Abstract

Objective

This study examined the consistency of self-reported symptoms and concussive events in combat veterans who reported experiencing concussive events.

Method

One hundred and forty, single deployed, Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn combat veterans with Veteran Health Administration (VHA) Comprehensive Traumatic Brain Injury Evaluations (CTBIE) and no post-deployment head injury were examined to assess consistency of self-reported (a) traumatic brain injury (TBI)-related symptoms, (b) post-traumatic stress disorder (PTSD)-related symptoms, and (c) TBI-related concussive events from soon after deployment to time of VHA CTBIE.

Results

Compared to their self-report of symptoms and traumatic events at the time of their Post-Deployment Health Assessment, at the time of their comprehensive VHA evaluation, subjects reported significantly greater impairment in concentration, decision making, memory, headache, and sleep. In addition, although half the subjects denied any PTSD symptoms post-deployment, approximately three quarters reported experiencing all four PTSD screening symptoms near the time of the VHA CTBIEs. At the latter time, subjects also reported significantly more TBI-related concussive events, as well as more post-concussive sequelae such as loss of consciousness immediately following these concussive events. Finally, although 84% reported a level of impairment so severe as to render all but the simplest activity doable, the vast majority simultaneously reported working and/or attending college.

Conclusions

These findings raise questions regarding the accuracy of veteran self-report of both near and distant traumatic events, and argue for the inclusion of contemporaneous Department of Defense (DOD) records in veteran assessment and treatment planning.

Introduction

Traumatic brain injury (TBI) and PTSD are often considered the signature injuries of war for Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans ( Brundage, Taubman, Hunt & Clark, 2015 ). Compared to other veteran groups, OEF/OIF/OND veterans tended to have longer deployments and a greater number of total deployments ( Institute of Medicine, 2013 ; Tanielian et al., 2008 ). These factors increased the likelihood that veterans would be exposed to multiple traumatic events, with greater risks of being injured during their deployment. At the same time, advances in defensive gear, combined with timely access to medical care, increased the likelihood of survival for those suffering physical injury ( Morissette et al., 2011 ; Vasterling, Verfaellie & Sullivan, 2009 ).

Recognizing the possible long-term consequences of these war-related injuries, and the moral obligation of caring for those injured in service to their country, both the Department of Defense (DOD) and the Veterans Health Administration (VHA) established systems of comprehensive evaluations based in part on veteran self-report of symptoms and concussive events. For example, the DOD mandated Post-Deployment Health Assessments (PDHA) for all OEF/OIF/OND veterans deployed at least 30 days ( DOD, 2002 , 2003 , 2006 ). The DOD PDHA consisted of both self-reported symptoms and a face-to-face post-deployment assessment interview with a credentialed health care provider to provide comprehensive health surveillance. The DOD PDHA evolved over time to include additional neuropsychologically relevant symptoms, such as concentration difficulties and difficulties making decisions. Later versions included detailed information on TBI-related sequelae and etiology. All PDHA versions included information on memory difficulties, as well as PTSD-related symptom categories. The DOD PDHA is typically given within 5 days of their departure from theater or shortly before leaving ( Collins, 2009 ).

Similarly, the VHA mandated TBI screens for every OEF/OIF/OND veteran entering the VHA, in order to identify all veterans reporting exposure to a TBI concussive event with alteration in consciousness and post-concussion symptoms ( Belanger, Vanderploeg & Sayer, 2016 ; Donnelly et al., 2011 ). Veterans scoring positive on the TBI screen are offered a comprehensive VHA TBI evaluation ( VHA, 2010a ) that includes an assessment of exposure to TBI-related concussive events, sequelae, as well as neurobehavioral symptoms based on the Cicerone and Kalmar (1995) Neurobehavioral Symptom Inventory. In addition, the VHA mandates screening of every OEF/OIF/OND veteran for PTSD-related symptoms ( VHA, 2005 ).

As Hendricks and colleagues (2013) noted, “effective screening programs prioritize sensitivity (the ability to detect the condition among all VHA patients with the condition) over specificity (the ability to rule out the condition when the patients do not have the condition) to minimize missed opportunities for treatment” (p. 126). In their review of the literature, Belanger and colleagues (2016) concluded: “review of the research literature on the psychometric properties of the TBI screen indicates that the screen has limited validity in terms of agreement with criterion standards but good sensitivity” (p. 212; see also Belanger, Vanderploeg, Soble, Richardson & Groer, 2012 ). Belanger and colleagues (2016) also found the VHA TBI screen to have “good internal consistency” and “variable test-retest reliability” (p. 204)

Utilization of self-report-based assessments has not been without its critics (see, e.g., Armistead-Jehle, 2010 ; Carlson et al., 2011 ; Frueh et al., 2005 ). Research consistently finds that self-reports of trauma-related PTSD and TBI symptoms are inconsistent over time, with subjects showing a tendency to report more symptoms during later assessments compared to earlier assessments (see, e.g., Bliese, Wright, Adler, Thomas & Hoge, 2007 ; King et al., 2000 ; Macera, Aralis, MacGrefor, Rauh & Galarneau, 2012 ; Milliken, Auchterlonie & Hoge, 2007 ; Roca & Freeman, 2001 , Russo, 2012 ; Southwick, Morgan, Nocolaou & Charney, 1997 ; Van Dyke, Bradley, Axelrod, & Schutte, 2010 ).

In addition, research has also consistently found inconsistent self-reporting of the traumatic events themselves. For example, in their 2005 review of the literature, Giezen, Arensman, Spinhoven and Wolters found that those exposed to combat showed significant inconsistencies in their memory of traumatic events across time, with a tendency to amplify combat-related memories. Later studies found similar results. For example, Van Dyke and colleagues (2010) compared the self-reports of 44 OEF/OIF combat veterans referred for a neuropsychological evaluation following a positive TBI screen with a second screen 6 months later, and found not only an increase in reported memory impairment over time, but also a tendency at the later time, to report more TBI-related concussive events and to report experiencing more TBI-related sequelae immediately following the concussive event.

