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. Author manuscript; available in PMC: 2022 Feb 1.
Published in final edited form as: Psychol Serv. 2019 Jun 13;18(1):124–133. doi: 10.1037/ser0000356

The Effects of PTSD Symptoms on Educational Functioning in Student Veterans

Sandra B Morissette 1, Clark Ryan-Gonzalez 2, Tomas Yufik 3, Bryann B DeBeer 4, Nathan A Kimbrel 5, Audrey M Sorrells 6, Lori Holleran-Steiker 7, Walter E Penk 8, Suzy B Gulliver 9, Eric C Meyer 10
PMCID: PMC7003209  NIHMSID: NIHMS1035339  PMID: 31192672

Abstract

Background

Posttraumatic stress disorder (PTSD) occurs at high rates among student veterans and is known to negatively impact educational functioning; however, the unique effects of PTSD are less clear, as PTSD is highly comorbid with many other conditions that could potentially affect educational functioning.

Objectives

The present study had two objectives: (1) Determine the impact of PTSD symptom severity on educational functioning after accounting for demographic variables, traumatic brain injury, and commonly co-occurring mental health conditions; and (2) Identify which symptom clusters of PTSD have the greatest impact on educational functioning.

Methods

Educational functioning and other commonly occurring mental health conditions were assessed cross-sectionally among 90 student veterans.

Results

TBI and major depressive disorder (MDD) were initially associated with impaired educational functioning; however, after adding PTSD into the final model, only PTSD (β = .44; p < .001) and MDD (β = .31; p = .001) remained associated with educational impairment. Follow-up analyses indicated that the re-experiencing symptom cluster was most strongly associated with impaired educational functioning (β = .28, p = .031).

Conclusions

Overall, these results suggest that PTSD symptoms—especially re-experiencing symptoms—may be a driving force behind impaired educational impairment, even after accounting for other commonly co-occurring mental health conditions.

Keywords: Veteran, PTSD, Higher Education, Educational Functioning

The Effects of PTSD Symptoms on Educational Functioning in Student Veterans Over 2.7 million service members have deployed in support of the conflicts in Iraq and Afghanistan (Wenger, O’Connell, & Cottrell, 2018). Due to continual, back-to-back deployments, many of these service members have experienced significant combat exposure resulting in a host of challenges including posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), and other co-occurring mental health conditions (Kimbrel et al., 2015; Seal et al., 2009). Following return from deployment and discharge, many veterans are seeking degrees in higher education (Veterans Benefits Administration [VBA], 2017) in order to pursue their next “missions” as civilians.

According to the Department of Veterans Affairs, approximately 653,424 post-9/11 Veterans Education Assistance Act (Post-9/11 GI Bill) beneficiaries (excluding children and spouse beneficiaries) were enrolled in higher education programs in 2016 (VBA, 2017). This number is expected to increase as the number of post-9/11 veterans grows to over five million by 2020 (Government Accountability Office [GAO], 2013). However, while many are successful in attaining degrees in higher education, approximately one in four GI Bill recipients become responsible for repaying their benefits due to dropping a class or withdrawing from college (GAO, 2015). This rate of drop out and potential for financial hardship is deeply concerning, making it critical to understand population-specific factors that contribute to problems with educational functioning.

Mental health conditions may partially explain high college dropout rates (Hartley, 2010; Kessler, Foster, Saunders, & Stang, 1995). Proportional to the increase of veterans in higher education, the number of veterans with mental health challenges, such as PTSD, has grown on college and university campuses (GAO, 2014; Vance & Miller, 2009). While this diagnosis certainly does not characterize all veterans pursuing higher education, a study surveying a national sample of student veterans (N = 628) found that 45.9% experienced significant symptoms of PTSD (Rudd, Goulding, & Bryan, 2011). PTSD is a mental health problem that can develop following experiencing or witnessing a life-threatening event (e.g., combat, motor vehicle accident, natural disaster) or sexual violence. Symptoms include re-experiencing memories of the event, feeling hyper-aroused, avoiding reminders of the event, or feeling cut off from others (American Psychiatric Association [APA], 2013). The high prevalence of PTSD symptoms poses a significant concern due to the known impact PTSD has on educational outcomes (e.g., GPA, academic self-efficacy, academic motivation, attrition rates; Bachrach & Read, 2012; Barry, Whiteman, & MacDermid Wadsworth, 2012a; Barry, Whiteman, MacDermid Wadsworth, & Hitt, 2012b; Duncan, 2000; Elliott, Gonzalez, & Larson, 2011; Rudd et al., 2011).

