Chronic Pain, TBI, and PTSD in Military Veterans: A Link to Suicidal Ideation and Violent Impulses?

  • Shannon M. Blakey
    Address reprint requests to Shannon M. Blakey, MS, University of North Carolina at Chapel Hill, Department of Psychology and Neuroscience, Davie Hall (CB # 3270), Chapel Hill, NC 27599-3270.
    Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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  • H. Ryan Wagner
    Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina

    Durham VA Medical Center, Durham, North Carolina

    Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
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  • Jennifer Naylor
    Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina

    Durham VA Medical Center, Durham, North Carolina

    Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
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  • Mira Brancu
    Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina

    Durham VA Medical Center, Durham, North Carolina

    Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
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  • Ilana Lane
    Durham VA Medical Center, Durham, North Carolina
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  • Meghann Sallee
    Durham VA Medical Center, Durham, North Carolina
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  • Nathan A. Kimbrel
    Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina

    Durham VA Medical Center, Durham, North Carolina

    Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
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  • VA Mid-Atlantic MIRECC Workgroup
  • Eric B. Elbogen
    Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina

    Durham VA Medical Center, Durham, North Carolina

    Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
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      • The polytrauma clinical triad includes chronic pain, traumatic brain injury, and posttraumatic stress disorder.
      • The polytrauma clinical triad was associated with suicidal ideation.
      • The polytrauma clinical triad was associated with violent impulses.
      • Pain interference was a stronger predictor of outcomes than was pain intensity.
      • Chronic pain is relevant to suicide and violence risk assessment in veterans.


      The polytrauma clinical triad refers to the co-occurrence of chronic pain, traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD). Despite research implicating dyadic relationships between these conditions and adverse outcomes, scant research has examined the polytrauma clinical triad's relation to suicide or violence. The present cross-sectional study was designed to examine whether this complex clinical presentation increases risk of suicidal ideation and violent impulses after accounting for other established risk factors. Veterans who served in the military since September 11, 2001 (N = 667) who reported chronic pain completed an interview and self-report battery. Bivariate analyses showed that suicidal ideation and violent impulses both correlated with PTSD, TBI+PTSD, pain intensity and interference, drug abuse, and major depressive disorder (MDD). Multiple regression analyses showed that: 1) race, chronic pain with PTSD, alcohol abuse, and MDD significantly predicted suicidal ideation, 2) pain interference, chronic pain with TBI, chronic pain with PTSD, chronic pain with TBI+PTSD, drug abuse, and MDD significantly predicted violent impulses, and 3) pain interference was a more critical predictor of suicidal and violent ideation than pain intensity. Implications for risk assessment and treatment are discussed.


      This article presents results from a study examining predictors of suicide and violence risk among a sample of post-9/11 U.S. Veterans with chronic pain. Health care professionals should assess for pain interference, TBI, PTSD, depression, and alcohol/drug abuse when conducting risk assessments with this population.

