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2 Neuropsychological Predictors of Posttraumatic Stress Disorder and Depressive Symptom Improvement in Compensatory Cognitive Training for Veterans with a History of Mild Traumatic Brain Injury
- Amber V Keller, Jillian M.R. Clark, Jacqueline E Maye, Amy J Jak, Maya E O’Neil, Rhonda M Williams, Aaron P Turner, Kathleen F Pagulayan, Elizabeth W Twamley
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 515-517
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Objective:
Mild traumatic brain injury (mTBI), depression, and posttraumatic stress disorder (PTSD) are a notable triad in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) Veterans. With the comorbidity of depression and PTSD in Veterans with mTBI histories, and their role in exacerbating cognitive and emotional dysfunction, interventions addressing cognitive and psychiatric functioning are critical. Compensatory Cognitive Training (CCT) is associated with improvements in areas such as prospective memory, attention, and executive functioning and has also yielded small-to-medium treatment effects on PTSD and depressive symptom severity. Identifying predictors of psychiatric symptom change following CCT would further inform the interventional approach. We sought to examine neuropsychological predictors of PTSD and depressive symptom improvement in Veterans with a history of mTBI who received CCT.
Participants and Methods:37 OEF/OIF/OND Veterans with mTBI history and cognitive complaints received 10-weekly 120-minute CCT group sessions as part of a clinical trial. Participants completed a baseline neuropsychological assessment including tests of premorbid functioning, attention/working memory, processing speed, verbal learning/memory, and executive functioning, and completed psychiatric symptom measures (PTSD Checklist-Military Version; Beck Depression Inventory-II) at baseline, post-treatment, and 5-week follow-up. Paired samples t-tests were used to examine statistically significant change in PTSD (total and symptom cluster scores) and depressive symptom scores over time. Pearson correlations were calculated between neuropsychological scores and PTSD and depressive symptom change scores at post-treatment and follow-up. Neuropsychological measures identified as significantly correlated with psychiatric symptom change scores (p^.05) were entered as independent variables in separate multiple linear regression analyses to predict symptom change at post-treatment and follow-up.
Results:Over 50% of CCT participants had clinically meaningful improvement in depressive symptoms (>17.5% score reduction) and over 20% had clinically meaningful improvement in PTSD symptoms (>10-point improvement) at post-treatment and follow-up. Examination of PTSD symptom cluster scores (re-experiencing, avoidance/numbing, and arousal) revealed a statistically significant improvement in avoidance/numbing at follow-up. Bivariate correlations indicated that worse baseline performance on D-KEFS Category Fluency was moderately associated with PTSD symptom improvement at post-treatment. Worse performance on both D-KEFS Category Fluency and Category Switching Accuracy was associated with improvement in depressive symptoms at post-treatment and follow-up. Worse performance on D-KEFS Trail Making Test Switching was associated with improvement in depressive symptoms at follow-up. Subsequent regression analyses revealed worse processing speed and worse aspects of executive functioning at baseline significantly predicted depressive symptom improvement at post-treatment and follow-up.
Conclusions:Worse baseline performances on tests of processing speed and aspects of executive functioning were significantly associated with improvements in PTSD and depressive symptoms during the trial. Our results suggest that cognitive training may bolster skills that are helpful for PTSD and depressive symptom reduction and that those with worse baseline functioning may benefit more from treatment because they have more room to improve. Although CCT is not a primary treatment for PTSD or depressive symptoms, our results support consideration of including CCT in hybrid treatment approaches. Further research should examine these relationships in larger samples.
59 Neuropsychiatric Clustering of Veterans with TBI: The Link Between Neuropsychological Test Validity and Somatic Post-Concussive Symptoms
- Nathalie Dugas, Morgan Caudle, Amber Keller, Jessica Bomyea, Amy Jak
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 164-165
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Objective:
There is a wide variability in the neuropsychiatric presentation of mild traumatic brain injury (mTBI), and accurate diagnosis and treatment is complicated by within-condition heterogeneity and overlapping symptoms of common comorbidities (e.g., PTSD). Such diagnostic complexities can obfuscate clinical decision-making and lead to suboptimal treatment response. In contrast to traditional diagnostic categories, person-centered analysis methods create data-derived groupings wherein individuals within a cluster are similar and individuals across clusters are different. The current study sought to apply clustering to dimensional emotional and neuropsychological features in treatment-seeking Veterans with mTBI, with the goal of identifying more precise, homogeneous clinical profiles.