Identifying the predominant factors accounting for differences among student veterans’ educational functioning is difficult in the context of many co-occurring challenges, such as PTSD, TBI, alcohol abuse/dependence, and depression (Hoge et al., 2008; Rudd et al., 2011; Tanielian et al., 2008). Given elevated rates of PTSD in veterans, it is important to establish the functional limitations accounted for by PTSD over and above that of other co-occurring mental health disorders. Moreover, in order to inform intervention efforts, it is important to gain a more fine-grained understanding of this relationship by examining which specific symptom clusters of PTSD limit educational functioning. The goals of the this study were to determine the associations of PTSD symptom severity and diagnosis with educational functioning after accounting for demographic variables and other commonly occurring mental health conditions, and to identify which symptom clusters of PTSD have the strongest associations with educational functioning.

Effects of PTSD Symptom Clusters on Educational Functioning

Particular PTSD symptom clusters may be more strongly associated than others with worse educational functioning, although this has not yet been examined in the extant literature. Specifically, re-experiencing and hyper-arousal can adversely affect concentration and attention (McNally et al., 1987, 1990; Uddo, Vasterling, Brailey, & Sutker, 1993; Vasterling et al., 2002; Zeitlin & McNally, 1991). Re-experiencing a traumatic event is characterized as experiencing involuntary and intrusive distressing memories of the traumatic event, or dissociative reactions in which the individual experiences the traumatic event as if it were reoccurring (APA, 2013). It can also include experiencing distressing dreams related to the event, and psychological distress or physiological reactions to internal or external cues of the traumatic events. Re-experiencing can directly limit cognitive resources allocated to learning and have disastrous effects on an individual’s ability to function in an educational environment (Hellawell & Brewin, 2002). .

Hyper-arousal is exemplified by an exaggerated startle response, problems concentrating, and sleep disturbances (APA, 2013). Similar to re-experiencing symptoms, these hyper-arousal symptoms can impair a student’s ability to focus. Hyper-arousal can also include irritable behavior and angry outbursts. Symptomatically driven, dysregulated behavior may, in turn, illicit a negative response from faculty and/or peers, which may reduce the chances that the student reengages in the classroom. In the most egregious outcomes, a highly symptomatic student may find him/herself without a support network to assist them with management or recovery (Elliot et al., 2011). These negative outcomes may be exacerbated by faculty and peer misunderstanding of the nature of PTSD, the effect of the severity of the trauma on an individual’s functioning, and how PTSD may manifest in an academic environment (Read, Ouimette, White, Colder, & Farrow, 2011).

The avoidant symptom cluster of PTSD is characterized by efforts to evade both distressing memories and the external reminders that arouse the distressing memories, thoughts, or feelings relating to the traumatic event (APA, 2013). Avoidance symptoms may account for findings that characterize student veterans as less engaged in the university environment or willing to seek help (Southwell, Whiteman, Wadsworth, & Barry 2018). In a cross-sectional study, Elliot et al. (2011) reported that PTSD symptoms predicted greater self-reported feelings of alienation among veterans at a midsize western university. Thus, PTSD symptoms may contribute to poorer academic performance not only via the symptoms themselves (e.g., difficulty attending large classes) but also via feelings of alienation. Qualitative analyses of veterans’ experiences in higher education programs have repeatedly cited noticeable differences in their experiences between military and civilian life on campus. Political opinions, prior life experiences, and a highly-structured military life that discourages questioning commanding officers are a few of the issues that divide student veterans from their college peers (DiRamio, Ackerman, & Mitchell, 2008; Ellison et al., 2012; Rumann & Hamrick et al., 2010). Indeed, social isolation and lack of belonging are considered “warning signs” in the academic literature (Walton, & Cohen, 2007; O’Keeffe, 2013; Strayhorn, 2012) that pose considerable threat to educational functioning due to the important contribution of student and faculty engagement to overall academic success (Kuh, Cruce, Shoup, Kinzie, & Gonyea, 2008). Students who devote a considerable amount of time and energy to educational activities inside and outside the classroom demonstrate higher graduation rates, better grades, higher retention, and report greater educational satisfaction (Astin & Sax, 1998; Astin, Vogelgesang, Ikeda, & Yee, 2000; Kuh, 2003; Kuh, Kinzie, Schuh, & Whitt, 2005, 2010; Pascarella & Terenzini, 1991, 2005). Similarly, engagement on university campuses allows for the development of student-faculty relationships, which are among the most impactful contributing factors to students’ success during their academic careers (Astin, 1985; Komarraju, Musulkin, & Bhattacharya, 2010).