The Institute of Medicine's 2009 study of the long-term consequences of TBI cautioned that self-reporting can introduce reporting bias, leading “to an overestimation of the incidence or prevalence of symptoms or diagnosis” (p. 118). In addition, in their systematic review of the literature, Carlson and colleagues (2011 , p. 110) concluded that screening for TBI and PTSD based on self-report “may lead to an overestimation of TBI and PTSD.”

The consistency of self-reported symptoms from time of DOD PDHA to time of VA TBI screen has been largely unexamined. A review of the literature only found one study that examined consistency of self-reported memory across this time span. Russo (2012) examined consistency of self-reported memory complaints in 50 OIF/OEF veterans. He found that although 49 of 50 veterans reported moderate to very severe memory impairment during the VHA comprehensive TBI evaluation, only 7 had reported any memory problem at the time of their DOD PDHA. He also found “an unexpected lack of consistency between veteran self-report of memory functioning and actual functioning” (p. 7). Of the 38 subjects reporting working and/or attending college, 24 reported severe to very severe memory impairment.

The purpose of this study was to ascertain the consistency of veteran self-report from time of DOD PDHA to time of the VHA Comprehensive TBI Evaluation (CTBIE) on report of (a) TBI-related cognitive symptoms, (2) PTSD-related symptoms, and (3) TBI-related concussive events in veterans seen for a comprehensive VHA TBI evaluation following positive TBI screens. This archival study was approved by the Veteran Affairs New York Healthcare System's Institutional Review Board. Statistical analyses were performed via the SPSS 15 software package. Because of the numerous tests of significance employed in this study, significance was set at p  < .01.

Method

Subjects

A retrospective chart review of the VHA computerized patient record system (CPRS) identified 140 OEF/OIF/OND combat veterans who (a) were consecutively seen by Physical Medicine and Rehabilitation for a comprehensive TBI assessment following positive TBI screens and (2) had their DOD PDHA available on the VHA CPRS. This study was conducted at the VANY Harbor Health Care System, which consists of medical centers in Manhattan, Brooklyn and an extended care center in Queens.

To control for number of deployments, only veterans with one deployment were included. Veterans reporting head injury post-deployment were excluded. Veterans used in an earlier pilot study ( Russo, 2012 ) were also excluded.

Measures

All information was obtained from the subjects medical records as documented in the VHA's CPRS. Data elements elicited from the respective DOD and VHA assessments can be found in the Appendix. To insure accuracy of data collection, 20% of subject records were checked for inter-rater reliability by the second author, with an agreement found between raters of over 99%.

Please note that a review of the CPRS failed to find complete information for every subject on every data set. With some subjects, data were missing from their DOD PDHA or VHA CTBIE, or both. Specifically, all subjects had complete data sets for demographic information, academic and occupational status, PTSD symptoms, and self-reported memory and headache symptoms. Two subjects lacked complete information on sleep disturbance, so the subject size used for analyzing sleep disturbance was n = 138. The subject size used to analyze consistency of concentration and decision making symptoms was n = 54 and n = 50, respectively. The data sets used to examine consistency of TBI-related concussive events and post-concussive sequelae were n = 51 for each. The size of each data set is also provided below in presenting the results.

Post-Deployment Health Assessment

Self-reports of TBI-related symptoms, PTSD symptoms, TBI-related concussive events, TBI-related concussive event sequelae, and select demographic information at the end of deployment were obtained from the DOD PDHA. The PDHA is an in-person interview conducted by a military health care provider, such as a physician, physician's assistant or nurse practitioner to all veterans deployed at least 30 days ( DOD, 2003 , 2006 ; Collins, 2009 ). This assessment is usually completed within 5 days of the veteran's departure from the combat theater or shortly before leaving ( Collins, 2009 ). Please note that there were slight variations in wording across revisions of the PDHA. Examples of these variations are provided subsequently.

TBI-related concussive events

TBI-related concussive events were rated based on the subject's response of yes or no to the following questions asked during their DOD PDHA. A yes response was coded as a positive response whereas a no response was coded as a negative response.

“During this deployment, did you experience any of the following events? (Mark all that apply.)

  1. Blast or explosion (IED, RPG, land mine, grenade, etc.)

  2. Vehicular accident/crash (any vehicle, including aircraft)

  3. Fragment wound or bullet wound above your shoulders

  4. Fall”

TBI-related concussive event sequelae

Sequelae experienced immediately after the TBI-related concussive events were rated based on the subject's response of yes or no to the following questions asked during DOD PDHA. A yes response was coded as a positive response whereas a no response was coded as a negative response.

“Did any of the following happen to you, or were you told happened to you, IMMEDIATELY after any of the event(s) you just noted in question [related to the TBI Concussive Event, immediately above]? (Mark all that apply.)

  1. Lost consciousness or got ‘knocked out’

  2. Felt dazed, confused, or ‘saw stars’ or ‘becoming disoriented, functioning differently, or nearly blacking out’

  3. Didn't remember the event or ‘losing memory of the event before or after the injury’”

TBI-related symptoms

Select TBI-related symptoms were rated based on the subject's response of yes or no to questions which asked whether the subject experienced at anytime during the deployment or currently, the following symptoms. A yes response to any part of a symptom was coded as a positive response whereas a no response to any part of a symptom question was coded as a negative response.

  1. Trouble concentrating, easily distracted

  2. Forgetful or trouble remembering things

  3. Hard to make up your mind or make decisions

  4. Headaches or bad headaches

  5. Problems sleeping or still feeling tired after sleeping.

PTSD symptoms

PTSD symptoms were rated based on the subject's response of yes or no to the following questions asked during DOD PDHA. A yes response was coded as a positive response whereas a no response was coded as a negative response.