Participants and Methods:Study participants were 190 Veterans with mTBI history participating in a clinical neuropsychological assessment of cognitive complaints (Mean age: 34.38, 89.6% male, average years of education: 13.14). Participants completed a diagnostic interview, neuropsychological tests, and symptom questionnaires (NBSI, PCL, BDI, BAI, AUDIT, PSQI). To identify clusters of similar neuropsychiatric presentations, we first conducted dimension reduction on data from the cognitive tests and self-report measures using principal components analysis. Second, cluster analysis and cluster validation was performed on the resultant principal components (R: kmeans, clusterboot, clusterValid) to find homogeneous subgroups of participants.
Results:The clinical data was best represented by principal components reflecting anxious arousal, depressive cognitions, somatic post-concussive symptoms, reexperiencing and avoidance symptoms, and objective cognitive deficits. Cluster analysis using bootstrapping and cluster validity indices (e.g., Silhouette width, Dunn index) indicated that a 6-subgroup solution was optimal (subgroups were labeled Group A-Group F). Group A was characterized by moderate levels across all dimension scores. Group B was characterized by elevated somatic post-concussive symptoms and cognitive deficits. Group C was characterized by intact cognitive performance and low somatic post concussive symptoms. Group D was characterized by elevated depressive cognitions. Group E was characterized by high anxious arousal but low depressive cognitions and reexperiencing and avoidance. Group F was characterized by elevated reexperiencing and avoidance. The subgroups did not differ statistically on any demographic items, such as years of education, age, or gender. However, there were statistically significant differences across groups in performance validity failure (x2(10) = 27.17, p=.002); Group B showed the highest rate of failure.
Conclusions:Results demonstrate that phenotypically similar subgroups of individuals can be identified within treatment-seeking Veterans with mTBI. Data suggest that somatic post-concussive symptoms may be linked to cognitive deficits, however the rate of validity failure indicates that neuropsychological test scores may not reflect true cognitive ability. In contrast to prior studies that treat mTBI as a unitary construct that accounts for symptoms, our data suggest that a nuanced evaluation yields vastly diverse clinical presentations. Cluster analytic frameworks hold promise for better assessment and treatment planning for Veterans, as both patients and their treating clinicians would be greatly served by the ability to use common clinical assessment tools to better identify a given individual’s clinical needs. A critical next step is to validate subgroups using novel samples and data sources (e.g., neurobiology, genetics) and to determine if these subgroupings can be effectively utilized to personalize treatment assignment.
68 Subjective Cognitive Functioning Following Non-Severe COVID-19 Acute Infections: A Meta-Analysis
- Tara A Austin, Jacqueline Maye, Cooper Hodges, Sarah Parr, Emily Darowski, Amber Keller, Rachel Bergsmans, Crystal Lantrip, Elizabeth W. Twamley
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 63-64
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Objective:
Emerging evidence suggests that individuals recovering from COVID-19 perceive changes to their cognitive function and psychological health that persist for weeks to months following acute infection. Although there is a strong relationship between initial COVID-19 infection severity and development of prolonged symptoms, there is only a modest relationship between initial COVID-19 severity and self-reported severity of prolonged symptoms. While much of the research has focused on more severe COVID-19 cases, over 90% of COVID-19 infections are classified as mild or moderate. Previous work has found evidence that non-severe COVID-19 infection is associated with cognitive deficits with small-to-medium effect sizes, though patients who were not hospitalized generally performed better on cognitive measures than did those who were hospitalized for COVID-19 infection. As such, it is important to also quantify subjective cognitive functioning in non-severe (mild or moderate) COVID-19 cases. Our meta-analysis examines self-reported cognition in samples that also measured objective neuropsychological performance in individuals with non-severe COVID-19 infections in the post-acute (>28 days) period.
Participants and Methods:This study’s design was preregistered with PROSPERO (CRD42021293124) and used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist for reporting guidelines. Inclusion criteria were established prior to article searching and required peer-reviewed studies to have (1) used adult participants with a probable or documented diagnosis of non-severe (asymptomatic, mild, or moderate) COVID-19 who were in the post-acute stage (>28 days after initial infection); (2) used objective neuropsychological testing to document cognitive functioning; and (3) include a self-report measure of subjective cognition. At least two independent reviewers conducted all aspects of the screening, reviews, and extraction process. Twelve studies with three types of study design met full criteria and were included (total n=2,744).