Co-Occurring Conditions

PTSD commonly occurs with other mental health conditions that can affect academic functioning, for example, problem alcohol use (Bachrach, & Read, 2012; Read et al., 2012). In particular, alcohol misuse is pervasive in both military (Mattiko, Olmsted, Brown, & Bray, 2011; Stahre, Brewer, Fonseca, & Naimi, 2009) and college campus cultures (Center for Behavioral Health Statistics and Quality, 2017; Wechsler et al., 2002). College campus cultures often have a norm of drinking and higher rates of binge drinking, which has the potential to enhance the risk for problematic drinking among students (Johnston, O’Malley, Bachman & Schulenberg, 2005). Multiple sources link PTSD symptoms among student veterans with problem drinking (Barry et al., 2012b; Elliot et al., 2011; Widome et al., 2011). Problem drinking has direct implications for student success (e.g., disciplinary action, absenteeism, receiving a lower grade on a paper or exam than expected; Read, Kahler, Strong, & Colder, 2006), and thus, it is critical to understand the impact of problematic alcohol use, and alcohol use disorders in particular, in analyses of PTSD and academic functioning among student veterans.

Depression is another commonly co-occurring problem for student veterans who are experiencing symptoms of PTSD (Rudd et al., 2011). Rudd and colleagues (2011) found that 24% of student veterans from a national sample experienced severe depression. Findings from DeRoma, Leach, and Leverett (2009) indicate a negative association between depressive symptoms and GPA among college students. The low motivation and low self-efficacy characteristics of depression may be avenues negatively affecting academic performance and persistence (Multon, Brown, & Lent, 1991). Moreover, depressed mood impairs comprehension (Ellis, Ottaway, Varner, Becker, & Moore, 1997). This is theorized to occur among those with depressed mood due to a greater amount of task-irrelevant thoughts that limit the amount of cognitive resources (e.g., memory capacity and processing efficiency) individuals can allocate to relevant tasks (Ingram, 1984; Seibert & Ellis, 1991).

PTSD is also associated with higher rates of TBI. TBI occurs when individuals encounter deceleration forces or blunt/penetrating trauma to the head (Defense and Veterans Brain Injury Center, 2016). Rates of TBI are elevated in the military, with primary causes related to exposure to blast (e.g., improvised explosive devices, rocket propelled grenades), motor vehicle accidents, and falling (Tanielian, & Jaycox, 2008; U.S. Department of Defense, 2017). Blast-related TBI may have a particularly strong relationship with PTSD symptom severity (Ryan-Gonzalez et al., 2018), and are associated with to worse verbal memory over time, even after accounting for number of TBIs and mental health symptoms ([masked citation]). Thus, head injuries sustained during military service, which include a high proportion of blast injuries, are likely to exert a negative impact on educational functioning, both directly and through their relationship with PTSD symptoms. Because both major depressive disorder (MDD) and post-concussive symptoms share common symptoms with PTSD (e.g., sleep problems, difficulty concentrating, irritability), we entered these predictors sequentially to evaluate the separate contribution of each variable on educational functioning. This method is important for selecting and prioritizing interventions, which are often designed to target specific diagnoses believed to be the most likely to improve educational functioning.

Study Objectives

The primary objectives of the present study were to: (1) determine the unique impact of PTSD symptom severity on educational functioning after accounting for demographic variables and other commonly occurring mental health conditions; and (2) identify which symptom clusters of PTSD have the greatest impact on educational functioning. We hypothesized that PTSD symptom severity would be associated worse educational functioning over and above relevant covariates (i.e., age, gender, education level, history of TBI, alcohol dependence, and MDD). Finally, we were interested in understanding the impact of specific PTSD symptom clusters on educational functioning, which has never been examined and could have important clinical implications for targeting treatment to improve educational functioning. As the current study was conducted prior to the release of DSM-5, we examined symptom clusters related to PTSD as defined in DSM-IV. We hypothesized that all DSM-IV Clusters (i.e., re-experiencing, avoidance/emotional numbing, and hyperarousal) would each be significantly associated with impaired educational functioning.

Method

Participants

This study represents a secondary analysis of a larger longitudinal research program examining functional recovery in returning veterans. A total of 345 post-9/11 veterans participated in the parent study. Participants were eligible if they were: 1) enrolled in the local Veterans Health Care System; and 2) able to provide informed consent and complete the baseline assessment. Participants were excluded if they were: 1) diagnosed with bipolar or a psychotic disorder; 2) in suicidal or homicidal crisis; 3) not stabilized in psychopharmacological or psychosocial treatment regimen if receiving such treatment (i.e., in order to limit symptom fluctuations related to recently starting or stopping treatment); or 4) planning to relocate out of the area within 4 months of the baseline assessment (i.e., as the parent study was a longitudinal study). Of the 309 that met eligibility for the longitudinal parent study, 105 (34%) self-identified as a student veteran. Of these, an additional 11 had no Criterion A event and four had missing data on either the TBI or outcome variable, resulting in a final sample size of 90.