“Have you ever had any experience that was so frightening, horrible, or upsetting that, IN THE PAST MONTH, you ...

  • Have had nightmares about it or thought about it when you did not want to?

  • Tried hard not to think about it or went out of your way to avoid situations that remind you of it?

  • Were constantly on guard, watchful, or easily startled?

  • Felt numb or detached from others, activities, or your surroundings?”

Comprehensive VHA CTBI Evaluation

Self-reports of neurocognitive symptoms, concussive events, concussive-related sequelae, and select demographic information at the time of VHA admission were obtained via the VHA CTBIE, and supplemented by contemporaneous information in the VHA CPRS. Self-report of PTSD symptoms at the time of VHA CTBIEs was taken from VHA PTSD screens contemporaneous to the VHA CTBIEs.

The data elements from the VHA CTBIE were identical to those used for the DOD PDHA, with the following exception. The responses to the five neurobehavioral problems used in this study, specifically (a) concentration, (b) memory, (c) making decision, (d) headaches, and (e) sleep, were coded differently. During the DOD PDHA veterans are asked whether they experienced the symptom. For this study, a yes answer was coded as 1 for present or 0 for absent, based on the subject's response of yes or no, respectively on the DOD PDHA. During the VHA CTBIE veterans are asked to rate the severity of experienced symptoms on a 1–5 point scale, as follows:

“Please rate the following symptoms with regard to how they have affected you over the past 30 days. Use the following scale:

  1. None: rarely if ever present; not a problem at all.

  2. Mild: occasionally present, but it does not disrupt activities; I can usually continue what I'm doing; doesn't really concern me.

  3. Moderate: often present, occasionally disrupts my activities; I can usually continue what I'm doing with some effort; I am somewhat concerned.

  4. Severe: frequently present and disrupts activities; I can only do things that are fairly simple or take little effort; I feel like I need help.

  5. Very Severe: almost always present and I have been unable to perform at work, school, or home due to this problem; I probably cannot function without help.”

For this study, the symptom responses were coded as 1–5, based on the subject's response of 1–5, respectively, on the VHA CTBIE.

Results

Demographic Information

Table 1 presents the demographic- and deployment-related information for this sample. The mean time from DOD PDHA to comprehensive VHA CTBIE was 3.92 years (SD = 2.47). The mean age at the time of comprehensive VHA CTBIE was 33.99 years (SD = 9.08). The vast majority was men (91%). All had a high-school-level education, with 59% having college credits. Ethnic breakdown was as follows: 34% Caucasian, 29% Black, 27% Hispanic, 4% Asian, and 5% other or not reported.

Table 1.

Demographic and deployment-related information

 Mean (SD) Min Max 
Age a (years)  34.0 (9.1) 21.4 61.8 
Gender (% men) 90.7%   
Length of deployment in days 266.1 (98.1) 6.0 698.0 
Time in years from DOD PDHA to VHA CTBIE 3.92 (2.5)   
Percent active versus reserve unit b 49.3%   
Percent with service connection a 75.0%   
Percent of service connection a 73.2 (24.0) 0.0 100.0 
 Mean (SD) Min Max 
Age a (years)  34.0 (9.1) 21.4 61.8 
Gender (% men) 90.7%   
Length of deployment in days 266.1 (98.1) 6.0 698.0 
Time in years from DOD PDHA to VHA CTBIE 3.92 (2.5)   
Percent active versus reserve unit b 49.3%   
Percent with service connection a 75.0%   
Percent of service connection a 73.2 (24.0) 0.0 100.0 

Note: SD, standard deviation; DOD PDHA, Department of Defense Post Deployment Health Assessment; VHA CTBIE, Veterans Health Administration Comprehensive Traumatic Brain Injury Evaluation.

a Service connection was determined at time of Veteran Health Administration Traumatic Brain Injury Evaluation. Percent with service connection is the percent of the sample with any service-connected rating; percent of service connection is the amount of service connection received.

b Reserve unit includes Reserves and National Guard.

All had one deployment. Active unit versus reserve unit status at the time of deployment was approximately equally (49% vs. 51%, respectively). Length of deployment in days was 266.11 (SD = 98.13). During deployment, the majority served in the Army (74%), with 20% serving in the Marine Corps, 4% in the Navy, and 3% in the Air Force.

The majority endorsed PTSD-related etiological events. At the time of their DOD PDHA, 68% responded yes when asked “Were you engaged in direct combat where you discharged your weapon”; 66% responded yes when asked, “Did you see anyone wounded, killed or dead during this deployment”; 71% responded yes when asked, “During this deployment, did you ever feel that you were in great danger of being killed?”

Mann–Whitney U- tests failed to find any significant differences between active and reserve units at the time of DOD PDHA or VHA TBI evaluation on TBI-related symptoms, PTSD-related symptoms, or TBI-related concussive events. There were also no significant differences reported at the time of the DOD PDHA on the previously mentioned PTSD etiologically related events. Given the lack of significant differences between active and reserve units on study variables, active and reserve unit data were combined.