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        • Asmundson G.J.
        • Coons M.J.
        • Taylor S.
        • Katz J.
        PTSD and the experience of pain: Research and clinical implications of shared vulnerability and mutual maintenance models.
        Can J Psychiatry. 2002; 47: 930-937
        • Babor T.F.
        • Biddle-Higgins J.C.
        • Saunders J.B.
        • Monteiro M.G.
        The Alcohol Use Disorders Identification Test: Guidelines for use in primary health care.
        (Geneva, Switzerland: World Health Organization)2001
        • Bahraini N.H.
        • Breshears R.E.
        • Hernandez T.D.
        • Schneider A.L.
        • Forster J.E.
        • Brenner L.A.
        Traumatic brain injury and posttraumatic stress disorder.
        Psychiatr Clin North Am. 2014; 37: 55-75
        • Beck A.T.
        • Steer R.A.
        Manual for the Beck Scale for Suicide Ideation.
        (San Antonio, TX: Psychological Corporation)1991
        • Beck A.T.
        • Steer R.A.
        • Brown G.K.
        Manual for the Beck Depression Inventory-II.
        (San Antonio, TX: Psychological Corporation)1996
        • Bohnert A.S.
        • Ilgen M.A.
        • Trafton J.A.
        • Kerns R.D.
        • Eisenberg A.
        • Ganoczy D.
        • Blow F.C.
        Trends and regional variation in opioid overdose mortality among Veterans Health Administration patients, fiscal year 2001 to 2009.
        Clin J Pain. 2014; 30: 605-612
        • Bongar B.M.
        Suicide: Guidelines for Assessment, Management, and Treatment.
        Oxford University Press, 1992
        • Bradley K.A.
        • McDonell M.B.
        • Bush K.
        • Kivlahan D.R.
        • Diehr P.
        • Fihn S.D.
        The AUDIT alcohol consumption questions: Reliability, validity, and responsiveness to change in older male primary care patients.
        Alcohol Clin Exp Res. 1998; 22: 1842-1849
        • Brancu M.
        • Wagner H.
        • Morey R.
        • Beckham J.
        • Calhoun P.
        • Tupler L.
        • Marx C.E.
        • Taber K.H.
        • Hurley R.A.
        • Rowland J.
        • McDonald S.D.
        • Hoerle J.M.
        • Moore S.D.
        • Kudler H.S.
        • Weiner R.D.
        • Mid-Atlantic V.A.
        • Workgroup M.I.
        • Fairbank J.A.
        The Post-Deployment Mental Health (PDMH) study and repository: A multi-site study of U.S. Afghanistan and Iraq era veterans.
        Int J Methods Psychiatr Res. 2017; 26: e1570
        • Brenner L.A.
        • Betthauser L.M.
        • Homaifar B.Y.
        • Villarreal E.
        • Harwood J.E.
        • Staves P.J.
        • Huggins J.A.
        Posttraumatic stress disorder, traumatic brain injury, and suicide attempt history among veterans receiving mental health services.
        Suicide Life Threat Behav. 2011; 41: 416-423
        • Brown G.K.
        • Beck A.T.
        • Steer R.A.
        • Grisham J.R.
        Risk factors for suicide in psychiatric outpatients: A 20-year prospective study.
        J Consult Clin Psychol. 2000; 68: 371-377
        • Bryant R.
        Post-traumatic stress disorder vs traumatic brain injury.
        Dialogues Clin Neurosci. 2011; 13: 251-262
        • Bryant R.A.
        • Marosszeky J.E.
        • Crooks J.
        • Baguley I.J.
        • Gurka J.A.
        Interaction of posttraumatic stress disorder and chronic pain following traumatic brain injury.
        J Head Trauma Rehabil. 1999; 14: 588-594
        • Buckenmaier C.C.
        • Galloway K.T.
        • Polomano R.C.
        • McDuffie M.
        • Kwon N.
        • Gallagher R.M.
        Preliminary validation of the Defense and Veterans Pain Rating Scale (DVPRS) in a military population.
