The Differential Pattern of Post-Concussive Symptoms Among Female Compared to Male OEF/OIF Veterans with Deployment-Related TBI

Errol Baker, Ph.D.

Katherine M. Iverson, Ph.D.

Mark Meterko, Ph.D.

Kelly L. Stolzmann, MS and

Ann Hendricks, Ph.D.

This work is supported by VA HSR&D Grant: SDR 08-405 (PI: Ann Hendricks)

Traumatic Brain Injury (TBI)

• High risk of TBI during OEF/OIF deployments Blow to the head that disrupts brain functioning Prevalence: 12-20%1-4 Most cases are mild in severity5

• Associated with: Persistent postconcussive symptoms6

Commonly co-occurs with posttraumatic stress disorder (PTSD) in VA patients (64%-67%)7,8

TBI and Women Veterans

• The impact of deployment-related TBI on women’s health is largely unknown Women comprise 13% of U.S. personnel who have

served in OEF/OIF

• 10.5% of women using VA services after OEF/OIF deployments screen positive for TBI1

• Persistent postconcussive symptoms may be worse for women than for men9,10

Study Aims

1) To examine gender differences in postconcussive symptom severity among OEF/OIF Veterans judged to have deployment-related TBI

2) To examine gender differences as a function of etiology and PTSD comorbidity

Data Source: Comprehensive TBI Evaluation

• Protocol to assist in making a clinical judgment about whether a TBI occurred

• Etiology of injury (self-report) Blast exposure Non-blast related head injuries

o e.g., vehicular accidents, bullet above the shoulders, falls, etc.

• Neurobehavioral Symptom Inventory (NSI-22)11

• PTSD comorbidity

Study Population

• Veterans who…

Completed a Comprehensive TBI Evaluation between FY 2008 and FY 2009

Been judged to have deployment-related TBI

Did not report TBI prior to or following deployment

• Random sample of 5,941 Veterans for analysis

Design

• Dependent Variable Severity of postconcussive symptoms (NSI-22)

• Independent Variables: Participants were stratified by:

o Etiology: Blast only, Blast + non-Blast, non-Blast only Gender PTSD comorbidity: Yes, No

• Three-way MANOVA and follow-up Univariate ANCOVAs

Sample Characteristics (N = 5,941)

• 306 women comprised 5.2% of study population

• Blast exposure 60% of the women 85% of men

• PTSD comorbidity 69% of women 76% of men

Affective Somatosensory Cognitive Vestibular0

0.5

1

1.5

2

2.5

3

3.5

4

Postconcussive Symptoms on NSI-22Stratified by Gender (N = 5,941)

Mean +/- 95% CIFemale Male

Mea

n S

ever

ity

Rat

ing

*

*

*

*

Very Severe

Note. The four symptom domains were determined in a previous factor analysis of the NSI-22 12 *p<.001

None

Blast Only Blast + Non-Blast

Non-Blast Only

0

0.5

1

1.5

2

2.5

3

MalesMean +/- 95% CIPTSD non-PTSD

Etiology of Injury

Mea

n S

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ity

Rat

ing

Blast Only Blast + Non-Blast

Non-Blast Only

0

0.5

1

1.5

2

2.5

3

FemalesMean +/- 95% CI

PTSD non-PTSD

Etiology of Injury

Affective Severity Stratified by PTSD Comorbidity & Etiology

Blast Only Blast + Non-Blast

Non-Blast Only

0

0.5

1

1.5

2

2.5

3

MalesMean +/- 95% CI

PTSD non-PTSD

Etiology of Injury

Mea

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ity

Rat

ing

Blast

Onl

y

Blast

+ N

on-..

.

Non-B

last

...

0

0.5

1

1.5

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FemalesMean +/- 95% CI

PTSD non-PTSD

Etiology of Injury

Somatosensory Severity Stratified by PTSD Status & Etiology

Summary

1) 60% of women reported blast exposure

2) Women report more severe postconcussive symptoms than men, especially related to blast

3) PTSD comorbidity was consistently associated with higher symptoms severity regardless of etiology for men, but this was not always the case for women

4) Women's affective and cognitive symptoms are impacted by a complex interaction of both etiology and PTSD comorbidity

Limitations and Future Research Directions

• Analyses are hypothesis-generating in that they only describe gender differences

• May have been gender-related biases in the reporting of symptoms or in the judgment of TBI

• Need to identify contributing factors for gender differences in postconcussive symptoms

Implications

• Attention to postconcussive symptoms of women Veterans Management of specific symptoms Collaboration and coordination of care Interdisciplinary teams

• Educate health care providers, Veterans and the public Increase detection Tailor treatment to women’s specific needs Increased VA service

• Polytrauma and Blast-Related Injuries (PT/BRI) QUERI

• Expert Advisory Panel

Drs. N. Sayer, D. Cifu, R. Vanderploeg, S. Fitzgerald, M. Jaffee, A. Nelson, C. Tun, and E. Bass

• My contact information: Katherine.Iverson@va.gov

• First author’s contact information: Errol.Baker@va.gov

• HSR&D PI’s contact information: Ann.Hendricks@va.gov

Acknowledgements and Contact Information

References

1. Hendricks, A., Amara, J., Baker, E., Charns, M., Gardner, J. A., Iverson, K. M., Kimerling, R., Krengel, M., Meterko, M., Pogoda, T. K., Stolzmann, K. L., Wolfsfeld, L., & Lew, H. L. (2010). Screening for mild Traumatic brain injury in OEF-OIF deployed military: An empirical assessment of the VA Experience. Unpublished manuscript.

