1. The Differential Pattern of Post- Concussive Symptoms Among Female Compared to Male OEF/OIF Veterans with Deployment-Related TBI Errol Baker, Ph.D. Katherine M. Iverson, Ph.D. Mark Meterko, Ph.D. Kelly L. Stolzmann, MS and Ann Hendricks, Ph.D. This work is supported by VA HSR&D Grant: SDR 08-405 (PI: Ann Hendricks)

2. Traumatic Brain Injury (TBI) High risk of TBI during OEF/OIF deployments  Blow to the head that disrupts brain functioning  Prevalence: 12-20% 1-4  Most cases are mild in severity 5 Associated with:  Persistent postconcussive symptoms 6  Commonly co-occurs with posttraumatic stress disorder (PTSD) in VA patients (64%-67%) 7,8

3. TBI and Women Veterans The impact of deployment-related TBI on women’s health is largely unknown  Women comprise 13% of U.S. personnel who have served in OEF/OIF 10.5% of women using VA services after OEF/OIF deployments screen positive for TBI 1 Persistent postconcussive symptoms may be worse for women than for men 9,10

4. Study Aims 1) To examine gender differences in postconcussive symptom severity among OEF/OIF Veterans judged to have deployment-related TBI 2) To examine gender differences as a function of etiology and PTSD comorbidity

5. Data Source: Comprehensive TBI Evaluation Protocol to assist in making a clinical judgment about whether a TBI occurred Etiology of injury (self-report)  Blast exposure  Non-blast related head injuries oe.g., vehicular accidents, bullet above the shoulders, falls, etc. Neurobehavioral Symptom Inventory (NSI-22) 11 PTSD comorbidity

6. Study Population Veterans who…  Completed a Comprehensive TBI Evaluation between FY 2008 and FY 2009  Been judged to have deployment-related TBI  Did not report TBI prior to or following deployment Random sample of 5,941 Veterans for analysis

7. Design Dependent Variable  Severity of postconcussive symptoms (NSI-22) Independent Variables:  Participants were stratified by: oEtiology: Blast only, Blast + non-Blast, non-Blast only  Gender  PTSD comorbidity: Yes, No Three-way MANOVA and follow-up Univariate ANCOVAs

8. Sample Characteristics (N = 5,941) 306 women comprised 5.2% of study population Blast exposure  60% of the women  85% of men PTSD comorbidity  69% of women  76% of men

10. Affective Severity Stratified by PTSD Comorbidity & Etiology

11. Somatosensory Severity Stratified by PTSD Status & Etiology

12. Summary 1) 60% of women reported blast exposure 2) Women report more severe postconcussive symptoms than men, especially related to blast 3) PTSD comorbidity was consistently associated with higher symptoms severity regardless of etiology for men, but this was not always the case for women 4) Women's affective and cognitive symptoms are impacted by a complex interaction of both etiology and PTSD comorbidity

13. Limitations and Future Research Directions Analyses are hypothesis-generating in that they only describe gender differences May have been gender-related biases in the reporting of symptoms or in the judgment of TBI Need to identify contributing factors for gender differences in postconcussive symptoms

14. Implications Attention to postconcussive symptoms of women Veterans  Management of specific symptoms  Collaboration and coordination of care  Interdisciplinary teams Educate health care providers, Veterans and the public  Increase detection  Tailor treatment to women’s specific needs  Increased VA service

15. Polytrauma and Blast-Related Injuries (PT/BRI) QUERI Expert Advisory Panel  Drs. N. Sayer, D. Cifu, R. Vanderploeg, S. Fitzgerald, M. Jaffee, A. Nelson, C. Tun, and E. Bass My contact information: Katherine.Iverson@va.govKatherine.Iverson@va.gov First author’s contact information: Errol.Baker@va.govErrol.Baker@va.gov HSR&D PI’s contact information: Ann.Hendricks@va.govAnn.Hendricks@va.gov Acknowledgements and Contact Information

