model which included TBI, Depression, and PTSD as predictors and self-rating of

anxiety as the dependent measure was significant.

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Table 4. Comparisons of Self-Ratings Across Conditions for Veteran and Civilian Groups With and Without Depression

Table 5. Comparisons of Self-Ratings Across Conditions for Veteran Groups With and Without PTSD

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Civilian:No DepressionN=173

Civilian: DepressionN=32

Significance Veteran:No DepressionN=101

Veteran: DepressionN=34

Significance

College Performance

3.67(.61) 3.63 (.61) t(204)= .36,p= .723

3.56 (.68) 3.38 (.74) t(133)=1.31, p=.19

Overall Memory

3.51 (.83) 3.26 (1.0) t(203)= 1.48, p= .140

3.19 (1.13) 2.82 (1.31) t(133)=1.56, p=.12

Class Memory

3.55 (.84) 3.34 (.84) t(204)= 1.32, p= .187

3.24 (.93) 2.76 (1.1) t(132)=2.45, p=.02

Overall Anxiety

1.67 (.90) 2.59 (.91) t(203)= -5.34, p<.001

1.55 (.83) 2.26 (.83) t(132)=-4.33, p<.001

Test Anxiety 1.93 (1.1) 2.38 (1.01) t(203)= -2.13, p=.034

1.80 (.96) 1.94 (.96) t(133)=-.69, p=.49

Ability Attend 1.39 (.92) 1.72 (.89) t(204)= -1.87, p= .063

1.62 (1.03) 1.97 (1.03) t(133)=-1.60, p=.11

Veteran:No PTSDN=121

Veteran: PTSDN=16

Significance

College Performance

3.52 (.70) 3.56 (.73) t(135)=-.23, p=.823

Overall Memory

3.19 (1.16) 2.56 (1.32) t(135)=2.01, p=.047

Class Memory

3.17 (1.00) 2.88 (1.26) t(17.38)=.89, p=.384

Overall Anxiety

1.64 (.85) 2.44 (.89) t(134)=-3.51, p=.001

Test Anxiety 1.85 (.97) 1.63 (1.26) t(135)=.84, p=.4

Ability Attend 1.68 (1.11) 1.94 (1.07) t(135)=-.89, p=.376

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Table 6. Results of Multiple Regression Analyses

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Overall Model Predictor Variable:TBI

Predictor Variable: PTSD

Predictor Variable: Depression

Anxiety

Civilians Adj. R2=.117 F(3,201)=10.01, p<.0001

=.027t=.406, p=.69

=-.081t=-1.18, p=.239

=.376t=5.47, p<.0001

Veterans Adj. R2=.158 F(3,130)=9.33, p<.0001

=.131t=1.56, p=.12

=.162t=1.84, p=.068

=.288t=3.44, p<.0001

Memory

Civilians Adj. R2=.022 F(3,201)=2.544, p<.0001

=-.157t=-.048, p<.0001

=-.048t=-.661, p=.509

=-.102t=-1.40, p=.162

Veterans Adj. R2=.057 F(3,201)=3.71, p<.0001

=-.220t=-2.48, p<.0001

=-.066t=-.71, p=.477

=-.09t=-1.02, p=.311

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Depression was the strongest and only significant predictor of anxiety. For

civilians, Depression was not a significant predictor, and, for veterans, neither

Depression nor TBI were significant predictors.

For civilians, the regression model which included TBI, Depression, and PTSD

as predictors and self-rating of memory as the dependent measure was not

significant. For veterans, the regression model which included TBI, Depression, and

PTSD as predictors and self-rating of memory as the dependent measure was

significant. TBI was the strongest and only predictor of memory rating for both the

civilians and veterans. For civilians and veterans, neither Depression nor PTSD were

significant predictor.

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Discussion

A higher proportion of veteran students reported a history of PTSD and

Depression, relative to the civilian students. However, the proportion of reported

TBI was similar across the groups. As well as in both groups, memory ratings for

participants with TBI were lower than those with no TBI. Relative to civilians, a

larger proportion of veterans reported their memory as being “somewhat” or “much

worse” than their peers (Veterans: 35% vs. Civilians: 15%). Additionally, veterans

were more likely than civilians to report negative changes in memory, attention

abilities, and anxiety level over time. For both groups, history of TBI was the

strongest predictor of Memory self-ratings, and history of Depression was the

strongest predictor of Anxiety self-ratings. Overall, the results show that veteran

college students show higher rates of service-related conditions and are more likely

than civilian students to report cognitive difficulties.