With the exception of student veterans being younger (student veterans: M = 35.0, SD = 8.99; non-student veterans: M = 40.23, SD = 9.62; t (259) = 3.53, p < .001), no differences were observed between student veterans and non-student veterans on demographics, history of TBI, alcohol dependence, MDD, PTSD symptom severity, or PTSD diagnosis (all p’s > .05).

Procedures

The local Institutional Review Board reviewed and approved all study procedures. Participants were recruited through mailings sent to randomly-selected groups of veterans who were enrolled in the local Veterans Health Care System, flyers posted throughout the medical center, and through in-service presentations to health care providers. Women and those with mental health conditions were oversampled as part of the larger study. Specifically, we mailed higher concentrations of letters to these target populations. Veterans provided informed consent and then completed a clinical interview and self-report measures.

Measures

Inclusion/Exclusion Criteria

The Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998) is a clinician-administered diagnostic assessment that was used to screen for bipolar disorder and psychotic disorders per exclusionary criteria.

Demographics and Military History

A questionnaire was developed for the current study to assess demographics and military history similarly used in other studies assessing these variables. A single item from the Psychosocial Functioning Inventory (IPF; Bovin et al., 2018) assessed educational status, “Have you been involved in a formal educational experience, either in or outside of the school setting, during the past 30 days?” This question was used to select our sample of student veterans from the larger sample.

Educational Functioning

Impairment in educational functioning was measured using a 15-item subscale from the Inventory of Psychosocial Functioning (IPF-ED; Bovin et al., 2018). Items are rated on a seven-point Likert scale ranging from never to always (e.g., attended classes regularly; patient with classmates and instructors; trouble remembering what instructor said; got along with others). Higher scores indicate more difficulty (range 1 – 7). A mean score was created from the 15 items. Internal consistency in the current study was acceptable (Cronbach’s alpha = .70).

Traumatic Brain Injury

Lifetime TBI was assessed using a clinician-administered structured interview developed by Vasterling and colleagues (Alosco et al., 2016). This measure assesses the number, recency, type of injury, and clinical sequelae associated with the five worst lifetime TBIs. In accordance with Department of Veteran Affairs and Department of Defense criteria (VA/DoD, 2016; Woodson, 2015), veterans screened positive for a TBI if they endorsed a head injury (e.g., from a blast, fragment or bullet wound above the shoulder, vehicular accident, fall) that resulted in a loss of consciousness (LOC), an alteration of consciousness (AOC; e.g., being dazed, confused, or “seeing stars”), or post-traumatic amnesia (PTA). The above criteria is further differentiated between mild (LOC = 0 – 30 minutes, AOC = a moment up to 24 hours, or PTA = 0 – 1 day), moderated (LOC > 30 minutes and < 24 hours, AOC > 24 hours, or PTA > 1 and < 7 days), and severe TBI (LOC > 24, AOC > 24 hours, or PTA > 7 days). For the purposes of analyses those without a history of TBI were coded as 0 and individuals with a history of mild, moderate, or severe TBI were coded as 1.

Alcohol Dependence/Major Depressive Disorder

The Structured Clinical Interview for DSM-IV (SCID; First, Spitzer, Gibbon, Williams, 1996) was administered to determine presence or absence of lifetime and current diagnosis of alcohol abuse/alcohol dependence and MDD, scored according to DSM-IV criteria. Individuals with current alcohol abuse or dependence were coded as 1, individuals with partial/full remission or no history of alcohol abuse and dependence were coded as 0. The SCID-IV has been shown to have moderate inter-rater reliability for both alcohol dependence and MDD (Lobbestael, Leurgans, & Arntz, 2011), as well as good to excellent validity for alcohol dependence and moderate validity for MDD (Kranzler, Kadden, Babor, Tennen, & Rounsaville, 1996).