        Pain Med. 2013; 14: 110-123
        • Calati R.
        • Laglaoui Bakhiyi C.
        • Artero S.
        • Ilgen M.
        • Courtet P.
        The impact of physical pain on suicidal thoughts and behaviors: Meta-analyses.
        J Psychiatr Res. 2015; 71: 16-32
        • Caldeiro R.M.
        • Malte C.A.
        • Calsyn D.A.
        • Baer J.S.
        • Nichol P.
        • Kivlahan D.R.
        • Saxon A.J.
        The association of persistent pain with out-patient addiction treatment outcomes and service utilization.
        Addiction. 2008; 103: 1996-2005
        • Chard K.M.
        • Schumm J.A.
        • McIlvain S.M.
        • Baily G.W.
        • Parkinson R.B.
        Exploring the efficacy of a residential treatment program incorporating cognitive processing therapy-cognitive for veterans with PTSD and traumatic brain injury.
        J Trauma Stress. 2011; 24: 347-351
        • Cleeland C.S.
        Pain assessment in cancer.
        in: Osoba D. Effect of Cancer on Quality of Life. CRC Press, Boca Raton, FL1991: 293-305
        • Cochrane-Brink K.A.
        • Lofchy J.S.
        • Sakinofsky I.
        Clinical rating scales in suicide risk assessment.
        Gen Hosp Psychiatry. 2000; 22: 445-451
        • Cuijpers P.
        • Vogelzangs N.
        • Twisk J.
        • Kleiboer A.
        • Li J.
        • Penninx B.W.
        Comprehensive meta-analysis of excess mortality in depression in the general community versus patients with specific illnesses.
        Am J Psychiatry. 2014; 171: 453-462
        • Derogatis L.R.
        Symptom Checklist 90–R: Administration, Scoring, and Procedures Manual.
        3rd ed. National Computer Systems, Minneapolis, MN1994
        • Duchnick J.J.
        • Ropacki S.
        • Yutsis M.
        • Petska K.
        • Pawlowski C.
        Polytrauma transitional rehabilitation programs: Comprehensive rehabilitation for community integration after brain injury.
        Psychol Serv. 2015; 12: 313-321
        • Elbogen E.B.
        • Wagner H.R.
        • Kimbrel N.A.
        • Brancu M.
        • Naylor J.
        • Graziano R.
        • Crawford E.
        • V.A. Mid-Atlantic MIRECC Workgroup
        Risk factors for concurrent suicidal ideation and violent impulses in military veterans.
        Psychol Assess. 2018; 30: 425-435
        • Fazel S.
        • Wolf A.
        • Chang Z.
        • Larsson H.
        • Goodwin G.M.
        • Lichtenstein P.
        Depression and violence: A Swedish population study.
        Lancet Psychiatry. 2015; 2: 224-232
        • Finkel E.J.
        The I3 model: Metatheory, theory, and evidence.
        in: Advances in Experimental Social Psychology. Vol. 49. Elsevier, San Diego, CA2014: 1-104
        • Finley E.P.
        • Bollinger M.
        • Noël P.H.
        • Amuan M.E.
        • Copeland L.A.
        • Pugh J.A.
        • Dassori A.
        • Palmer R.
        • Bryan C.
        • Pugh M.J.
        A national cohort study of the association between the polytrauma clinical triad and suicide-related behavior among US veterans who served in Iraq and Afghanistan.
        Am J Public Health. 2015; 105: 380-387
        • Fishbain D.A.
        • Bruns D.
        • Disorbio J.M.
        • Lewis J.E.
        Correlates of self-reported violent ideation against physicians in acute- and chronic-pain patients.
        Pain Med. 2009; 10: 573-585
        • Gironda R.J.
        • Clark M.E.
        • Massengale J.P.
        • Walker R.L.
        Pain among veterans of operations enduring freedom and Iraqi freedom.
        Pain Med. 2006; 7: 339-343
        • Gironda R.J.
        • Clark M.E.
        • Ruff R.L.
        • Chait S.
        • Craine M.
        • Walker R.