Nonsignificant difference between active and reserve units at time of DOD PDHA is as follows: concentration difficulties ( U  = 297.0, z  = −0.767; p  > .05); decision-making difficulties ( U  = 257.0, z  = −0.600, p  > .05); memory difficulties ( U  = 2321.0, z  = −0.817, p  > .05); headaches ( U  = 2234.0, z  = −1.050, p  > .05); sleep difficulties ( U  = 1884.0, z  = −2.461, p  > .05); any TBI concussive event ( U  = 193.5, z  = −2.271, p  > .05); total PTSD symptoms ( U  = 1957.0, z  = −2.213, p  > .05); see anyone wounded, killed, dead ( U  = 1365.0, z  = −1.154, p  > .05); engaged in direct combat/fire weapon ( U  = 450.0, z  = −1.218, p  > .05); feel great danger of being killed ( U  = 1326.0, z  = −1.503, p  > .05). Nonsignificant difference between active and reserve units at time of VHA CBTIE is as follows: concentration difficulties ( U  = 2197.0, z  = −1.077; p  > .05); decision-making difficulties ( U  = 2049.0, z  = −1.443, p  > .05); memory difficulties ( U  = 2239.5, z  = −0.898, p  > .05); headaches ( U  = 1983.0, z  = −2.010, p  > .05); sleep difficulties ( U  = 2348.0, z  = −0.136, p  > .05); any TBI concussive event ( U  = 2415.0, z  = −0.986, p  > .05); total PTSD symptoms ( U  = 2436.0, z  = −0.073, p  > .05).

The majority (75%) had a service-connected condition. As Russo (2012) noted, the Veteran Benefits Administration awards a service-connected rating to veterans for conditions that were caused by, or exacerbated by their military service. The mean service-connected rating for those with a service-connected rating was 73%. Of note, service-connected ratings increased by over 10% during the course of this study, as seen in a comparison of the service connection reported during the initial data collection period with the 2 months later data check. Because service connection was considered an unstable variable, it was not included for further study.

At the time of the VHA TBI screen, the most common symptoms reported were sleep (88%), headache (77%), and memory (65%). Forty-three percent reported all three symptoms, 44% reported two of three, and only 13% reported one of these symptoms.

Consistency of Self-Reported Concentration, Decision Making, and Memory Symptoms

Table 2 presents the consistency of self-reported concentration, decision making, and memory impairments at time of DOD PDHA to time of comprehensive VHA CTBIE. In their factor analytic study, Meterko, Baker, Stolzmann, Hendricks and Cicerone (2012) found that these three symptoms made up the “cognitive symptom dimension” of the Neurobehavioral Symptom Inventory. Concentration, decision making, and memory were studied using the sample sizes of n = 54, n = 50, and n = 140, respectively, based on all those who had complete information in both their DOD PDHA and VHA CTBIE.

Table 2.

Consistency of self-reported concentration, memory, and decision-making impairments at time of Department of Defense Post Deployment Health Assessment and Veteran Health Administration Comprehensive Traumatic Brain Injury Evaluation

DOD PDHA VHA CTBIE 
None Mild Moderate Severe Very severe 
Impaired concentration ( n = 54 a )  
 No (45) 11 13 
 Yes (9) 
Impaired decision making ( n = 50 a )  
 No (45) 13 12 11 
 Yes (5) 
Impaired memory ( n = 140 a )  
 No (116) 13 20 28 30 25 
 Yes (24) 
DOD PDHA VHA CTBIE 
None Mild Moderate Severe Very severe 
Impaired concentration ( n = 54 a )  
 No (45) 11 13 
 Yes (9) 
Impaired decision making ( n = 50 a )  
 No (45) 13 12 11 
 Yes (5) 
Impaired memory ( n = 140 a )  
 No (116) 13 20 28 30 25 
 Yes (24) 

Note : DOD PDHA, Department of Defense Post Deployment Health Assessment; VHA CTBIE, Veterans Health Administration Comprehensive Traumatic Brain Injury Evaluation.

an equals the total number of records in which the variable was reported both at the time of the DOD PDHA and the VHA CTBIE.

There was a 378% increase in reported concentration impairment (from 9 to 43), a 600% increase in reported impairment in making decisions (from 5 to 35), and a 429% increase in reported memory impairment (from 24 to 127) from time of DOD PDHA to time of VHA CTBIE. As Russo (2012) noted, this is the opposite pattern expected of TBI sequelae; the expected pattern is improvement rather than deterioration over time (also see VHA, 2010b ). In other words, the expected null hypotheses were that there would either be no difference or a decrease in symptoms over time, which were rejected given the finding of the increase in symptoms over time. A Wilcoxon Signed Ranks test found these increases in reported cognitive impairment from time of the DOD PDHA to time of VHA CTBIE to be highly significant (concentration impairment, z = −5.709, p < .00001; decision-making impairment, z = −5.121, p < .00001; memory impairment, z = −9.667,  p < .00001).

Consistency of Self-Reported Headache and Sleep Problem Symptoms

Since headache and sleep disturbance were commonly reported during the VHA TBI screens, they were included for analysis in this study. Headache and sleep problems were studied using the sample sizes of n = 140 and n = 138, respectively, based on those who had complete information in both their DOD PDHA and VHA CTBIE.

As seen in Table 3 , report of headache and sleep disturbance more than doubled from time of DOD PDHA to time of comprehensive VHA CTBIE. There was a 115% increase in reported headaches (from 59 to 127), and a 124% increase in reported sleep disturbance (from 58 to 130) from time of DOD PDHA to time of VHA TBI evaluation. A Wilcoxon Signed Ranks test found these increases in reported impairment at time of the DOD PDHA to time of VHA TBI evaluation to be highly significant (headache, z = −9.570, p < .00001; sleep disturbance, z = −9.787, p < .00001).

Table 3.

Consistency of self-reported headaches and sleep problems at time of Department of Defense Post Deployment Health Assessment and Veteran Health Administration Comprehensive Traumatic Brain Injury Evaluation

DOD PDHA VHA CTBIE 
None Mild Moderate Severe Very severe 
Headaches ( n = 140 a )  
 No (81) 10 28 25 
 Yes (59) 12 20 14 
Impaired sleep ( n = 138 a )  
 No (80) 12 34 25 
 Yes (58) 11 18 20 
DOD PDHA VHA CTBIE 
None Mild Moderate Severe Very severe 
Headaches ( n = 140 a )  
 No (81) 10 28 25 
 Yes (59) 12 20 14 
Impaired sleep ( n = 138 a )  
 No (80) 12 34 25 
 Yes (58) 11 18 20 

Note : DOD PDHA, Department of Defense Post Deployment Health Assessment; VHA CTBIE, Veterans Health Administration Comprehensive Traumatic Brain Injury Evaluation.

an equals the total number of records in which the variable was reported both at the time of the DOD PDHA and the VHA CTBIE.