16. References 1.Hendricks, A., Amara, J., Baker, E., Charns, M., Gardner, J. A., Iverson, K. M., Kimerling, R., Krengel, M., Meterko, M., Pogoda, T. K., Stolzmann, K. L., Wolfsfeld, L., & Lew, H. L. (2010). Screening for mild Traumatic brain injury in OEF-OIF deployed military: An empirical assessment of the VA Experience. Unpublished manuscript. 2.Hoge, C. W., McGurk, D., Thomas, J. L., Cox, A. L., Engel, C. C., & Castro, C. A. (2008). Mild traumatic brain injury in U.S. soldiers returning from Iraq. New England Journal of Medicine, 358, 453-463. 3.Schneiderman, A. I., Braver, E. R., & Kang, H. K. (2008). Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts of Iraq and Afghanistan: Persistent postconcussive symptoms and posttraumatic stress disorder. American Journal of Epidemiology, 167, 1446-1452. 4.Tanielian, T., & Jaycox, L. H. (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Corp. 5.Hoge, C. W., Goldberg, H. M., & Castro, C. A. (2009). Care of war Veterans with mild traumatic brain injury— Flawed Perspectives. New England Journal of Medicine, 360, 1588-1591. 6.Sayer, N. A., Rettmann, N. A., Carlson, K. F., Bernardy, N., Sigford, B. J., Hamblen, J. L., Friedman, M. J. (2009). Veterans with history of mild traumatic brain injury and posttraumatic stress disorder: Challenges from provider perspective. Journal of Rehabilitation Research & Development, 46, 703-716. 7.Carlson, K. F., Nelson, D., Orazem, R. J., Nugent, S., Cifu, D. X., & Sayer, N. A. (2010). Psychiatric diagnoses among Iraq and Afghanistan war veterans screened for deployment-related traumatic brain injury. Journal of Traumatic Stress, 23, 17-24. 8.Iverson, K. M., Hendricks, A., Kimerling, R., Krengle, M., Meterko, M., Stolzmann, K., Baker, E., Pogoda, T., Vasterling, J., & Lew, H. (under review). Psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF VA patients with deployment-related TBI. 9.Colvin, A. C., Mullen, J., Lovell, M. R., West, R. V., Collins, M. W., & Groh, M. (2009). The role of concussive history and gender in recovery from soccer-related concussion. The American Journal of Sports Medicine, 37, 1699-1704. 10.Farace, E., & Alves, W. M. (2000). Do women fare worse? A metaanalysis of gender differences in outcome after traumatic brain injury. Neurosurgery Focus, 8, 1-8. 11.Cicerone, K. D., & Kalmar, K. (1995). Persistent postconcussion syndrome: The structure of subjective complaints after mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 10, 1–17. 12.Meterko, M., Baker, E., Stolzmann, K. L., Cicerone, K. D., Hendricks, K. M., & Lew, H. L. (2010). Psychometric assessment of the NSI-22. Unpublished manuscript.

17. Neurobehavioral Symptom Inventory (NSI-22) + Pain Item: Factor Structure 12 ScalekαScale Content Affective 6.88 Low frustration tolerance Irritability Anxiety/tension Fatigue Difficulties sleeping Depressed or sad Somatosensory 8.81 Light sensitivity Noise sensitivity Vision problems Headaches Nausea Numbness/tingling Change in taste/smell Pain Cognitive 4.89 Difficulties getting organized/can’t finish things Poor concentration Forgetfulness Difficulties making decisions Vestibular 3.82 Loss of balance Feeling dizzy Poor coordination/clumsy Unassigned2NA Loss or increase in appetite Hearing difficulty

18. Cognitive Severity Stratified by PTSD Status & Etiology

19. Vestibular Severity Stratified by PTSD Status & Etiology

20. GenderEtiologyTotal Blast Only Blast + Non-Blast Non-Blast Only Count% % % % Female79 25.8 104 34.0 12340.2306100 Male2,06436.62,73248.583914.95,635100 Total2,14336.12,83647.796216.25,941100 Sample Characteristics: Gender and Injury Etiology (N = 5,941)

21. Sample Characteristics: Gender and PSTD Comorbidity (N = 5,941) GenderPSTD ComorbidityTotal PresentAbsent Count% % % Female 210 68.6 9631.4306100 Male 4,281 76.0 1,35424.05,635100 Total 4,49175.61,45024.45,941100

22. Sample Characteristics: Gender, PTSD Comorbidity, Injury Etiology GenderPTSDEtiology Total Blast Only Blast + Non-Blast Non-Blast Only n%n%n%n% FemaleNo1717.72020.85961.596100 Yes6229.58440.06430.5210100 MaleNo44833.153539.537127.41354100 Yes161637.7219751.346810.94281100 Total214336.1283647.796216.25941100