        • Scholten J.
        Traumatic brain injury, polytrauma, and pain: Challenges and treatment strategies for the polytrauma rehabilitation.
        Rehabil Psychol. 2009; 54: 247-258
        • Gradus J.L.
        • Wisco B.E.
        • Luciano M.T.
        • Iverson K.M.
        • Marx B.P.
        • Street A.E.
        Traumatic brain injury and suicidal ideation among U.S. Operation Enduring Freedom and Operation Iraqi Freedom veterans.
        J Trauma Stress. 2015; 28: 361-365
        • Guerra V.S.
        • Calhoun P.S.
        Examining the relation between posttraumatic stress disorder and suicidal ideation, in an OEF/OIF sample.
        J Anxiety Disord. 2011; 25: 12-18
        • Heilbrun K.
        • Yasuhara K.
        • Shah S.
        Violence risk assessment tools: Overview and critical analysis.
        in: Otto R.K. Douglas K.S. Handbook of Violence Risk Assessment. Routeledge, New York, NY2010: 1-18
        • Helmer D.A.
        • Chandler H.K.
        • Quigley K.S.
        • Blatt M.
        • Teichman R.
        • Lange G.
        Chronic widespread pain, mental health, and physical role function in OEF/OIF veterans.
        Pain Med. 2009; 10: 1174-1182
        • Higgins D.M.
        • Kerns R.D.
        • Brandt C.A.
        • Haskell S.G.
        • Bathulapalli H.
        • Gilliam W.
        • Goulet J.L.
        Persistent pain and comorbidity among Operation Enduring Freedom/Operation Iraqi Freedom/operation New Dawn veterans.
        Pain Med. 2014; 15: 782-790
        • Howe C.Q.
        • Sullivan M.D.
        The missing “P” in pain management: How the current opioid epidemic highlights the need for psychiatric services in chronic pain care.
        Gen Hosp Psychiatry. 2014; 36: 99-104
        • Ilgen M.A.
        • Kleinberg F.
        • Ignacio R.V.
        • Bohnert A.S.
        • Valenstein M.
        • McCarthy J.F.
        • Blow F.C.
        • Katz I.R.
        Noncancer pain conditions and risk of suicide.
        JAMA Psychiatry. 2013; 70: 692-697
        • Ilgen M.A.
        • Zivin K.
        • Austin K.L.
        • Bohnert A.S.
        • Czyz E.K.
        • Valenstein M.
        • Kilbourne A.M.
        Severe pain predicts greater likelihood of subsequent suicide.
        Suicide Life Threat Behav. 2010; 40: 597-608
        • Ivins B.J.
        • Schwab K.A.
        • Warden D.
        • Harvey S.
        • Hoilien M.
        • Powell J.
        • Johnson E.W.
        • Salazar A.M.
        Traumatic brain injury in U.S. army paratroopers: Prevalence and character.
        J Trauma. 2003; 55: 617-621
        • Jakupcak M.
        • Conybeare D.
        • Phelps L.
        • Hunt S.
        • Holmes H.A.
        • Felker B.
        • Klevens M.
        • McFall M.E.
        Anger, hostility, and aggression among Iraq and Afghanistan war veterans reporting PTSD and subthreshold PTSD.
        J Trauma Stress. 2007; 20: 945-954
        • Joiner T.E.
        Why People Die by Suicide.
        Harvard University Press, Cambridge, MA.2005
        • Kanzler K.E.
        • Bryan C.J.
        • McGeary D.D.
        • Morrow C.E.
        Suicidal ideation and perceived burdensomeness in patients with chronic pain.
        Pain Pract. 2012; 12: 602-609
        • Kay T.
        • Harrington D.E.
        • Adams R.
        • Anderson T.
        • Berrol S.
        • Cicerone K.
        • Dahlberg C.
        • Gerber D.
        • Goka R.
        • Harley P.
        • Hilt J.
        • Horn L.
        • Lehmkuhl D.
        • Malec J.
        Definition of mild traumatic brain injury.
        J Head Trauma Rehabil. 1993; 8: 86-87
        • Kelley M.
        • Runnals J.
        • Pearson M.
        • Miller M.
        • Fairbank J.