Consistency of Self-Reported TBI-Related Concussive Events

TBI-related concussive events were defined as subject self-report of experiencing a (a) blast or explosion, (b) fall, (c) motor vehicle accident, and/or (d) wound above the shoulders. TBI-related concussive events were studied using the sample size of n = 51, based on all those who had complete information in both their DOD PDHA and VHA CTBIE.

Of the 51 subjects reporting TBI-related concussive events at time of DOD PDHA and time of VHA TBI evaluation, only 20 subjects, or 39%, reported the same concussive events at both time periods. A qualitative review found that some discrepancies were easily understandable; a veteran driving over an improvised explosive device (IED) might report both the blast and motor vehicle accident during one time period but only the blast (or motor vehicle accident) during the other period. Other discrepancies were less amenable to understanding, as in those subjects reporting no TBI-related concussive event during their DOD PDHA but multiple events during their VHA TBI CTBIEs. Rather than weigh the reasonableness of these discrepancies, the conservative approach of defining any TBI-related concussive events as a positive event was used.

As seen in Table 4 , of the 51 subjects reporting TBI-related concussive events both at the time of DOD PDHA and VHA CTBIEs, 37 or 73% reported experiencing some TBI-related concussive event at the time of DOD PDHA, whereas all but one (50 or 98%) reported experiencing a TBI-related concussive event at the time of their VHA CTBIEs. A pairwise comparison using a continuity-corrected McNemar test found this increase from reported TBI-related concussive event at time of DOD PDHA to time of the VHA CTBIE to be highly significant ( p < .001).

Table 4.

Consistency of self-reported traumatic brain injury-related concussive events a at Department of Defense Post Deployment Health Assessment and Veteran Health Administration Comprehensive Traumatic Brain Injury Evaluation: report of any event ( n = 51 b )

DOD PDHA VHA CTBIE 
None Yes 
None (14) 14 
Yes (37)  36 c 
DOD PDHA VHA CTBIE 
None Yes 
None (14) 14 
Yes (37)  36 c 

Note : DOD PDHA, Department of Defense Post Deployment Health Assessment; VHA CTBIE, Veterans Health Administration Comprehensive Traumatic Brain Injury Evaluation.

a Concussive events included (a) blast or explosion exposure, (b) falls, (c) motor vehicle accidents, and (d) wounds above the shoulder.

bn equals the total number of records in which the variable was reported both at the time of the DOD PDHA and the VHA CTBIE.

c Of these 51 subjects, 20 had perfect agreement from DOD PDHA to VHA CTBIE on types of concussive events experienced, whereas 31 differed in whole or part on number or type of concussive events.

Consistency of Self-Reported Post-Concussive Sequalae

Post-concussive sequelae was studied using the sample sizes of n = 51, based on all those who had complete information in both their DOD PDHA and VHA CTBIE.

Veteran report of TBI post-concussive sequelae also increased significantly from time of DOD PDHA to time of the VHA CTBIE. As seen in Table 5 , there was a 133% increase in reported loss of concentration (from 9 to 21), a 169% increase in reported feeling dazed or seeing stars (from 16 to 43), and a 380% increase in reported post-event amnesia (from 5 to 24) from time of DOD PDHA to time of VHA CTBIE. Although at the time of their DOD PDHA 67% of subjects (34 of 51) denied experiencing any TBI-related sequelae, at the time of the VHA CTBIE 84% reported at least one sequelae, with 61% reported two or more sequelae.

Table 5.

Consistency of self-reported traumatic brain injury-related post-concussive sequelae at Department of Defense Post Deployment Health Assessment and Veteran Health Administration Comprehensive Traumatic Brain Injury Evaluation: total number of reported symptoms ( n = 51 a )

DOD PDHA VHA CTBIE 
No Yes 
(1) Lost consciousness or got "knocked out" 
 No (42) 29 13 
 Yes (9) 
(2) Felt dazed, confused, or "saw stars" 
 No (35) 28 
 Yes (16) 15 
(3) Post-event amnesia or did not remember the event 
 No (46) 26 20 
 Yes (5) 
DOD PDHA VHA CTBIE 
No Yes 
(1) Lost consciousness or got "knocked out" 
 No (42) 29 13 
 Yes (9) 
(2) Felt dazed, confused, or "saw stars" 
 No (35) 28 
 Yes (16) 15 
(3) Post-event amnesia or did not remember the event 
 No (46) 26 20 
 Yes (5) 

Note : DOD PDHA, Department of Defense Post Deployment Health Assessment; VHA CTBIE, Veterans Health Administration Comprehensive Traumatic Brain Injury Evaluation.

an equals the total number of records in which the variable was reported both at the time of the DOD PDHA and the VHA CTBIE.

A Wilcoxon Signed Ranks test found these increases in reported TBI-related sequelae from time of the DOD PDHA to time of VHA TBI evaluation to be highly significant (loss of consciousness, z = −3.207, p < .002; feeling dazed, z = −5.014, p < .00001; post-event amnesia, z = −4.146, p < .00001; total reported sequelae, z = −4.871, p < .00001).

Consistency of Self-Reported PTSD Symptoms

Both the DOD and VHA used the same four category PTSD screen to assess for trauma-related re-experiencing, numbing, avoidance, and hyper-arousal ( Prins et al., 2003 ). Because all subjects had completed information on self-reported PTSD symptoms at both time of DOD PDHA and VHA CBTIE, an n of 140 was used to study consistency of self-reported PTSD symptoms.