2. Hoge, C. W., McGurk, D., Thomas, J. L., Cox, A. L., Engel, C. C., & Castro, C. A. (2008). Mild traumatic brain injury in U.S. soldiers returning from Iraq. New England Journal of Medicine, 358, 453-463.

3. Schneiderman, A. I., Braver, E. R., & Kang, H. K. (2008). Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts of Iraq and Afghanistan: Persistent postconcussive symptoms and posttraumatic stress disorder. American Journal of Epidemiology, 167, 1446-1452.

4. Tanielian, T., & Jaycox, L. H. (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Corp.

5. Hoge, C. W., Goldberg, H. M., & Castro, C. A. (2009). Care of war Veterans with mild traumatic brain injury—Flawed Perspectives. New England Journal of Medicine, 360, 1588-1591.

6. Sayer, N. A., Rettmann, N. A., Carlson, K. F., Bernardy, N., Sigford, B. J., Hamblen, J. L., Friedman, M. J. (2009). Veterans with history of mild traumatic brain injury and posttraumatic stress disorder: Challenges from provider perspective. Journal of Rehabilitation Research & Development, 46, 703-716.

7. Carlson, K. F., Nelson, D., Orazem, R. J., Nugent, S., Cifu, D. X., & Sayer, N. A. (2010). Psychiatric diagnoses among Iraq and Afghanistan war veterans screened for deployment-related traumatic brain injury. Journal of Traumatic Stress, 23, 17-24.

8. Iverson, K. M., Hendricks, A., Kimerling, R., Krengle, M., Meterko, M., Stolzmann, K., Baker, E., Pogoda, T., Vasterling, J., & Lew, H. (under review). Psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF VA patients with deployment-related TBI.

9. Colvin, A. C., Mullen, J., Lovell, M. R., West, R. V., Collins, M. W., & Groh, M. (2009). The role of concussive history and gender in recovery from soccer-related concussion. The American Journal of Sports Medicine, 37, 1699-1704.

10. Farace, E., & Alves, W. M. (2000). Do women fare worse? A metaanalysis of gender differences in outcome after traumatic brain injury. Neurosurgery Focus, 8, 1-8.

11. Cicerone, K. D., & Kalmar, K. (1995). Persistent postconcussion syndrome: The structure of subjective complaints after mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 10, 1–17.

12. Meterko, M., Baker, E., Stolzmann, K. L., Cicerone, K. D., Hendricks, K. M., & Lew, H. L. (2010). Psychometric assessment of the NSI-22. Unpublished manuscript.

Neurobehavioral Symptom Inventory (NSI-22) + Pain Item: Factor Structure12

Scale k α Scale Content

Affective 6 .88• Low frustration tolerance• Irritability• Anxiety/tension

• Fatigue • Difficulties sleeping• Depressed or sad

Somatosensory 8 .81

• Light sensitivity• Noise sensitivity• Vision problems• Headaches

• Nausea• Numbness/tingling • Change in taste/smell• Pain

Cognitive 4 .89

• Difficulties getting organized/can’t finish things • Poor concentration • Forgetfulness • Difficulties making decisions

Vestibular 3 .82• Loss of balance• Feeling dizzy• Poor coordination/clumsy

Unassigned 2 NA• Loss or increase in appetite • Hearing difficulty

Blast

Onl

y

Blast

+ N

on-B

last

Non-B

last

Onl

y0

0.5

1

1.5

2

2.5

3

MalesMean +/- 95% CI

PTSD non-PTSD

Etiology of Injury

Mea

n S

ever

ity

Rat

ing

Blast

Onl

y

Blast

+ N

on-B

last

Non-B

last

Onl

y0

0.5

1

1.5

2

2.5

3

FemalesMean +/- 95% CI

PTSD non-PTSD

Etiology of Injury

Cognitive Severity Stratified by PTSD Status & Etiology

Blast

Onl

y

Blast

+ N

on-B

last

Non-B

last

Onl

y0

0.5

1

1.5

2

2.5

3

MalesMean +/- 95% CI

PTSD non-PTSD

Etiology of Injury

Mea

n S

ever

ity

Rat

ing

Blast

Onl

y

Blast

+ N

on-..

.

Non-B

last

...

0

0.5

1

1.5

2

2.5

3

FemalesMean +/- 95% CI

PTSD non-PTSD

Etiology of Injury

Vestibular Severity Stratified by PTSD Status & Etiology

Gender Etiology Total

Blast Only

Blast + Non-Blast

Non-Blast Only

Count % Count % Count % Count %

Female 79 25.8 104 34.0 123 40.2 306 100

Male 2,064 36.6 2,732 48.5 839 14.9 5,635 100

Total 2,143 36.1 2,836 47.7 962 16.2 5,941 100

Sample Characteristics: Gender and Injury Etiology (N = 5,941)

Sample Characteristics:Gender and PSTD Comorbidity (N = 5,941)

Gender PSTD Comorbidity Total

Present Absent

Count % Count % Count %

Female 210 68.6 96 31.4 306 100

Male 4,281 76.0 1,354 24.0 5,635 100

Total 4,491 75.6 1,450 24.4 5,941 100

Sample Characteristics:Gender, PTSD Comorbidity, Injury Etiology

Gender PTSD Etiology Total

Blast OnlyBlast +

Non-BlastNon-Blast

Only

n % n % n % n %

Female No 17 17.7 20 20.8 59 61.5 96 100

Yes 62 29.5 84 40.0 64 30.5 210 100

Male No 448 33.1 535 39.5 371 27.4 1354 100

Yes 1616 37.7 2197 51.3 468 10.9 4281 100

Total 2143 36.1 2836 47.7 962 16.2 5941 100