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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
NoneSomeModerateFairly SevereVery Severe
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
NoneSomeModerateFairly SevereVery Severe
9%
23%
34%
26%
8%
Civilian Test Anxiety
NoneSomeModerateFairly SevereVery Severe
1%
14%
37%
38%
10%
Civilian Overall Memory
Much WorseSomewhat WorseThe SameSomewhat BetterMuch Better
9%
26%
24%
28%
13%
Veteran Overall Memory
Much WorseSomewhat WorseThe SameSomewhat BetterMuch Better
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
Much WorseSomewhat WorseThe SameSomewhat BetterMuch Better
6%
18%
42%
27%
8%
Veteran Class Memory
Much WorseSomewhat WorseThe SameSomewhat BetterMuch Better
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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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Worse No Change Better0%
20%
40%
60%
80%Reported Attention Changes
Civilian StudentsVeteran Students
Pro
por
tion
Rep
orti
ng
Figure 4. Proportion of Civilian and Veteran Groups Self-Reporting Attention Changes over time
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Worse No Change Better0%
20%
40%
60%
80%Reported Anxiety Changes
Civilian StudentsVeteran Students
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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