Posttraumatic stress disorder

The Clinician Administered PTSD Scale (CAPS; Blake et al., 1995) is a semi-structured clinical interview that assesses PTSD based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000). The CAPS assessment focused on the worst Criterion A event that the participant reported experiencing during their post-9/11 deployment(s). Participants were asked to complete the Full Combat Exposure Scale (Hoge et al., 2004) and Deployment Risk and Resilience Inventory-Relationships within Unit (King, King & Vogt, 2003), which assessed for military sexual trauma Scale, prior to beginning the CAPS to cue their memory to think about Criterion A events. Participants were then asked to determine which of these events was the “worst.” If no post-9/11 deployment DSM-IV Criterion A traumatic event could be identified, the CAPS was conducted based on a Criterion A1 event (in keeping with DSM-5). In this manner, a continuous CAPS total symptom severity score could be calculated for all participants. Likewise, continuous symptom cluster scores could be derived. Items are rated in terms of frequency (0=none of the time, 4 = most or all of the time) and intensity (0=none, 4=extreme) of symptoms to devise a total severity score. Possible range of scores is 0 – 136. When diagnosing PTSD, the “1, 2” rule of frequency and intensity (Weathers, Ruscio, & Keane, 1999) was utilized to indicate that a particular symptom met criteria for diagnosis. The CAPS has demonstrated excellent internal consistency for the three symptom clusters as well as strong convergent validity with other measures of PTSD (Weathers, Keane & Davidson, 2001).

Data Analytic Plan

Hierarchical regression was performed in two separate analyses to determine the association between PTSD symptom severity versus diagnosis and education impairment. In the first analysis, the contribution of overall PTSD symptom severity on educational impairment was examined over and above covariates (gender, age, years of education completed, history of TBI, current alcohol dependence diagnosis, current MDD). This analysis was repeated with PTSD coded dichotomously in order to compare the impact of symptoms continuously vs. full diagnosis. In the third analysis, specific PTSD symptom clusters were examined instead of total symptom severity in order to better understand the impact of different PTSD symptom clusters on educational impairment. Statistical assumptions were met for all analyses. Demographic variables (age, gender, years of education completed) were entered into step 1, history of a TBI in step 2, current alcohol dependence in step 3, current MDD in step 4, and current PTSD symptom severity in step 5.

Results

Demographic variables and military characteristics are presented in Table 1 for the final sample of eligible student veterans (N = 90). Overall, the sample was largely male (62.2%) and had an average age of 35.93 years (SD = 8.96). A significant proportion (41.2%) had earned an associate’s degree or higher. Nearly three-fourths (72.2%) of the sample endorsed a history of having sustained a TBI. The modal head injury was categorized as mild (52.2%). Half (50%) of the sample endorsed a diagnosis of alcohol abuse/dependence at some point in their lifetime and 18.9% endorsed a current diagnosis. Half (50%) reported a diagnosis of MDD at some point during their lifetime and 17.8 % endorsed a current diagnosis. Reflective of our oversampling strategy, 31.1% of participants endorsed symptoms consistent with a diagnosis of current PTSD, and 55.6% met criteria for a lifetime PTSD diagnosis. Participants with a current PTSD diagnosis reported an average score of 69.93 (SD = 18.4, range 39–120) on the CAPS, suggesting severe PTSD symptoms. The average level of educational impairment was 2.53 (SD = 1.01; range 1–7), thus the majority of student veterans fell within the mild to moderate impairment range. Bivariate correlations indicated education impairment was significantly correlated with each PTSD symptom cluster: re-experiencing (r = .54, p < .001), avoidance/numbing (r = .59, p < .001 hyperarousal (r = .56, p < .001).

Table 1.

Sample Characteristics of Participants Included in Final Analyses

Variable M (SD)/ n (%) Rangea
Male (Yes) 56(62.2%)
Age 35.93 (8.96) 23–56
Military Rank
 E1 – E4 26 (28.9%)
 E5 – E6 43 (47.8%)
 E7 – E9 18 (20%)
 O1 – O9 1 (1%)
Number of OEF/OIF Deployments 1.55 (.83) 0–6
Education Impairment Score 2.53 (1.01) 1–7
Highest Degree Attained
 High school/GED 52 (57.8%)
 Associate’s degree 14 (15.6%)
 Bachelor’s Degree 14 (15.6%)
 Master’s Degree or higher 9 (10%)
History of TBI (Yes) 65 (72.2%)
Number of TBIs (up to 5 assessed) 1.62 (1.51) 0–5
Highest Severity of TBIs
 None 25 (27.8%)
 Mild 47 (52.2%)
 Moderate 14 (15.6%)
 Severe 4 (4.4%)
Lifetime Alcohol Abuse/Dependence (Yes) 45 (50%)
Current/Partial Alcohol Abuse/Dependence (Yes) 17 (18.9%)
Lifetime MDD (Yes) 45 (50%)
Current MDD (Yes) 16 (17.8%)
Current/Past Month PTSD Diagnosis (Yes) 28 (31.1%)
PTSD Symptom Total Score 32.07 (30.5) 0–120
PTSD Symptom Cluster Scores
 Re-experiencing 6.72 (9.17) 0–36
 Avoidance/Numbing 11.51 (12.75) 0–47
 Hyperarousal 13.83 (11.81) 0–37
PTSD/MDD 12 (13%)
PTSD/Alcohol Abuse/Dependence 5 (5.5%)
MDD/Alcohol Abuse/Dependence 4 (4.4%)
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Note. N = 90. E1-E9 = enlisted rank; O1-W05 = Officer rank and Warrant Officer rank; OEF = Operation Enduring Freedom; OIF Operation Iraqi Freedom; TBI = Traumatic brain injury; MDD = Major depressive disorder; PTSD = Posttraumatic stress disorder.