Veteran report of PTSD symptoms increased significantly from time of DOD PDHA to time of VHA CTBIE. As seen in Table 6 , there was a 155% increase in reported re-experiencing of a trauma (from 44 to 112), a 231% increase in reported avoidance (from 35 to 116), a 135% increase in reported watchfulness (from 51 to 120), and a 354% increase in reported numbing (from 26 to 118) from time of DOD PDHA to time of VHA CTBIE. Although at the time of their DOD PDHA half of all subjects (71 of 140) denied experiencing any PTSD symptoms, at the time of the VHA CTBIE almost three quarters (104 of 140) reported experiencing all four symptoms.

Table 6.

Consistency of self-reported post-traumatic stress disorder symptoms at Department of Defense Post Deployment Health Assessment and Veteran Health Administration Comprehensive Traumatic Brain Injury Evaluation: ( n = 140 a )

DOD PDHA VHA CTBIE 
No Yes 
(1) Had any nightmares about it or thought about it when you did not want to 
 No (96) 21 75 
 Yes (44) 37 
(2) Tried hard not to think about it… avoid situations that remind you of it 
 No (105) 21 84 
 Yes (35) 32 
(3) Were constantly on guard, watchful, or easily startled 
 No (89) 14 75 
 Yes (51) 45 
(4) Felt numb or detached from others, activities, or your surroundings 
 No (114) 16 98 
 Yes (26) 20 
DOD PDHA VHA CTBIE 
No Yes 
(1) Had any nightmares about it or thought about it when you did not want to 
 No (96) 21 75 
 Yes (44) 37 
(2) Tried hard not to think about it… avoid situations that remind you of it 
 No (105) 21 84 
 Yes (35) 32 
(3) Were constantly on guard, watchful, or easily startled 
 No (89) 14 75 
 Yes (51) 45 
(4) Felt numb or detached from others, activities, or your surroundings 
 No (114) 16 98 
 Yes (26) 20 

Note : DOD PDHA, Department of Defense Post Deployment Health Assessment; VHA CTBIE, Veterans Health Administration Comprehensive Traumatic Brain Injury Evaluation.

an equals the total number of records in which the variable was reported both at the time of the DOD PDHA and the VHA CTBIE.

A Wilcoxon Signed Ranks test found these increases in reported PTSD symptoms from time of the DOD PDHA to time of VHA CTBIE to be highly significant (re-experiencing of trauma, z = −7.509, p < .00001; avoidance, z = −8.684, p < .00001; watchfulness, z = −7.667, p < .00001; numbing, z = −9.021, p < .00001; total reported PTSD symptoms, z = −8.824, p < .00001).

Consistency of Self-Reported Occupational and Educational Functioning

All subjects had information related to self-reported occupational and educational functioning available in both their DOD PDHA and VHA CBTIE. An n of 140 was used to study consistency of self-reported occupational and educational functioning.

Table 7 presents the relationships of self-reported worse impairment at time of VHA CTBIE with contemporaneous self-report of occupational functioning and/or college enrollment. Worse impairment was defined as the highest score subjects reported for impaired concentration, decision making, memory, headaches, or sleep. All 140 subjects reported some level of impairment, with the vast majority (84%) reporting a severe or very severe level impairment on one or more of these symptoms. Of the 117 subjects reporting severe or very severe level impairment, 93 reported that they were employed and/or enrolled in college. This was at odds with the functional definitions of impairment. Severe level impairment only allowed performing “things that are fairly simple or take little effort,” whereas very severe level impairment included the functional definition of being “unable to perform” at work or school.

Table 7.

Relationship of level of greatest self-reported impairment at time of comprehensive Veteran Health Administration Comprehensive Traumatic Brain Injury Evaluation with contemporaneous report of occupational functioning and/or college enrollment: ( n = 140 a )

Highest impairment Employed and/or enrolled in college 
Employed College Both Neither 
None 
Mild 
Moderate 10 
Severe 23 16 
Very severe 27 19 14 
Highest impairment Employed and/or enrolled in college 
Employed College Both Neither 
None 
Mild 
Moderate 10 
Severe 23 16 
Very severe 27 19 14 

an equals the total number of records in which the variable was reported at the time of the Veteran Health Administration Comprehensive Traumatic Brain Injury Evaluation.

Discussion

The main finding of this study is the marked lack of consistency of combat veteran self-report of trauma-related symptoms and events from time of DOD PDHA to time of VHA CTBIE (mean time interval was 3.92 years; SD = 2.47). This was seen across all five data categories examined. Compared to their self-report at the time of their DOD PDHA, at the time of their VHA CTBIEs, subjects (a) reported significantly more TBI-related symptoms, such as impaired concentration, decision-making ability, headache, memory, and sleep; (b) reported significantly more PTSD-related symptoms such as re-experiencing trauma, increased avoidance, increased watchfulness, and increased numbness; (c) reported significantly more TBI-related concussive events, such as blast/explosion, falls, motor vehicle accidents, and wounds above the shoulders; and (d) reported significantly more post-concussive sequelae, such as loss of concentration, feeling dazed, and post-event amnesia. Finally, although the vast majority reported severe or very severe levels of current functional impairment, most also reported that they were working and/or attending college despite their professed levels of marked impairment. These results are consistent with the considerable research on the inconsistency of veteran self-reported symptoms, and the limited research on inconsistency of recalled traumatic events and inconstancy of reported current functioning.

This study was descriptive, and did not address issues of causation. A review of the literature on inconsistent veteran self-report of combat trauma-related symptoms and memories finds several hypotheses, none of which seem able to account for the range of inconsistencies found in this study, as seen for example in the following discussion of the five hypotheses, which the authors found most prevalent, (a) emerging psychopathology, (b) attribution error, (c) self-state consistency, (d) comorbidity, and (e) financial incentive.