Rates of reported TBI were about equivalent in our sample of civilians and

veterans. This result was surprising because it was expected that the rate of TBI

would be higher in the veteran group. The higher rate of TBI could be related to the

fact that a majority of our civilian sample are from the age range at highest risk of

TBI. The veterans had a higher rate of depression relative to the civilians (25%

versus 15% respectively) and a higher rate of PTSD (12% versus less than 2%

respectively). Additionally, veterans were much more likely than civilians to have

TBI and another condition (PTSD, depression). In the veteran group, almost 30%

who had TBI also had PTSD. None of the civilians had both PTSD and TBI. In the

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veteran group, 32% of veterans had TBI and depression, whereas only 9% of the

civilians have TBI and depression. None of the civilians reported having TBI,

depression, and PTSD, whereas almost 18% of veterans did. The higher rates of

concurrent conditions demonstrate how the TBI profile in veterans is different from

the TBI profile in civilians.

The higher frequency of TBI and depression/PTSD in the veteran sample

may arise from the conditions under which they suffered the TBI. The veterans’

injuries usually took place in service and situations could range from active combat

to intense training sessions. TBI’s experienced under these circumstances could lead

to PTSD or Depression. For example, if the injury occurred at a time when others

were more severely injured it could possibly lead to guilty or negative feelings. If

the injury occurred during a startling unexpected event (e.g., explosion causing an

accident), their anxiety levels may be heightened increasing the likelihood of PTSD.

Also, even in training, the circumstances are often highly emotional and highly

stressful. Common circumstances under which civilians experience TBI mostly

include sports/recreational situations (e.g., soccer, biking) or falls. PTSD and

Depression are unlikely to develop after these injuries because they are less intense

and emotionally charged.

Veterans and civilians reported similar anxiety ratings (23% and 19%

respectively). This result was surprising because it was expected that the rate of

anxiety would be higher in the veteran group. There is a possible difference in

perception of anxiety in the two populations. The high proportion of anxiety in

civilians could be due to how their frame of reference is compared to their stress

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levels in college to their stress levels in high school (both of which would likely be

within normal range). The frame of reference for veterans is likely to be very

different given their training for military service, especially for those trained for

active combat. When the veterans rate higher anxiety, they are probably conceiving

of anxiety levels that are considerably higher than a civilian who has not had any

military experiences.

There was a significant difference in the civilians and veterans on their self-

reflection on memory, anxiety, and attention and changes over time. The civilians

were asked: How has your memory, anxiety, or attention compared to 5 years ago?

The veterans were asked: How is your memory, anxiety, or attention different from

when they entered the service? A 5-year mark was used because it is 4-year service

requirement for the veteran G.I. Bill. A majority of the civilians thought their

cognitive abilities remained relatively stable over time. More veterans stated their

memory, anxiety, and attention worsened than civilians. More of the veteran

students reported that their memory became worse since they were in the service,

relative to the civilian students. Given that subgroups (TBI vs. No TBI, etc.) reported

significantly different self-ratings of cognition, it is likely that these self-perceived

worsening of symptoms is likely due to one or more service-related conditions.

In both groups, individuals with depression self-reported higher levels of

anxiety than individuals with no depression. This is not surprising as anxiety is

typically part of the depression syndrome. TBI is the strongest and the only

significant predictor of memory rating. The regression analyses revealed that

history of TBI was a significant predictor of memory ratings, even when effects of

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PTSD and Depression were accounted for (and neither of them were significant

predictors). History of TBI was significantly associated with lower memory self-

ratings and this effect was not the result of other service-related conditions.

It is possible that these self-ratings may not truly reflect their actual

cognitive abilities. For example, someone with depression or mTBI will just think

that their memory is worse because they have this medical condition. If so, the self-

ratings are revealing something about self-perception, but not much about actual

cognitive deficits. In order to establish that the self-ratings are valid, researchers

need to relate the self-ratings to performance on actual cognitive tests. If the self-

ratings do have a strong relationship with performance on cognitive tests, then self-

ratings of cognitive impairment could be used as part of a screen or assessment to

indicate that further in-person testing should be conducted. This may increase the

number of veterans who are identified as having cognitive deficits due to service

related conditions. This study shows that the profile of veterans and civilians with

TBI share some similarities, but also some important differences.

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