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. 2020 Dec 17;33(1):23–28. doi: 10.1080/08995605.2020.1842037

The effect of mTBI and PTSD symptoms on computerized cognitive performance: Results from a sample of treatment-seeking active duty US service members

Larissa L Tate a,✉, Maegan M Paxton Willing a, Louis M French a,b,c, Wendy A Law a,b, Layne D Bennion a, Katherine W Sullivan b, David S Riggs a
PMCID: PMC10013420  PMID: 38536319

ABSTRACT

TBI and PTSD occur in a significant number of service members and can each result in considerable distress and cognitive challenges. Past research has established the individual impact of mild TBI (mTBI) and PTSD on cognitive performance; however, findings regarding the combined effects of mTBI and PTSD on cognitive performance are inconsistent. The present study examined the potentially synergistic effects of mTBI and PTSD symptoms on cognitive performance in a sample of 180 treatment-seeking active duty service members. As part of a larger clinical study, participants completed several self-report measures and an objective cognitive assessment via computer-based testing. Compared to norms, service members with mTBI-only, PTSD-symptoms-only, and comorbid TBI and PTSD performed significantly worse on cognitive tests, and there was a significant effect of group on cognitive performance, even when controlling for performance validity. Notably, individuals experiencing both mTBI and PTSD performed worse than those with either condition alone; service members with mTBI-only and those with PTSD symptoms-only did not differ. Findings further illustrate the complexity of the relationship between these two conditions, indicating comorbid mTBI and PTSD may represent a unique challenge to cognitive performance. Additional research is needed to clarify their combined impact on post-injury functioning.

KEYWORDS: TBI, PTSD, military, cognitive performance, ANAM

What is the public significance of this article?—The present study suggests that active duty service members who have experienced a combination of mild traumatic brain injury (mTBI) as well as symptoms of posttraumatic stress disorder (PTSD) perform worse on certain cognitive functions, such as memory and concentration, than service members with either condition alone. Our study suggests the combination of these conditions is particularly detrimental in regards to cognition. These results should be considered when designing therapeutic interventions for individuals with TBI and PTSD. Additionally, these findings may be useful in informing healthcare policy and treatment strategies for patients with these disorders.

Nearly 330,000 incidents of traumatic brain injury (TBI), the vast majority being mild TBI (mTBI; Ryan & Warden, 2003), and over 140,000 posttraumatic stress disorder (PTSD) diagnoses have occurred among US service members deployed to the wars in Iraq and Afghanistan (Fischer, 2015). Due to their high frequency in this population, these conditions were labeled “signature wounds” of these wars (Howlett & Stein, 2016). Each can significantly impair functioning, but understanding the true impact of TBI and PTSD is complicated because the two often co-occur (Betthauser et al., 2018). Also, many symptoms, such as concentration and memory difficulties, are associated with both conditions. As a result, prevalence estimates from studies in military samples range widely from 10% to 40% (Carlson et al., 2011).

It is well known that TBI and PTSD are independently linked with cognitive difficulties (Dolan et al., 2012; Vasterling, Verfaellie, & Sullivan, 2009). Though awareness of, and attention to, the comorbidity of these disorders has increased, there is a paucity of research examining their combined effects on cognitive performance particularly within a treatment-seeking active duty population. Most existing studies have been conducted with Veterans and have produced inconsistent findings as to whether the comorbidity of mTBI and PTSD leads to overlapping or cumulative cognitive deficits.

Brenner et al. (2009) found no differences on a variety of neuropsychological measures between groups of Veterans with a history of mTBI and/or a current PTSD diagnosis. Gordon, Fitzpatrick, and Hilsabeck (2011) found similar results, concluding PTSD does not necessarily have exacerbating effects on cognitive performance deficits among Veterans with mTBI.