        • Brancu M.
        Alcohol use and trauma exposure among male and female veterans before, during, and after military service.
        Drug Alcohol Depend. 2013; 133: 615-624
        • Kerns R.D.
        • Otis J.
        • Rosenberg R.
        • Reid C.
        Veterans' reports of pain and associations with ratings of health, health-risk behaviors, affective distress, and use of the healthcare system.
        J Rehabil Res Dev. 2003; 4: 371-380
        • Kessler R.C.
        • Borges G.
        • Walters E.E.
        Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey.
        Arch Gen Psychiatry. 1999; 56: 617-626
        • Lew H.L.
        • Otis J.D.
        • Tun C.
        • Kerns R.D.
        • Clark M.E.
        • Cifu D.X.
        Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: Polytrauma clinical triad.
        J Rehabil Res Dev. 2009; 46: 697-702
        • Maguen S.
        • Lau K.M.
        • Madden E.
        • Seal K.
        Relationship of screen-based symptoms for mild traumatic brain injury and mental health problems in Iraq and Afghanistan veterans: Distinct or overlapping symptoms?.
        J Rehabil Res Dev. 2012; 49: 1115-1126
        • Marshall A.
        • Panuzio J.
        • Taft C.
        Intimate partner violence among military veterans and active duty servicemen.
        Clin Psychol Rev. 2005; 25: 862-876
        • Martell C.R.
        • Dimidjian S.
        • Herman-Dunn R.
        Behavioral Activation for Depression: A Clinician's Guide.
        Guilford Press, New York, NY2010
        • Mosher H.J.
        • Krebs E.E.
        • Carrel M.
        • Kaboli P.J.
        • Weg M.W.
        • Lund B.C.
        Trends in prevalent and incident opioid receipt: An observational study in Veterans Health Administration 2004–2012.
        J Gen Intern Med. 2015; 30: 597-604
        • Nampiaparampil D.E.
        Prevalence of chronic pain after traumatic brain injury: A systematic review.
        JAMA. 2008; 300: 711-719
        • Nock M.K.
        • Borges G.
        • Bromet E.J.
        • Alonso J.
        • Angermeyer M.
        • Beautrais A.
        • Bruffaerts R.
        • Chiu W.T.
        • de Girolamo G.
        • Gluzman S.
        • de Graaf R.
        • Gureje O.
        • Haro J.M.
        • Huang Y.
        • Karam E.
        • Kessler R.C.
        • Lepine J.P.
        • Levinson D.
        • Medina-Mora M.E.
        • Ono Y.
        • Posada-Villa J.
        • Williams D.
        Cross-national prevalence and risk factors for suicidal ideation, plans and attempts.
        Br J Psychiatry. 2008; 192: 98-105
        • O'Mahony S.
        • Goulet J.
        • Kornblith A.
        • Abbatiello G.
        • Clarke B.
        • Kless-Siegel S.
        • Breitbart W.
        • Payne R.
        Desire for hastened death, cancer pain and depression: Report of a longitudinal observational study.
        J Pain Symptom Manage. 2005; 29: 446-457
        • Otis J.D.
        • Keane T.M.
        • Kerns R.D.
        • Monson C.
        • Scioli E.
        The development of an integrated treatment for veterans with comorbid chronic pain and posttraumatic stress disorder.
        Pain Med. 2009; 10: 1300-1311
        • Otis J.D.
        • McGlinchey R.
        • Vasterling J.J.
        • Kerns R.D.
        Complicating factors associated with mild traumatic brain injury: Impact on pain and posttraumatic stress disorder treatment.
        J Clin Psychol Med Settings. 2011; 18: 145-154
        • Pietrzak R.H.
        • Russo A.R.
        • Ling Q.
        • Southwick S.M.
        Suicidal ideation in treatment-seeking veterans of operations enduring freedom and Iraqi freedom: The role of coping strategies, resilience, and social support.