a

Observed range.

Predictors of Educational Functioning

In step 1 of the first analysis, no demographic variables were significantly associated with educational impairment (Table 2). In step 2, history of TBI was statistically significant and positively associated with educational impairment (β = .24, p = .025). Alcohol abuse/dependence was entered into step 3 and was non-significant. MDD was entered into step 4 and was significant and positively associated with educational impairment (β = .53, p < .001). However, once PTSD symptom severity was entered into the model in step 5, history of TBI was no longer significantly associated with educational impairment. In the final model, the only two statistically significant predictor variables remaining were MDD (β = .31; p = .001) and PTSD symptom severity (β = .44; p < .001), such that MDD and PTSD symptom severity were both positively associated with educational impairment. The final model explained 45% of the overall variance in educational impairment and was a statistically significant improvement over prior models [F(1, 82) = 20.98, p < .001].

Table 2.

Summary of hierarchical regression analysis for seven variables predicting educational impairment (N = 90)

Step 1
 Step 2
 Step 3
 Step 4
 Step 5
Independent Variable B SE B β B SE B β B SE B β B SE B β B SE B β
Constant 3.35 .884 3.32 .864 3.31 .871 3.42 .742 3.08 .670
Age .020 .013 .180 .016 .012 .146 .016 .012 .146 .005 .011 .041 −.002 .010 −.016
Gender .012 .225 .006 −.127 .228 −.061 −.123 .230 −.059 .071 .199 .034 .019 .179 .009
Education Completed −.111 .060 −.210 −.121 .059 −.228* −.120 .059 −.226* −.116 .051 −.219* −.091 .046 −.171
TBI .547 .240 .244* .551 .242 .246* .427 .207 .190* .225 .191 .100
Current Alcohol Abuse/ Dependence −.054 .269 −.021 −.152 .229 −.059 −.028 .208 −.011
Current MDD 1.39 .242 .529*** .826 .250 .314***
Current PTSD
Symptom Severity .015 .003 .443***
Adjusted R2 .019 .065 .054 .315 .448
ΔR2 .052 .055 .000 .254 .130
F of ΔR2 1.58 5.19* .040 33.01*** 20.98***
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Note. Predictor variables were coded as: Male = 1, Positive screen for TBI = 1, diagnosis of current alcohol abuse/dependence = 1, and diagnosis of current major depressive disorder (MDD) = 1.

*

p < .05.

**

p < .01.

***

p ≤ .001.

We also analyzed these data using CAPS PTSD diagnosis coded as a dichotomous variable. In the final model, the three statistically significant predictor variables remaining were education completed (β = −.21; p = .025), MDD (β = .44; p < .001) and PTSD diagnosis (β = .22; p = .027), such that there was a negative association with education completed, and a positive association between MDD and PTSD diagnosis and educational impairment. The final model explained 35% of the overall variance in educational impairment and was a statistically significant improvement over prior models [F(1, 82) =5.08, p = .027].

An additional hierarchical regression was performed using the same steps, except DSM-IV PTSD symptom clusters (re-experiencing, avoidance/emotional numbing, and hyperarousal) were entered into step 5 (Table 3). Inconsistent with our predictions, the re-experiencing symptom cluster was the most influential predictor of educational functioning and only statistically significant symptom cluster (β = .28, p = .031), after accounting for covariates. The final model explained 45% of the overall variance in educational impairment and was a statistically significant improvement over the prior models [F(3, 80) = 7.53, p < .001].

Table 3.