Other studies of Veterans support the conclusion that the combination of TBI and PTSD is particularly detrimental to cognitive functioning. Nelson, Yoash-Gantz, Pickett, and Campbell (2009) found Afghanistan and Iraq war Veterans with comorbid mTBI and PTSD scored worse on tests of processing speed and inhibition than those with a history of mTBI-only. Combs et al. (2015) found Veterans with comorbid mTBI and PTSD performed worse than those with mTBI-only or PTSD-only on most neuropsychological measures administered. Veterans with mTBI-only did not differ on any measures from the PTSD-only group. The authors concluded mTBI negatively impacted cognitive functioning, whether presenting alone or concurrently with PTSD.

Shandera-Ochsner et al. (2013) found Afghanistan and Iraq war Veterans with comorbid mTBI and PTSD performed worse than a control group on several neuropsychological measures. However in contrast to the study conducted by Combs et al. (2015) with a similar sample, they did not detect any significant differences in neuropsychological performance between the comorbid group and PTSD-only group or between the mTBI-only and control groups. This led these authors to conclude that PTSD, rather than mTBI history, dampened cognitive functioning.

Merritt et al. (2019), again with a similar sample, found results inconsistent with both Combs et al. (2015) and Shandera-Ochsner et al. (2013). They found no significant differences in neuropsychological performance across four groups (comorbid mTBI and PTSD, mTBI-only, PTSD-only, and control). These authors suggested that mTBI, PTSD, or their comorbidity did not appear to have lasting deleterious effects on cognitive functioning, at least at the group level.

Currently, there is little research examining how mTBI in the post-acute and chronic phases combined with PTSD symptoms affects cognitive performance in active duty personnel, with the few existing studies revealing mixed results. Among soldiers returning from Iraq, Vasterling et al. (2006) found more severe PTSD symptoms were associated with deficits on several neuropsychological measures; yet, history of TBI did not significantly impact cognitive performance. Notably, elevated PTSD symptoms together with mTBI were associated with better performance on a simple reaction time test. Subsequently, Vasterling et al. (2012) found higher levels of PTSD symptoms were associated with worse performance on several cognitive tasks, even after adjusting for a history of TBI sustained during the most recent deployment. Cognitive performance was unrelated to mTBI sustained during deployment. In contrast to the earlier study, more severe PTSD was related to worse reaction time. Diverging from these studies, Betthauser et al. (2018), found combined mTBI and PTSD was associated with worse cognitive performance than either condition alone among soldiers completing post-deployment assessments. They concluded that although mTBI history impacts cognitive functioning for some individuals, current PTSD symptoms seem to exacerbate those deficits for a nontrivial minority.

These inconsistent results highlight the need for additional research on the impact of mTBI and PTSD on cognitive performance, particularly in active duty samples. Of note, existing active duty studies are limited to Army soldiers on normal duty status undergoing routine post-deployment screening (i.e., not treatment-seeking). The long-term impact of mTBI and PTSD on treatment-seeking active duty service members remains largely unstudied. It is important to note the distinction between a history of mTBI and the acute cognitive symptoms immediately following mTBI. Most individuals who experience mTBI typically recover quite rapidly, within 1 to 2 weeks (McCrea et al., 2009), and only a small percentage experience lingering symptoms. To address the shortcomings of previous studies, we examined the impact of a history of mTBI and current PTSD symptoms on cognitive functioning in a group of active duty service members seeking treatment for cognitive complaints. We hypothesized service members with both a history of mTBI and current PTSD symptoms would perform worse on objective cognitive tests than would those with either condition alone; also, those with only PTSD symptoms would perform worse than those with only mTBI.

Methods

The study employed a cross-sectional design using data collected between 2008 and 2017 as part of a larger clinical assessment project at the National Intrepid Center of Excellence’s (NICoE) Brain Fitness Center (BFC) at Walter Reed National Military Medical Center (WRNMMC) and Fort Belvoir Community Hospital (FBCH).1 The BFC provides patients who complain of cognitive dysfunction access to commercially available brain-training technology in a structured, supportive environment. Treatment is offered as an adjunct to ongoing rehabilitation or as a stand-alone service for those discharged from cognitive rehabilitation. Most are referred to the BFC by providers, but self-referrals are also accepted. Most BFC patients have a history of TBI identified by their referring provider through standard procedures; however, the BFC also serves patients with other medical and psychiatric conditions (see Sullivan et al., 2020).