        J Psychiatr Res. 2011; 45: 720-726
        • Placidi G.P.
        • Oquendo M.A.
        • Malone K.M.
        • Huang Y.Y.
        • Ellis S.P.
        • Mann J.J.
        Aggressivity, suicide attempts, and depression: Relationship to cerebrospinal fluid monoamine metabolite levels.
        Biol Psychiatry. 2001; 50: 783-791
        • Plagge J.M.
        • Lu M.W.
        • Lovejoy T.I.
        • Karl A.I.
        • Dobscha S.K.
        Treatment of comorbid pain and PTSD in returning veterans: A collaborative approach utilizing behavioral activation.
        Pain Med. 2013; 14: 1164-1172
        • Pompili M.
        • Sher L.
        • Serafini G.
        • Forte A.
        • Innamorati M.
        • Dominici G.
        • Lester D.
        • Amore M.
        • Girardi P.
        Posttraumatic stress disorder and suicide risk among veterans: A literature review.
        J Nerv Ment Dis. 2013; 201: 802-812
        • Pugh M.J.
        • Finley E.P.
        • Wang C.P.
        • Copeland L.A.
        • Jaramillo C.A.
        • Swan A.A.
        • Elnitsky C.A.
        • Leykum L.K.
        • Mortensen E.M.
        • Eapen B.A.
        • Noel P.H.
        • Pugh J.A.
        • TRACC Research Team
        A retrospective cohort study of comorbidity trajectories associated with traumatic brain injury in veterans of the Iraq and Afghanistan wars.
        Brain Inj. 2016; 30: 1481-1490
        • Rao V.
        • Rosenberg P.
        • Bertrand M.
        • Salehinia S.
        • Spiro J.
        • Vaishnavi S.
        • Rastogi P.
        • Noll K.
        • Schretlen D.J.
        • Brandt J.
        • Cornwell E.
        • Makley M.
        • Miles Q.S.
        Aggression after traumatic brain injury: Prevalence and correlates.
        J Neuropsychiatry Clin Neurosci. 2009; 21: 420-429
        • Rogers R.
        Structured Clinical Interview for DSM–IV Disorders (SCID) and other Axis I interviews.
        in: Rogers R. Handbook of Diagnostic and Structured Interviewing. Guilford Press, New York2001: 103-148
        • Ruff R.L.
        • Ruff S.S.
        • Wang X.F.
        Improving sleep: Initial headache treatment in OIF/OEF veterans with blast-induced mild traumatic brain injury.
        J Rehabil Res Dev. 2009; 46: 1071-1084
        • Runnals J.J.
        • Van Voorhees E.
        • Robbins A.T.
        • Brancu M.
        • Straits-Troster K.
        • Beckham J.C.
        • Calhoun P.S.
        Self-reported pain complaints among Afghanistan/Iraq era men and women veterans with comorbid posttraumatic stress disorder and major depressive disorder.
        Pain Med. 2013; 14: 1529-1533
        • Saunders J.B.
        • Aasland O.G.
        • Babor T.F.
        • de la Fuente J.R.
        • Grant M.
        Development of the Alcohol Use Disorders Screening Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption—II.
        Addiction. 1993; 88: 791-804
        • Schry A.R.
        • Hibberd R.
        • Wagner H.R.
        • Turchik J.A.
        • Kimbrel N.A.
        • Wong M.
        • Elbogen E.E.
        • Strauss J.L.
        • Brancu M.
        • Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center Workgroup
        Functional correlates of military sexual assault in male veterans.
        Psychol Serv. 2015; 12: 384-393
        • Shipherd J.C.
        • Keyes M.
        • Jovanovic T.
        • Ready D.J.
        • Baltzell D.
        • Worley V.
        • Gordon-Brown V.
        • Hayslett C.
        • Duncan E.
        Veterans seeking treatment for posttraumatic stress disorder: What about comorbid chronic pain?.
        J Rehabil Res Dev. 2007; 44: 153-166
        • Skinner H.A.
        The drug abuse screening test.
        Addict Behav. 1982; 7: 363-371