Summary of hierarchical regression analysis for nine variables predicting educational impairment (N = 90)

Step 1
 Step 2
 Step 3
 Step 4
 Step 5
Independent Variable B SE B β B SE B β B SE B β B SE B β B SE B β
Constant 3.36 .884 3.32 .864 3.31 .871 3.42 .742 3.39 .717
Age .020 .013 .180 .016 .012 .146 .016 .012 .146 .005 .011 .041 .002 .010 .021
Gender .012 .225 .006 −127 .228 −061 −123 .230 −059 .071 .199 .034 .015 .180 .007
Education Completed −111 .060 −210 −121 .059 −228* −120 .059 −226* −116 .051 −219* −117 .050 −221*
TBI .547 .240 .244* .551 .242 .246* .427 .207 .190* .192 .194 .086
Current Alcohol Abuse/ Dependence −054 .269 −021 −152 .229 −059 .014 .211 .005
Current MDD 1.39 .242 .529*** .880 .260 .335
Current PTSD Symptom Clusters
 Re-Experiencing .031 .014 .284*
 Hyperarousal .003 .012 .030
 Avoidance/Numbing .013 .012 .167
Adjusted R2 .019 .065 .054 .315 .446
ΔR2 .052 .055 .000 .254 .141
F of ΔR2 1.58 5.19* .040 33.01*** 7.53***
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Note. Predictor variables were coded as: Male = 1, Positive screen for TBI = 1, diagnosis of current alcohol abuse/dependence = 1, and diagnosis of current major depressive disorder (MDD) = 1.

*

p < .05.

**

p < .01.

***

p ≤ .001.

Discussion

More and more veterans are capitalizing on their GI Bill benefits and pursuing higher education, yet many drop out prematurely (Rein, 2015). Universities are in a vital position of helping student veterans reset their missions as productive civilian citizens, and ensuring their success in postsecondary education and beyond is a high priority. PTSD is of particular concern within academic settings due to disproportionately high rates among veterans (Fulton et al., 2015; Rudd et al., 2011). PTSD is known to negatively influence educational functioning, yet commonly co-occurs with TBI, alcohol abuse/dependence, and MDD, which can likewise impair educational functioning. Until now, little has been known about the unique impact of PTSD symptom severity on educational functioning after controlling for these co-occurring conditions. Elucidating the relative effects of each condition will inform allocation of resources for both treatment providers and university administrators.

Consistent with our hypotheses, we found that PTSD symptom severity was positively associated with impaired educational functioning, even after accounting for demographics, TBI, current alcohol abuse/dependence, and current MDD. Although we postulated that all symptom clusters would affect educational functioning, surprisingly, our results suggest that the greatest levels of problems with educational functioning can be attributed to PTSD’s re-experiencing symptoms. Clearly, this finding needs to be replicated, but has important implications for directed intervention in academic settings. Specifically, student veterans with PTSD symptoms may be able to bring themselves to attend class, but may be nonetheless troubled by perseverative, intrusive memories of traumatic experiences, increased psychological distress from reminders, and physiological reactivity while in the classroom. In turn, these symptoms can impede concentration, comprehension, learning, and memory (Hellawell & Brewin, 2002; Vasterling, Brailey, Constans, & Sutker, 1998). Furthermore, distressing dreams or nightmares may interfere with consolidation of memory during sleep due to enhanced levels of cortisol during the rapid eye movement sleep (Born & Wagner, 2004).

It is critical for college counseling centers to be equipped to treat PTSD using empirically-supported treatments and to explicitly target symptoms of re-experiencing. Such care models will need to fit within postsecondary educational settings (e.g., semester schedules), be easily accessible (i.e., on campus), and will likely need to simultaneously address PTSD along with academic success and career planning to set student veterans on their best path. Moreover, faculty education may be critical so that faculty are aware of how PTSD and its re-experiencing symptoms can impact educational functioning and can proactively reach out to student veterans. Initiatives may be necessary that draw in student veterans and provide strategies to help them with concentration and studying strategies.

A strength of the current study was its use of well-validated clinical interviews to assess PTSD, TBI, alcohol abuse/dependence, and MDD. Further, by using the CAPS as the primary PTSD measure, symptoms could be evaluated both continuously and categorically. Continuous symptoms allowed for evaluating the full range of potential PTSD symptoms, which is critical in light of data from Brancu et al. (2015) that even subthreshold PTSD can interfere with functioning. However, not all participants met criteria for PTSD, and thus not all symptoms on the CAPS might be reflective of PTSD symptoms; accordingly, evaluating the data categorically indicated that PTSD diagnosis negatively affected educational functioning.

