Military Mild Traumatic Brain Injury Predicts Greater Negative Metacognitive Bias

Objective: To determine if remote military mild traumatic brain injury (mTBI) is uniquely associated with deficits in global metacognition, independent of psychopathology.

Setting: Translational Research Center for TBI and Stress Disorders, VA Boston Healthcare System.

Participants: A total of 567 community-dwelling post-9/11 veterans (mean age = 34): 182 veterans with no mTBI, 134 with at least one nonmilitary mTBI, and 251 with at least one military mTBI. Exclusion criteria were severe neurologic, psychiatric, or cognitive impairment; moderate/severe TBI; or effort-measure failure.

Design: Cross-sectional examining predictors of global metacognition of cognitive abilities.

Main measures: Global metacognitive bias, calculated as self-reported cognition (WHODAS-II Understanding/Communicating) minus objective cognitive performance (attention, memory, executive composite). Secondary measures included self-reported and objective cognition and global metacognitive sensitivity (correlation between self-reported and objective cognition).

Results: Self-reported cognition scores for veterans with remote military mTBI were significantly lower than their objective cognition scores, resulting in significantly more negative metacognitive bias (M = -0.27, SD = 1.05) than those with a nonmilitary mTBI (M = 0.24, SD = 0.84) or no mTBI (M = 0.33, SD = 0.99). Notably, this effect remained significant after accounting for post-traumatic stress disorder (PTSD), depression, and anxiety/stress. It was not explained by blast exposure, peritraumatic context, or time since last mTBI, although it was modestly related to lifetime mTBI count.

Conclusion: Military mTBI is associated with more negative metacognitive bias independent of psychiatric conditions. Such bias may impede recovery and treatment effectiveness, suggesting that metacognitive interventions could be a valuable component of mild TBI care.