Results:Healthy comparison group comparison: Compared with healthy comparison participants, the post-COVID-19 group reported moderately worse subjective cognition (d=0.546 [95% CI (0.054, 1.038)], p=0.030). Severity comparison: When comparing hospitalized and not hospitalized groups, patients who were hospitalized reported modestly worse subjective cognition (d=-0.241, [95% CI (-0.703, 0.221)], p=0.30), though the difference was not statistically significant. Normative data comparison: When all non-severe groups (mild and moderate; k=12) were compared to the normative comparison groups, there was a large, statistically significant effect (d=-1.06, [95% CI (-1.58, -0.53)], p=0.001) for self-report of worse subjective cognitive functioning.
Conclusions:There was evidence of subjective report of worse cognitive functioning following non-severe COVID-19 infection. Future work should explore relationships between objective neuropsychological functioning and subjective cognitive difficulties following COVID-19.
67 Examination of Neuropsychological Functioning and Current Suicidal Ideation and Suicide Attempt History in Individuals with Severe Mental Illness
- Amber V. Keller, Emma M. Parrish, Samantha A. Chalker, Elizabeth W. Twamley, Amy E. Pinkham, Philip D. Harvey, Colin A. Depp
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 851-852
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Objective:
Suicide risk among individuals with psychosis is elevated compared to the general population (e.g., higher rates of suicide attempts [SA] and completions, more severe lethality of means). Importantly, suicidal ideation (SI) seems to be more predictive of near-term and lifetime SAs in people with psychosis than in the general population. Yet, many randomized controlled trials in psychosis have excluded individuals with suicidality. Additionally, research suggests better cognitive and functional abilities are associated with greater suicide risk in psychotic disorders, which is dissimilar to the general population, but studies examining the link between cognition and suicidality are scarce. Because neuropsychological abilities can affect how individuals are able to attend to their environment, solve problems, and inhibit behaviors, further work is needed to consider how they may contribute to suicide risk in people with psychotic disorders. We sought to examine associations between neuropsychological performance and current SI and SA history in a large sample of individuals with psychosis.
Participants and Methods:176 participants with diagnoses of schizophrenia, schizoaffective disorder, and bipolar disorder with psychotic features completed clinical interviews, a neuropsychological assessment (MATRICS Consensus Cognitive Battery subtests), and psychiatric symptom measures (Positive and Negative Syndrome Scale [PANSS]; Montgomery-Asberg Depression Rating Scale [MADRS]. First, participants were divided into groups based on their current endorsement of SI in the past month on the Colombia Suicide Severity Rating scale (C-SSRS): those with current SI (SI+; n=86) and without current SI (SI-; n=90). We also examined lifetime history of SA (n=114) vs. absence of lifetime SA (n=62). Separate t-tests, chi-square tests, and logistic regressions were used to examine associations between neuropsychological performance and the two dichotomous outcome variables (current SI; history of SA).
Results:The SI groups did not differ on diagnosis, demographics (e.g., age, gender, race, ethnicity, years of education, premorbid functioning), or on positive and negative symptoms. The SI+ group reported more severe depressive symptoms (t(169)= -5.90, p<.001) and had significantly worse performance on working memory tests than the SI- group (t(173)=2.28, p=.024). Logistic regression revealed that working memory performance uniquely predicted current SI+ group membership above and beyond depressive symptoms (B= -.040; OR= .96; 95% CI [.93, .99]; p= .034). The SA groups did not significantly differ on demographic variables or on positive/negative symptoms, but those with a history of SA had more severe depressive symptoms (t(169)= -2.80, p=.006) and worse performance on tests of working memory (t(173)=2.16, p=.033) and processing speed (t(166)=2.28, p=.024) than did those without a history of SA. Logistic regression demonstrated that after controlling for depressive symptom severity, working memory and processing speed did not predict unique variance in SA history (p=.25).
Conclusions:Worse working memory performance was associated with SI in the past month in individuals with psychotic disorders. Although our finding is consistent with literature in other psychiatric populations, it conflicts with existing psychosis literature. Thus, a more nuanced examination of how cognition relates to SI/SA in psychosis is warranted to identify and/or develop optimal interventions.
