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higher levels of commitment to life and work, belief in one’s remote mild TBI; (2) age 16 or older at the time of injury; and
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ability to control outcomes, and enjoyment of challenges. At (3) admission to a TBI inpatient or residential rehabilitation
the beginning of their careers, SOF personnel are more psycho- program. 22
logically resilient than CF. 15,16 During their careers, SOF also
engage in more disciplined lifestyles than CF (i.e., have health- For the current study, additional criteria included: (4) comple-
ier diets, more physical activity, and better sleep habits), which tion of a baseline or follow-up interview after 4/01/2018 to
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are protective against mental health disorders. However, due obtain SOF status (SOF status was backfilled if collected at a
to intense training, frequent deployments, and chronic stress follow-up assessment), (5) non-missing SOF status data, and
in combat situations, SOF are exposed to more risk factors (6) at least one PTSD self-report measure completed at any as-
that can increase their allostatic load, which can lead to phys- sessment time. Participants were categorized into two groups:
ical and psychological injuries. 10,18 Consistently, increasing age SOF and a demographically matched sample of CF.
(proxy for advanced career level and more deployments) is
related to greater PTSD severity in SOF. When studies use Procedure
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anonymous data collection methods, point prevalence rates of The VA TBIMS study protocols were approved by local In-
probable PTSD in a sample of active duty SOF (8%) are con- stitutional Review Boards and Research and Development
sistent with rates identified in CF (6%–13%). 20 Committees at each data collection site. Informed consent
was obtained from the participant or legal proxy prior to any
Importantly, compared to CF, typical SOF duties confer addi- research activities. The study adheres to all state and federal
21
tional risk for sustaining TBIs, which are related to higher research standards and regulations.
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rates of PTSD. Among SOF personnel receiving inpatient TBI
rehabilitation, rates of probable PTSD are as high as 36% as Baseline measures were completed at the time of study enroll-
compared with 14% in CF. Complicating the clinical picture, ment, which occurred during the participant’s inpatient admis-
6
SOF personnel usually seek medical and mental health treat- sion at a PRC for TBI rehabilitation. Follow-up assessments
ment at the end of their careers rather than acutely following occurred via telephone at times that were anchored to the TBI
injury. By the time they receive treatment for symptoms poten- at 1, 2, 5, and 10 years following injury. Those with mild TBI
tially related to the TBI, they report more mental health and often do not receive any medical attention until years after the
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physical symptoms than CF. No studies have documented the injury; thus, the baseline assessment could be any time after
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trajectory of PTSD symptoms after TBI in SOF. Given the dif- the index TBI. For example, a participant who entered rehabil-
ference in duties and potential exposures between SOF and CF itation 3 years after sustaining a TBI and then enrolled in the
over their military careers, results from CF may not generalize study would complete their baseline assessment during the in-
to SOF. Further examination of PTSD in SOF is warranted. patient stay and be eligible for their first follow-up assessment
at 5 years post-injury.
Current Study
Meeting the unique needs of SOF, including treatment plan- Measures and Variables of Interests
ning and resource allocation, requires knowledge about the
trajectory of PTSD symptoms after TBI among SOF. Treatment Demographics and Military Characteristics
facilities that would benefit from this knowledge include the Participant characteristics, including sociodemographic vari-
Department of Defense (DoD) and the Department of Veterans ables, military service, and behavioral health history, were col-
Affairs (VA). Those outside the DoD and VA who may also lected at baseline (at the time of admission to rehabilitation)
benefit from knowing the evolution of PTSD symptoms in this via a clinical interview with the study team. 22,23
population include community providers who accept Tricare
(insurance for active duty and retired Service Members). Due to SOF are generally grouped into Tier 1 or Tier 2 units. Tier 1
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the high comorbidity between PTSD and TBI and the occupa- units are also known as Special Mission Units and are com-
tional hazards that put SOF at risk for these conditions, 10,18,19,21 manded by the national-level Joint Special Operations Com-
we compared the chronicity of PTSD symptoms in SOF who mand. Tier 1 units include 1st Special Forces Operational
have experienced a TBI with a matched sample of CF. Detachment (DELTA), Naval Special Warfare Development
Group (DEVGRU), 24th Special Tactics Squadron, and Intel-
ligence Support Activity (ISA). USSOCOM commands Tier 2
Methods
units, including Navy SEALs, Marine Raiders, Marine Force
Participants and Settings Recon, Combat Controllers, Rangers, and Special Forces.
Participants were recruited from five VA Polytrauma Rehabil-
itation Centers (PRCs) and enrolled in the VA TBI Model Sys- To be classified as SOF personnel in the current study, partic-
tems (VA TBIMS) study between 2009 and 2022. ipants answered “yes” to the question, “Have you ever served
in a Tier 1 or Tier 2 unit? Examples of these units include
The VA TBIMS is a longitudinal study of recovery and rehabil- Army Green Berets and Rangers, Navy SEALs, Marine Forces
itation outcomes among SM/Vs with a history of TBI. TBI is Special Operations Command, Joint Special Operations Com-
defined as a traumatically induced structural brain injury and/ mand, SOF para-rescuers, and Combat Controllers.” A partic-
or physiological disruption of brain functioning due to exter- ipant’s role in the SOF units was not assessed.
nal force as evidenced by onset or worsening of any of the fol-
lowing: loss/decreased consciousness, mental state alteration, TBI
memory loss for events immediately before or after the injury, The index TBI (defined as the primary TBI being treated in re-
transient or stable neurological deficits, or intracranial lesion. habilitation) and its characteristics were abstracted from the
Eligibility criteria for the parent VA TBIMS study included: medical record at baseline. The cause of the index TBI was clas-
(1) an admission diagnosis of TBI of any severity, including sified as follows: motor vehicular, fall (including hard parachute

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