Participants

We analyzed data from patients: (a) with a history of mTBI and/or a score ≥ 35 on the PTSD Checklist-Civilian version (PCL-C), (b) completed the Automated Neuropsychological Assessments Metrics (Version 4) Traumatic Brain Injury (ANAM-4 TBI), (c) were at least 18 years of age, and (d) were active duty. Individuals were excluded if they: (a) were unable to provide informed consent or HIPAA authorization or (b) had incomplete data on the PCL-C or the ANAM. Demographic and military characteristics of the 180 patients who met the inclusion criteria are depicted in Table 1. As noted below, some participants (n = 76) had questionable ANAM performance scores; to increase the confidence in our results, we replicated the planned analyses excluding those participants. Demographics of the replication subsample (n = 104) are in Table 2. We were able to determine a year of injury for 105 of 116 participants with a history of mTBI in the full sample. Time between injury and BFC enrollment ranged from 1 to 250 months (M = 35.81, SD = 38.98). A year of injury was available for 60 of 66 participants in the replication subsample; time since injury ranged from 1 to 250 months (M = 38.38, SD = 43.35).

Table 1.

Total sample demographics

  mTBI-Only (N = 40) PTSD-Only (N = 64) Comorbid (N = 76) Total Sample (N = 180)
Mean Age (Years) 35.3 35.4 34.7 35.1
Gender        
 Male 31 32 64 127 (70.6%)
 Female 9 32 12 53 (29.4%)
Branch        
 USA 19 33 45 97 (53.9%)
 USN 9 18 9 36 (20.0%)
 USMC 6 5 18 29 (16.1%)
 USAF 5 7 3 15 (8.3%)
 USPHS 0 1 1 2 (1.1%)
 USCG 1 0 0 1 (.6%)
Rank        
 Enlisted 28 49 54 131 (72.8%)
 WO or Officers 11 15 19 45 (25.0%)
 Other 1 – 3 4 (2.2%)
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Table 2.

Subsample demographics utilizing ANAM-PVI cut-point of ≥ 5

  mTBI-Only (N = 29) PTSD-Only (N = 38) Comorbid (N = 37) Total Sample (N = 104)
Mean Age (Years) 35.3 35.4 34.7 34.49
Gender        
 Male 24 19 30 73 (70.2%)
 Female 5 19 7 31 (29.8%)
Branch        
 USA 15 18 23 56 (53.8%)
 USN 6 11 4 21 (20.2%)
 USMC 4 4 7 15 (14.4%)
 USAF 3 5 2 10 (9.6%)
 USPHS 0 0 1 1 (1.0%)
 USCG 1 0 0 1 (1%)
Rank        
 Enlisted 19 27 25 71 (68.3%)
 WO or Officers 9 11 9 29 (27.9%)
 Other 1 – 3 4 (3.8%)
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Materials and procedure

As part of BFC standard of care, participants completed an intake interview, self-report measures, and an objective cognitive assessment. Patients were asked to participate in a database study. Data from patients who consented were de-identified and entered into a research database.

PTSD symptoms

The PCL-C (Weathers, Huska, & Keane, 1991) assesses PTSD symptoms not necessarily linked to a specific event. Patients with PCL-C scores of 35 or greater were considered to have significant PTSD symptoms. This cut-point is recommended by the VA National Center for PTSD for medical clinics (e.g., TBI clinic) or VA primary care settings, and previous research supported its use in settings similar to the BFC (Bliese et al., 2008; Murphy, Ross, Ashwick, Armour, & Busuttil, 2017). The PCL-C has high internal consistency in prior research (α =.94 to .97; Blanchard et al., 1996) and the present samples (α = 0.95 utilizing all cases; α = 0.94 utilizing only “valid” cases). The PCL-C has strong test-retest reliability (Blanchard et al., 1996), and correlates highly with the Clinician Administered PTSD Scale (CAPS; r =.92; Blanchard et al., 1996).