Psychological Symptoms and Rates of Performance Validity Improve Following Trauma-Focused Treatment in Veterans with PTSD and History of Mild-to-Moderate TBI
- Sarah M. Jurick, Laura D. Crocker, Victoria C. Merritt, Samantha N. Hoffman, Amber V. Keller, Graham M. L. Eglit, Kelsey R. Thomas, Sonya B. Norman, Dawn M. Schiehser, Carie S. Rodgers, Elizabeth W. Twamley, Amy J. Jak
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- Journal:
- Journal of the International Neuropsychological Society / Volume 26 / Issue 1 / January 2020
- Published online by Cambridge University Press:
- 29 October 2019, pp. 108-118
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Objective:
Iraq and Afghanistan Veterans with posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) history have high rates of performance validity test (PVT) failure. The study aimed to determine whether those with scores in the invalid versus valid range on PVTs show similar benefit from psychotherapy and if psychotherapy improves PVT performance.
Method:Veterans (N = 100) with PTSD, mild-to-moderate TBI history, and cognitive complaints underwent neuropsychological testing at baseline, post-treatment, and 3-month post-treatment. Veterans were randomly assigned to cognitive processing therapy (CPT) or a novel hybrid intervention integrating CPT with TBI psychoeducation and cognitive rehabilitation strategies from Cognitive Symptom Management and Rehabilitation Therapy (CogSMART). Performance below standard cutoffs on any PVT trial across three different PVT measures was considered invalid (PVT-Fail), whereas performance above cutoffs on all measures was considered valid (PVT-Pass).
Results:Although both PVT groups exhibited clinically significant improvement in PTSD symptoms, the PVT-Pass group demonstrated greater symptom reduction than the PVT-Fail group. Measures of post-concussive and depressive symptoms improved to a similar degree across groups. Treatment condition did not moderate these results. Rate of valid test performance increased from baseline to follow-up across conditions, with a stronger effect in the SMART-CPT compared to CPT condition.
Conclusion:Both PVT groups experienced improved psychological symptoms following treatment. Veterans who failed PVTs at baseline demonstrated better test engagement following treatment, resulting in higher rates of valid PVTs at follow-up. Veterans with invalid PVTs should be enrolled in trauma-focused treatment and may benefit from neuropsychological assessment after, rather than before, treatment.
Mild Traumatic Brain Injury Burden Moderates the Relationship Between Cognitive Functioning and Suicidality in Iraq/Afghanistan-Era Veterans
- Laura D. Crocker, Amber V. Keller, Sarah M. Jurick, Jessica Bomyea, Chelsea C. Hays, Elizabeth W. Twamley, Amy J. Jak
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- Journal:
- Journal of the International Neuropsychological Society / Volume 25 / Issue 1 / January 2019
- Published online by Cambridge University Press:
- 16 November 2018, pp. 79-89
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Objectives: Suicidal ideation (SI) is highly prevalent in Iraq/Afghanistan-era veterans with a history of mild traumatic brain injury (mTBI), and multiple mTBIs impart even greater risk for poorer neuropsychological functioning and suicidality. However, little is known about the cognitive mechanisms that may confer increased risk of suicidality in this population. Thus, we examined relationships between neuropsychological functioning and suicidality and specifically whether lifetime mTBI burden would moderate relationships between cognitive functioning and suicidal ideation. Methods: Iraq/Afghanistan-era Veterans with a history of mTBI seeking outpatient services (N = 282) completed a clinical neuropsychological assessment and psychiatric and postconcussive symptom questionnaires. Results: Individuals who endorsed SI reported more severe post-traumatic stress disorder (PTSD), depression, and postconcussive symptoms and exhibited significantly worse memory performance compared to those who denied SI. Furthermore, mTBI burden interacted with both attention/processing speed and memory, such that poorer performance in these domains was associated with greater likelihood of SI in individuals with a history of three or more mTBIs. The pattern of results remained consistent when controlling for PTSD, depression, and postconcussive symptoms. Conclusions: Slowed processing speed and/or memory difficulties may make it challenging to access and use past experiences to solve current problems and imagine future outcomes, leading to increases in hopelessness and SI in veterans with three or more mTBIs. Results have the potential to better inform treatment decisions for veterans with history of multiple mTBIs. (JINS, 2019, 25, 79–89)