  1. Emerging psychopathology explanations argue that the increase in self-reported symptoms at time two can be accounted for by an actual increase in symptoms from time one to time two. This explanation is found primarily in the literature on delayed onset PTSD (for a review, see Andrews, Brewin, Philpott, & Stewart, 2007 ; McNally & Frueh 2013 ). Emerging psychopathology explanations also recognize that increases in self-reported symptoms may reflect stresses experienced following the first evaluation. However, although emerging psychopathology may explain the increase in reported PTSD symptoms for some veterans, this explanation does not seem able to address the increase in those self-reported TBI-related symptoms, which are expected to decrease over time ( VHA, 2010b ). In addition, emerging psychopathology explanations do not explain the increase in self-reported TBI-related sequelae, TBI-related concussive events, or the inconsistency in self-reported current impairment and actual functioning.

  2. Attribution error explanations refer to increases in self-reported symptoms due to errors of judgment regarding the etiology of one's problematic experiences ( Hoge, Goldberg & Castro, 2009 ; Roth & Spencer, 2013 ). For example, one might attribute anxiety or forgetfulness due to the everyday strains of living to a generic pathological process or a specific, combat-related pathological process. Hoge (2008 , 2010 ) has commented on how the popularization of TBI and PTSD in the popular press, and the repeated VHA screening for PTSD and mild TBI, may prime veterans to attribute problematic experiences to these causes. Roth and Spencer (2013 , p. 1) argue that the very efforts to diagnose mild TBI within the VA “may increase the risk for misattribution of clinical symptoms to mTBI and, therefore, promote iatrogenic influence on patient suffering and perceived disability.” However, although attribution error explanations might explain an increase in PTSD or TBI-related symptoms at time two as due to the impact of repeated screenings, they seem less able to explain the increase in reported historical events, such as recall of TBI-related sequelae and concussive events, or the inconsistency in self-reported current impairment and functioning.

  3. Self-state consistency explanations argue that traumatic memories are largely reconstructed, so that recall of trauma-related events is more consistent with current self-states than with actual historical events ( Dasse, Juback, Morissette, Dolan, & Weaver, 2015 ; McNally, 2003 ; Rubin, Bernsten, & Bohni, 2008 ). For example, veterans experiencing life stresses after their first evaluation might not only report more symptoms, but change how they reconstruct their pasts in light of how they see themselves. Because veteran self-states may differ from end of deployment to the many months later when they enter the VHA system, their recall of trauma-related memories would also differ. Although self-state consistency explanations might explain the increases in memory of trauma-related etiological events and sequelae, they seem less able to explain the increased reporting of symptoms nor the inconsistent reporting of current impairment and functioning.

  4. Comorbidity explanations argue that inconsistencies in the reporting of TBI-related symptoms can be better explained by the presence of PTSD symptoms. Hoge (2008) found that U.S. Army infantry soldiers with mild TBI and post-concussive sequelae were more like to report a “high number of somatic and post-concussive symptoms than were soldiers with other injuries. However, after adjustment for PTSD and depression, mild TBI was no longer significantly associated with these physical health outcomes or symptoms, except for headache” (p. 453). Nelson and colleagues (2015 ; also reported in Polusny et al., 2011 ) reported a similar finding in their study of U.S. National Guard soldiers. However, Macera and colleagues (2012) noted in their review of the literature, that other studies “have identified an independent association between mild TBI and post-concussive symptoms such as memory and sleep problems after controlling for or stratifying by PTSD” (p. 1198). Brenner and colleagues (2010) found just such an independent association between concussion and symptoms in their study of 1247 U.S. soldiers, as did Macera and colleagues (2012) in their study of 55,047 Navy and Marine Iraq and Afghanistan war veterans. In addition, following their review of the literature, Macera and colleagues (2012) argue that “his apparent discrepancy between findings may be the result of vastly different target populations, sample sizes, and post-deployment data collection time points” (p. 1198). Macera and colleagues’ (2012) argument seems to find support from the previously mentioned studies. Hoge (2008) and Nelson and colleagues (2015 , also reported in Polusney et al. 2011 ) used anonymous surveys or questionnaires and found that reported PTSD symptoms accounted for the reports of TBI-related symptoms. Brenner and colleagues (2010) and Macera and colleagues (2012) used data found in the DOD PDHA and found “an independent association” between concussive events and symptoms even after controlling for PTSD ( Macera et al., 2012 , p. 1198).

    Given that DOD PDHAs are officially mandated health evaluations in which veterans provide information that directly affects their care, it seems possible that issues of accountability might be at play. However, regardless of these differences in research settings and findings, the comorbid hypothesis does not account for the increase in reported historical events such as concussive events and post-concussive sequelae, nor the inconsistent reporting of current impairment and functioning.

  5. Financial incentive explanations argue that veterans exaggerate their symptoms, as well as their recall of trauma-based etiological events in an effort to receive service-connected disability compensation for their military service (see, e.g., McNally & Frueh, 2013 ). Although this explanation may account for the increased self-report of PTSD and TBI-related symptoms, as well as the increased report of TBI-related concussive events and sequelae found in this study, it seems less able to account for the inconsistent report of current impairment and functioning. In addition, financial benefit explanations do not seem able to explain the increases in self-reported symptoms from DOD PDHA to PDHA reassessments using strictly military samples, as seen for examples in the studies by Macera and colleagues (2012) and Miliken and colleagues (2007) .

There are several limitations to this study. First, the generalizability of these findings is limited by the fact that subjects were combat veterans with positive VHA TBI screens who sought VHA services after a single deployment many months after deployment. Although this study may be representative of this select group, it may not generalize to veterans who did not seek VHA services, to those who did not provide a positive TBI screen or to those with multiple deployments. In addition, over 90% of the subjects were men, so the extent to which these findings might apply to female combat veterans is unknown.

