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System for Focal, Closed-System Central Nervous System Injury

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Military Mild Traumatic Brain Injury Predicts Greater Negative Metacognitive Bias.

Alan Chen¹, Catherine B Fortier, William P Milberg

¹Author Affiliations:Boston Attention and Learning Lab, VA Boston Health Care System, Boston, Massachusetts (Mr Chen, Dr Esterman, Dr DeGutis); National Center for PTSD, VA Boston Health Care System, Boston, Massachusetts (Dr Fortier, Dr Milberg, Dr Esterman); Translational Research Center for TBI and Stress Disorders, VA Boston Health Care System, Boston, Massachusetts (Mr Chen, Dr Fortier, Dr Milberg, Dr Esterman, Dr DeGutis); Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts (Dr Milberg); Department of Psychiatry, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts (Dr Fortier, Dr Milberg, Dr Esterman, Dr DeGutis); and Department of Psychiatry, Harvard Medical School, Boston, Massachusetts (Dr Fortier, Dr Milberg).

The Journal of Head Trauma Rehabilitation

|May 20, 2026

Summary

Remote military mild traumatic brain injury (mTBI) is linked to impaired self-awareness of cognitive abilities, independent of mental health conditions. This metacognitive bias may hinder recovery, suggesting a need for targeted interventions in mTBI care.

Keywords:

Post-traumatic stress disorder anxiety bias depression mTBI metacognition stress veteran

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Published on: April 11, 2025

Area of Science:

Neuroscience
Psychology
Military Health

Background:

Mild traumatic brain injury (mTBI) is prevalent in military personnel.
Metacognition, or the awareness of one's own cognitive processes, is crucial for daily functioning and recovery.
Previous research has not fully elucidated the specific impact of military-related mTBI on global metacognition, particularly independent of comorbid psychopathology.

Purpose of the Study:

To investigate whether remote military mTBI is uniquely associated with deficits in global metacognition.
To determine if these metacognitive deficits are independent of common psychopathological conditions such as PTSD, depression, and anxiety.
To explore the relationship between military mTBI and metacognitive bias.

Main Methods:

A cross-sectional study was conducted with 567 community-dwelling post-9/11 veterans.
Participants were categorized into three groups: no mTBI, nonmilitary mTBI, and military mTBI.
Global metacognitive bias was calculated by comparing self-reported cognitive function (WHODAS-II) with objective cognitive performance (attention, memory, executive functions).

Main Results:

Veterans with remote military mTBI exhibited significantly more negative metacognitive bias compared to those with nonmilitary mTBI or no mTBI.
This association remained significant even after controlling for the effects of PTSD, depression, and anxiety/stress.
The observed metacognitive bias was not explained by blast exposure, peritraumatic context, or time since injury, but was modestly related to the lifetime count of mTBI.

Conclusions:

Military mTBI is independently associated with impaired metacognition, characterized by a negative metacognitive bias.
This bias may negatively impact recovery trajectories and the effectiveness of treatments for individuals with military mTBI.
Metacognitive interventions should be considered as a potentially valuable component of comprehensive mild TBI care for military personnel.