        • Spitzer R.L.
        The Structured Clinical Interview for DSM-III-R (SCID): I: History, rationale, and description.
        Arch Gen Psychiatry. 1992; 49: 624-629
        • Summers J.D.
        • Rapoff M.A.
        • Varghese G.
        • Porter K.
        • Palmer R.E.
        Psychosocial factors in chronic spinal cord injury pain.
        Pain. 1991; 47: 183-189
        • Taylor B.C.
        • Hagel E.M.
        • Carlson K.F.
        • Cifu D.X.
        • Cutting A.
        • Bidelspach D.E.
        • Sayer N.A.
        Prevalence and costs of co-occurring traumatic brain injury with and without psychiatric disturbance and pain among Afghanistan and Iraq War Veteran V.A. users.
        Med Care. 2012; 50: 342-346
        • Thomas J.L.
        • Wilk J.E.
        • Riviere L.A.
        • McGurk D.
        • Castro C.A.
        • Hoge C.W.
        Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq.
        Arch Gen Psychiatry. 2010; 67: 614-623
        • Vasterling J.J.
        • Jacob S.N.
        • Rasmusson A.
        Traumatic brain injury and posttraumatic stress disorder: Conceptual, diagnostic, and therapeutic considerations in the context of co-occurrence.
        J Neuropsychiatry Clin Neurosci. 2018; 30: 91-100
        • Walter K.H.
        • Kiefer S.L.
        • Chard K.M.
        Relationship between posttraumatic stress disorder and postconcussive symptom improvement after completion of a posttraumatic stress disorder/traumatic brain injury residential treatment program.
        Rehabil Psychol. 2012; 57: 13-17
        • Watkins L.E.
        • Sippel L.M.
        • Pietrzak R.H.
        • Hoff R.
        • Harpaz-Rotem I.
        Co-occurring aggression and suicide attempt among veterans entering residential treatment for PTSD: The role of PTSD symptom clusters and alcohol misuse.
        J Psychiatr Res. 2017; 87: 8-14
        • Wilder C.M.
        • Miller S.C.
        • Tiffany E.
        • Winhusen T.
        • Winstanley E.L.
        • Stein M.D.
        Risk factors for opioid overdose and awareness of overdose risk among veterans prescribed chronic opioids for addiction or pain.
        J Addict Dis. 2016; 35: 42-51
        • Williams J.B.
        The Structured Clinical Interview for DSM-III-R (SCID): II. Multisite test-retest reliability.
        Arch Gen Psychiatry. 1992; 49: 630-636
        • Wisco B.E.
        • Marx B.P.
        • Holowka D.W.
        • Vasterling J.J.
        • Han S.C.
        • Chen M.S.
        • Gradus J.L.
        • Nock M.K.
        • Rosen R.C.
        • Keane T.M.
        Traumatic brain injury, PTSD, and current suicidal ideation among Iraq and Afghanistan U.S. veterans.
        J Trauma Stress. 2014; 27: 244-248
        • Wolf G.K.
        • Strom T.Q.
        • Kehle S.M.
        • Eftekhari A.
        A preliminary examination of prolonged exposure therapy with Iraq and Afghanistan veterans with a diagnosis of posttraumatic stress disorder and mild to moderate traumatic brain injury.
        J Head Trauma Rehabil. 2012; 27: 26-32
        • Wortzel H.
        • Arciniegas D.
        A forensic neuropsychiatric approach to traumatic brain injury, aggression, and suicide.
        J Am Acad Psychiatry Law. 2013; 41: 274-286
        • Yu W.
        • Ravelo A.
        • Wagner T.H.
        • Phibbs C.S.
        • Bhandari A.
        • Chen S.
        • Barnett P.G.
        Prevalence and costs of chronic conditions in the VA Health Care System.
        Med Care Res Rev. 2003; 60: 146-167
        • Yudko E.
        • Lozhkina O.
        • Fouts A.
        A comprehensive review of the psychometric properties of the drug abuse screening test.
        J Subst Abuse Treat. 2007; 32: 189-198