Cognitive performance

The ANAM-4 TBI evaluates various cognitive domains using a battery of seven cognitive tests and has shown to be valid and reliable (Roebuck-Spencer, Vincent, Gilliland, Johnson, & Cooper, 2013; Vincent et al., 2008). For each test, reaction time, accuracy, and throughput (a composite of accuracy and reaction time) are captured. Throughput scores were used in the present study as a metric of effectiveness of participants’ cognitive functioning as this score is most commonly used in extant literature and is considered a good measure of cognitive efficiency (Thorne, 2006). We analyzed cognitive performance using an ANAM composite score (ACS) incorporating performance from all subtests; ACS is a z-score based on military-specific norms (Vincent, Roebuck-Spencer, Gilliland, & Schlegel, 2012).

The ANAM has an embedded validity measure, the ANAM Performance Validity Index (ANAM-PVI). Roebuck-Spencer, Vincent, Gilliland, Johnson, and Cooper (2013) used Receiver Operating Characteristic analysis to identify a cut-point of ≥ 5 as the “most optimal” for eliminating scores presumed to be invalid. They indicated this score provided excellent discriminability of the ANAM-PVI in an outpatient sample and a simulator sample. We chose to use this cut-point to identify participants with questionable ANAM scores due to its very good sensitivity and specificity. Additionally, the BFC patient population is best characterized as falling between the healthy controls and the outpatient population sampled by Roebuck-Spencer et al. (2013)

Results

We compared ACS among three groups: those with a history of mTBI without significant PTSD symptoms (mTBI-only), those with significant PTSD symptoms without a history of mTBI (PTSD-symptoms-only), and those with both a history of mTBI and significant PTSD symptoms (comorbid). All three groups performed well below the norms for service members matched for age and gender, with a mean ACS 2.26 standard deviations below the normative mean. A one-way ANOVA revealed a significant group effect on ACS, F(2, 177) = 5.406, p = .005, ω = .21. Pairwise comparisons using least significant difference (LSD) post-hoc tests revealed significant differences between the comorbid group (x‾ = −3.01) and both the PTSD-symptoms-only group (x‾ = −2.06, p =.014) and the mTBI-only group (x‾ = −1.70, p = .003). The PTSD-symptoms-only group and the mTBI-only group did not significantly differ (p = .430). Welch’s t-tests showed no significant ACS differences based on gender (t(75.0) = −1.40, p = .165) or enlisted/officer status (t(78.8) = .094, p = .095). A Kruskal-Wallis H test revealed no significant differences among branch of service (X2(5) = 2.472, p = .781).

Because of concerns about the possibility of invalid performances, we re-analyzed the data removing those with ACS considered “invalid” by the embedded validity measure (n = 76). With those participants removed, similar results were found. All three groups performed below the norms, although less extreme (mean ACS = −1.01). A one-way ANOVA revealed a significant group effect on ACS, F(2, 101) = 3.984, p = .022, ω = .23. LSD post-hoc tests revealed significant differences between the comorbid group (x‾ = −1.60) and both the PTSD-symptoms-only group (x‾ = −0.86, p = .043) and the mTBI-only group (x‾ = −0.57, p = .043). There was no significant difference between the PTSD-symptoms-only group and the mTBI-only group (p = .440). In this subsample, there were no significant ACS differences based on gender (Welch’s t(38.2) = −1.22, p = .227), enlisted/officer status (Welch’s t(34.5) = 1.85., p = .073), or branch of service (Kruskal-Wallis X2(5) = 2.38, p = .794).