Second, there were several limitations due to the research design. As an archival study, data consisted of existing medical records, with the consequent that some information was missing from the data set. In addition, TBI-related neurocognitive symptom questions were coded in a more nuanced manner in the VHA records than in the available DOD records. The DOD PDHA assessed impairment using a true/false forced-choice paradigm, whereas VHA TBI evaluations used a 5 point Likert scale. So a veteran experiencing only a mild level impairment might endorse the “mild” rating on the VHA scale, but hesitate to endorse the “true” rating on the DOD scale.

The literature now supports a growing consensus that self-reported PTSD and TBI-related symptoms are inconsistent over time. Although there are consistent findings that recall of combat-related TBI events and sequelae is inconsistent over time, the studies are few and more research needs to be conducted to determine if there is consensus. In addition, there is only one other study ( Russo, 2012 ), which examined inconsistency of current report of functioning and impairment, so further studies should be conducted to determine consensus. With the growing acceptance of gender equality in combat situations, future studies should examine the consistency of self-report and recall of trauma among female combat veterans.

In closing, there are several recommendations related to these findings. First, the repeated finding that veteran self-report of trauma-related symptoms and events are inconsistent over time argues for the use of contemporaneous DOD records (see also Russo, 2012 ). Prior to 2010, military personnel self-initiated in-theater TBI screens ( Center for Disease Control and Prevention/National Institute of Health, 2013 ). However, by 2012 the Department of Defense mandated the screening of all service members who experienced a potentially concussive event within 24 hr of the event, when possible ( DOD, 2012 ). Efforts should be made to have these assessments available to VHA clinicians.

Second, veterans are better served when the DOD and VHA employ the same assessments and metrics where possible. This allows for the more accurate comparison of information across time periods.

Third, the VHA currently employs a standardized format for the comprehensive TBI evaluation following positive TBI screen, which assesses not only symptoms, but TBI-related concussive events, and post-deployment TBI-related concussive events. However, the VHA does not currently employ a similar standardized format for PTSD evaluations. Given the overlap between TBI and PTSD symptoms, a standardized format would facilitate research. In addition, eliciting PTSD etiological events would aid in the assessment and treatment of veterans.

Fourth, whenever inconsistencies are found in veteran self-reports, it is important that clinicians take steps to understand this discrepancy in a sensitive manner as opposed to simply ignoring this information ( Russo, 2014 ). The authors know of only one study ( Russo, 2012 ) in which veterans were asked why they had changed their report of symptoms, with veterans reporting an experienced increase in memory impairment over time. These veterans accounted for the inconsistency by stating that their memory became gradually more impaired over time. As noted earlier, there are many potential reasons for changes in self-report of symptoms and trauma-related events, each having clinical implications for treatment and legal implications for benefits.

Conflict of Interest

None declared.

Acknowledgements

This paper is the result of work supported in part with resources and the use of facilities at the Department of Veterans Affairs New York Harbor Healthcare System; as such it is in the public domain. Contents do not necessarily reflect the views of the Department of Veterans Affairs or U.S. Government.

Appendix

Data used in this study.

Demographic Data

Age at time of VHA CTBIE

Sex

Ethnicity

Education at time of VHA CTBIE

Duration of deployment

Service during deployment (Air Force, Army, Marines, Navy)

Active unit or reserve unit service status (National Guard or Reserve) during deployment

Service-connected condition (yes/no, percent if yes)

Currently on a profile or light duty at time of DOD PDHA (yes/no)

Self-report of health at time of DOD PDHA (rated excellent, very good, good, fair or poor)

Employed at time of VHA CTBIE (yes/no)

Enrolled in college at time of VHA CTBIE (yes/no)

DOD Post-Deployment Health Assessment Data

Please note that there were slight variations in wording across different PDHA versions.

Date of DOD PDHA

Difficulty anytime during deployment and/or at the time of the PDHA with (a) concentration, (b) memory, (c) making decision, (d) headaches, and (e) sleep (yes/no)

TBI-related concussive events, including (a) blast or explosion, (b) fall, (c) motor vehicle accident, and/or (d) wound above the shoulders

TBI-related sequelae, including (a) lost consciousness or got "knocked out", (b) felt dazed, confused, or "saw stars", and (c) post-event amnesia or did not remember the event

PTSD symptoms categories, including (a) Have had any nightmares about it or thought about it when you did not want to? (b) Tried hard not to think about it or went out of your way to avoid situations that remind you of it? (c) Were constantly on guard, watchful, or easily startled? and (d) Felt numb or detached from others, activities, or your surroundings?

PTSD-related etiological questions, including (a) Did you see anyone wounded, killed or dead during this deployment? (b) Were you engaged in direct combat where you discharged your weapon? and (c) During this deployment, did you ever feel that you were in great danger of being killed?

VHA Comprehensive Traumatic Brain Injury Evaluation Data

Date of VHA CTBIE

Impairments in (a) concentration, (b) memory, (c) making decision, (d) headaches, and (e) sleep rated as follows:

  1. None: rarely if ever present; not a problem at all.

  2. Mild: occasionally present, but it does not disrupt activities; I can usually continue what I'm doing; doesn't really concern me.

  3. Moderate: often present, occasionally disrupts my activities; I can usually continue what I'm doing with some effort; I am somewhat concerned.

  4. Severe: frequently present and disrupts activities; I can only do things that are fairly simple or take little effort; I feel like I need help.

  5. Very severe: almost always present and I have been unable to perform at work, school, or home due to this problem; I probably cannot function without help.

TBI-related concussive events (same categories as per DOD PDHA)TBI-related sequelae (same categories as per DOD PDHA)PTSD symptoms categories (same categories as per DOD PDHA).

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