Several limitations should be taken into account when interpreting the findings. First, student veterans in our sample endorsed mild to moderate educational impairment, and our sample may not be reflective of those students who dropped out of college due to more severe impairment. Second, the study was cross-sectional in design. Although it is important to understand the real-time impact of PTSD and comorbidities on academic functioning, future research is also needed to examine longitudinal predictors throughout all stages of college. Students with PTSD have a worse grade point average than those without PTSD during their first year of college (Bachrach & Read, 2012), which may lead to subsequent challenges later on that would be important to investigate. Third, the study included a relatively small sample size of post-9/11 student veterans who were primarily male and enrolled within VA health care. Findings may not generalize to other war theatres, primarily female samples, and veterans who are not enrolled in VA health care. Fourth, due to the design of the parent study, the CAPS was completed based on the worst military-related event on the CAPS. It is plausible that a civilian trauma could have been more severe and the reported CAPS score is an underestimation of PTSD symptom severity. Fifth, although the current study is limited by the use of DSM-IV criteria and symptom clusters, studies with military personnel have demonstrated similar rates of provisional PTSD when using DSM-IV vs. DSM-5 criteria (Kuester et al., 2017). Future research is needed to determine whether the re-experiencing symptom cluster within the context of DSM-5 similarly interferes with educational functioning. Sixth, although increased rates of alcohol misuse are observed among both college students and military/veterans (Barry et al., 2012b; Wechsler et al., 2002), we opted to evaluate the impact of alcohol abuse/dependence on educational functioning because these disorders would likely have the most severe impact. However, future research should examine drinking patterns in relation to PTSD and academic functioning in more detail. Seventh, the sample primarily included veterans with mild TBI, and in light of data from Carroll et al. (2014), most individuals with mild TBI will fully recover within the first year post-injury. Although it is important to understand a history of TBI on long-term functioning, future studies should examine the impact of ongoing cognitive and post-concussive symptoms. Eigth, it is possible that symptoms of mental health conditions could influence perceptions and self-reporting of impaired educational functioning. Lastly, it is possible that the nature of some of the variables assessed in the regression analyses may have favored their emergence as parsimonious indicators. Specifically, continuous variables may account for more variance in a regression analyses than binary variables because of their increased reliability.

In summary, findings from the current study indicate that PTSD interferes with educational functioning over and above other mental health conditions. Studies are needed to determine whether universities that proactively address PTSD are able to increase success and retention rates among students, including veterans. Unfortunately, campus support systems often do not feel equipped to provide adequate services for students with PTSD (Salzer et al., 2008). Thus, providing training opportunities in empirically-supported treatments for PTSD to counseling services staff may be a critical and necessary step. Short of expertise in treating military-related PTSD, veterans may also benefit from being referred for VA care or community settings. Military culture should be taken into account, as many student veterans have considerable life experience related to their military service and often struggle with connecting with traditional college students. Training faculty and students in understanding military culture may ease the transition and warrants research. Likewise, Student Veteran Associations or other veteran group membership may be an important vehicle for outreach and foster belongingness and teamwork (e.g., studying together, sharing notes from class). Finally, psychologists in the public sector who are working with student veterans with PTSD may want to contextualize their treatment plan within the challenges of the academic environment in order to foster functional recovery. Future research using longitudinal methodology is clearly needed to develop a clearer picture of the long-term effects of PTSD across all years of college, and how remission of PTSD following treatment may alter educational functioning trajectories. This should include objective measures of educational achievement (e.g., GPA), as well as the impact of PTSD on graduation and retention rates. Further, work is also needed to examine the impact of different types of trauma (e.g., civilian, military), various combinations of co-occurring disorders on educational functioning, as well as specific factors that interfere with educational achievements (e.g., completing assignments, difficulty working in groups, challenges with studying). Such studies would further inform targeted interventions to improve educational success.

Acknowledgments

This work was supported by VA Merit Awards to Dr. Morissette (#I01RX000304–01A1) and Drs. Morissette and Meyer (#I01RX000304–01A4) from the Rehabilitation Research and Development Service of the VA Office of Research and Development. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Contributor Information

Sandra B. Morissette, The University of Texas at San Antonio

Clark Ryan-Gonzalez, The University of Texas at San Antonio.

Tomas Yufik, St. Edwards University.

Bryann B. DeBeer, Department of Veterans Affairs VISN 17 Center of Excellence for Research on Returning War Veterans, Central Texas Veterans Health Care System; and Texas A&M Health Science Center

Nathan A. Kimbrel, Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center; and Duke University Medical

Audrey M. Sorrells, University of Texas at Austin

Lori Holleran-Steiker, University of Texas at Austin.

Walter E. Penk, Texas A&M Health Science Center

Suzy B. Gulliver, Warrior Research Institute, Baylor Scott and White Healthcare System

Eric C. Meyer, Department of Veterans Affairs VISN 17 Center of Excellence for Research on Returning War Veterans, Central Texas Veterans Health Care System; Warrior Research Institute, Baylor Scott and White Healthcare System; and Texas A&M Health Science Center

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