Discussion

As predicted, service members with both a history of mTBI and current PTSD-symptoms performed worse cognitively than individuals with either condition alone, even when eliminating participants with presumed invalid ANAM performance. Cognitive performance of individuals with PTSD-symptoms-only did not differ significantly from those with a history of mTBI-only. Notably, in the full sample, cognitive performance of all groups was well below norms for US military personnel – two standard deviations for the mTBI-only and PTSD-symptoms-only groups and three standard deviations for the comorbid group. The poor cognitive performance was not surprising as our sample consisted of patients seeking treatment for cognitive complaints often years after sustaining the mTBI. However, the severity of deficit was greater than expected. After eliminating participants with questionable ANAM validity scores, mean scores remained low, though less dramatically, suggesting some of the observed deficits may reflect low effort.

This study is the first to find a significant deficit in cognitive performance among a diverse sample of treatment-seeking active duty service members who have sustained an mTBI and have PTSD symptoms. These results suggest that, for a small group of service members who sustain an mTBI, persistent difficulties can be seen well after expected recovery times. The etiology of this is unclear, but may represent a synergistic effect, individual variation, or other unclear factors. Regardless, our results reinforce previous findings that the presence of both mTBI history and current PTSD symptoms is particularly detrimental to cognitive performance.

The present results highlight the importance of attending to the clinical impact of PTSD symptoms with a history of TBI and the need for more research, particularly longitudinal research, in the treatment-seeking population. Additionally, cognitive performance deficits in the PTSD-symptoms-only group suggests cognitive complaints should not be immediately attributed to a history of TBI. The number of participants in each group excluded for performance validity concerns reinforces multiple previous observations that complaints of cognitive performance should not necessarily be taken at face value. Future studies also should examine performance differences associated with demographics, motivation, chronicity, and TBI severity as well as potential variation across the ANAM’s subtests.

Cognitive deficits associated with a combined history of mTBI and current PTSD symptoms were striking. However, cognitive performance is not synonymous with cognitive ability. There are multiple factors that can impact the former without changing the latter. Given the treatment-seeking nature of the present sample, participants are likely to have more emotional and cognitive complaints than the military, or general, population; they also are more likely to experience factors that could negatively impact cognitive performance, such as medication side-effects, chronic pain, sleep problems, and variable motivation. Future research utilizing clinical samples should work to clarify the impact on cognitive performance of mTBI history and PTSD and these other clinically relevant factors.

The use of a clinical sample in the present study fills a significant gap in the literature, but our dependence on available clinical data raises some issues. Concerns regarding the ecological validity of neuropsychological tests in general (Chaytor, Machamer, & Dikmen, 2007), and the ANAM specifically (Gresma, 2018), suggest the deficits documented here may not adequately characterize the difficulties experienced by those with a history of mTBI, current PTSD or the combination. Further, we were unable to verify TBI diagnoses through medical record review and therefore relied on referring providers’ diagnoses. The use of the PCL-C to assess PTSD symptoms rather than a clinical diagnosis leaves open questions regarding the impact of psychological trauma on cognitive performance. Finally, reliable data on the number of TBIs experienced by participants was unavailable. It is likely some participants experienced multiple TBIs and others experienced only one. More research on the long-term impact of multiple brain injuries is needed.

As we work to improve care for active duty service members with a history of TBI and PTSD, attention to the management of the co-occurrence of these disorders is vital. The present results highlight the need to take into account active duty patients reporting symptoms of PTSD and persistent sequelae of mTBI may have more cognitive difficulties than those with either condition alone. Providers should consider how this might affect the planned course of treatment and be aware of ways in which treatments may need to be modified. Our results provide further support for the idea that emotional distress may impact the persistence and expression of mTBI sequelae. Concurrent care addressing psychological and neuro-cognitive issues and emphasizing collaboration among various disciplines is likely to lead to improved patient outcomes.

Note

1.

The study started at Walter Reed Army Medical Center before the Base Relocation and Closure of 2011.

Disclosure statement

No potential conflict of interest was reported by the authors.

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