“To care for him who shall have borne the battle and for his widow and orphan” Abraham Lincoln (1865)
Perhaps, no institution has had greater influence on American clinical neuropsychology than the Veterans Administration (VA). Injuries sustained in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) as well as the aging of the Vietnam era cohort are resulting in an upsurge of veterans requiring neuropsychological services. Many disorders incurred by veterans, the context in which they develop, and systems devised to provide appropriate care are distinctive. Neuropsychological Practice with Veterans, the first book of its kind, could not be more welcome. Editor Shane Bush has assembled a roster of talented VA neuropsychologists to provide a remarkably useful volume.
The book is divided into three sections. Part I, “Neuropsychological Assessment and Treatment,” includes four chapters. The first provides an overview of neuropsychological assessment in the VA, including common differential diagnostic issues, psychiatric co-morbidities, symptom validity assessment, and inpatient assessment considerations. I found the concise review of the neuropsychological aspects of psychiatric co-morbidities particularly useful. A chapter dealing with improbable symptom presentation follows. This chapter provides an empirically based argument for the use of symptom validity measures in veterans and provides guidance for implementation in the context of the VA benefits system. Included is a thoughtful discussion of the thorny issue of screening for mild traumatic brain injury (TBI). The next chapter provides an overview of the neuropsychological treatment of veterans, a topic which could easily fill an entire book. While the chapter provides valuable insights into the treatment of disorders common in veterans, readers seeking in-depth coverage of a particular area may be disappointed. For example, only a little over two pages are devoted to cognitive rehabilitation. The final chapter of Part I is devoted to the VA Polytrauma System of Care (PSC), a program recently developed to address blast injuries. The chapter critiques PSC from the neuropsychological perspective and offers guidance for PSC assessment and treatment. For those unfamiliar with PSC, the chapter provides a clear, insightful overview.
Part II, “Injuries, Illnesses, and Disorders,” contains seven chapters. The section begins with companion chapters covering TBI and blast injury. While the TBI chapter covers moderate/severe TBI, combat-related concussion is the focus, including VA TBI screening, VA department of defense (DoD) injury severity classification, pathophysiology, critical review of the OIF/OEF concussion literature, and examination of chronic post-concussion symptoms. The chapter provides practical guidance relating to neuropsychological interview, test selection (including measures not used routinely by most neuropsychologists), and treatment approaches. The 10 clinical “take-home” suggestions concluding the chapter will be particularly useful for those using this book for training. The accompanying chapter on blast injuries provides up-to-date answers to questions facing DoD/VA neuropsychologists since OEF commenced: Can blasts serve as a mechanism for TBI? Do those with blast-related TBI exhibit distinct patterns on neuroimaging, symptom profiles, and neuropsychological testing? What are the long-term effects of blast injury? These questions are addressed, and studies tackling the disquieting topic of chronic traumatic encephalopathy are covered. Also, pertinent to the OIF/OEF veterans is the chapter on posttraumatic stress disorder (PTSD). After a brief overview, the chapter covers PTSD from the neurobiological and neuropsychological standpoints, with the discussion of the unique aspects of combat PTSD.
Three chapters in Part II deal with diseases common in veterans. A chapter on dementia summarizes neuromedical information about the major etiologies. The chapter is brief, and for those regularly involved in geriatric neuropsychology will not provide much new information. It does, however, contain some interesting tidbits regarding the incidence of dementia in veterans and PTSD as a dementia risk factor. A chapter on HIV and hepatitis C is important, as the VA is the nation's largest provider of care for both. As a neuropsychologist who sees patients with these disorders infrequently, I found the synopsis of the literature dealing with the biological aspects of both diseases clear and helpful. Discussion of cognitive profiles is nicely embedded in a neuromedical framework. Substance use disorders (SUDs), also common in the VA population (e.g., 15% lifetime history in one survey), are covered in the next chapter. Following the review of epidemiology, treatment, and the neural basis of SUDs, the chapter tackles the sizeable task of summarizing the neuropsychological findings in SUDs. The heart of the chapter is an excellent table with associated commentary summarizing neuropsychological deficit effect sizes in individuals with SUDs by cognitive domain, substance, and length of remission. The final chapter in Part II is titled “Neuropsychological Conditions Experienced Solely or More Commonly by Military and Veteran Populations” and covers topics ranging from decompression sickness to cysticercosis. As someone responsible for developing a military relevant fellowship curriculum, this is a chapter I have been waiting for! The chapter does a fine job of pulling together information about a host of disorders seen primarily in military and VA clinics.
Part III, “Training, Ethics, and Trends,” concludes the volume. The initial chapter reviews the history of VA neuropsychology training and then presents results of a survey of VA neuropsychology training programs. Survey data will be informative not only to VA neuropsychologists, but all involved in neuropsychology training. A chapter on program development describes an alternative to the familiar “referral/consultation” system: An integrated VA neuropsychology service where neuropsychologists are embedded into clinics (e.g., oncology, TBI), provide screening and comprehensive evaluations, produce rapid, succinct reports, and lead cognitive wellness groups. The chapter will be thought provoking for all developing neuropsychology programs in this era of rapid change for healthcare service delivery. All interested in the evolution of our field will enjoy the final chapter which chronicles in detail the rich history of VA neuropsychology.
This clearly written, engaging volume is noteworthy for the high level of scholarship. All chapters are well researched and current. The book is a must-read for all who provide neuropsychological services or training within the VA and DoD. We will be incorporating the book into our joint DoD/VA didactics. Even those who do not work with veterans may want this book as a reference, as multiple chapters provide concise, up-to-date topical overviews. All neuropsychologists charged with fulfilling the promise of providing superior care to veterans will profit from reading this book.
Conflict of interest
The views expressed in this manuscript are those of the author and do not necessarily reflect the official policy or position of the Department of the Army, Department of the Navy, Department of Defense, or the United States government.