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2
History, Diagnostic Criteria,
and Epidemiology
T
his chapter provides an overview of the epidemiology of posttrau-
matic stress disorder (PTSD). It begins with a brief history of the
disorder in the American military, which is followed by a discussion
of its diagnostic criteria. The remainder of the chapter presents factors as-
sociated with trauma and PTSD, first in the general population and then
in military and veteran populations, with an emphasis on combat as the
traumatic event that triggered the development of PTSD. Although other
traumatic events—such as the terrorist attacks of September 11, 2001, and
Hurricane Katrina—have increased knowledge about PTSD, this chapter
does not focus on civilian populations or nonmilitary related trauma.
The chapter concludes with special epidemiologic considerations regarding
PTSD in military populations and their implications for screening, diagno-
sis, and treatment.
HISTORY OF PTSD
Prior to the codifying of PTSD by the American Psychiatric Association
(APA) as a distinct mental health disorder in 1980 (APA, 1980), charac-
teristic symptoms of PTSD had been recognized and documented in the
19th century in civilians involved in catastrophic events, such as railway
collisions, and in American soldiers fighting in the Civil War (Birmes et al.,
2003; Jones, 2006; Welke, 2001). Many Civil War soldiers had diagnoses
of nostalgia or melancholia, characterized by lethargy, withdrawal, and
“excessive emotionality” (Birmes et al., 2003). Others had diagnoses of
exhaustion, effort syndrome, or heart conditions variously called “irritable
25
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26 PTSD IN MILITARY AND VETERAN POPULATIONS
heart,” “soldier’s heart,” and “cardiac muscular exhaustion.” Many medi-
cal professionals and surgeons at the time believed that those conditions
arose from the heavy packs that soldiers carried, insufficient time for new
recruits to acclimatize to the military lifestyle, homesickness, and, as one
army surgeon stated, poorly motivated soldiers who had unrealistic expec-
tations of war (Jones, 2006). For much of the 20th century, psychologic
conditions and impairments in military personnel were not accorded high
medical priority because of the high fatality rates from disease, infection,
and accidental injuries during war.
During World War I, shell shock and disordered action of the heart
were commonly diagnosed in combat veterans (Jones, 2006). Symptoms of
shell shock included tremors, tics, fatigue, memory loss, difficulty in sleep-
ing, nightmares, and poor concentration—similar to many of the symptoms
associated with PTSD. What is now known as delayed-onset PTSD was
termed old-sergeant syndrome during the era of the world wars, when after
prolonged combat, experienced soldiers were no longer able to cope with
the constant threats of death or serious injury (Shephard, 2000). Stemming
from the World War I definition of shell shock, other common diagnoses
of soldiers during World War II included exhaustion, battle exhaustion, fly-
ing syndrome, war neurosis, cardiac neurosis, and psychoneurosis (Jones,
2006).
It was not until after the Vietnam War that research and methodical
documentation of what was then termed combat fatigue began to accelerate
in response to the many veterans suffering from chronic psychologic prob-
lems that resulted in social and occupational dysfunction (IOM, 2008a).
The National Vietnam Veterans Readjustment Survey (NVVRS) was one
of the first large-scale studies to examine PTSD and other combat-related
psychologic issues in a veteran population (Kulka, 1990). The NVVRS
helped to illuminate PTSD as a signature wound of the Vietnam War and
resulted in greater recognition of PTSD as a mental health disorder. The
findings contributed to the formal recognition of PTSD as a distinct dis-
order by the APA and later refining of the characteristic symptoms and
diagnostic criteria.
DIAGNOSTIC CRITERIA FOR PTSD
Since 1980, PTSD has been the focus of much epidemiologic and
clinical research, which in turn has led to modifications in the defining
diagnostic criteria for PTSD. The current diagnostic criteria, taken from
the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edi-
tion, Text Revision (DSM-IV-TR), can be found in Box 2-1 (APA, 2000).
The Department of Defense (DoD) and the Department of Veterans Affairs
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27
HISTORY, DIAGNOSTIC CRITERIA, AND EPIDEMIOLOGY
BOX 2-1
DSM-IV-TR Diagnostic Criteria for
Posttraumatic Stress Disorder
A1. The person experienced, witnessed, or was confronted with an event or
events that involved actual or threatened death or serious injury, or a threat
to the physical integrity of self or others
A2. The person’s response involved intense fear, helplessness, or horror
B. Re-experiencing Symptoms (requires one or more of):
B1. Intrusive recollections
B2. Distressing nightmares
B3. Acting/feeling as though event were recurring (flashbacks)
B4. Psychological distress when exposed to traumatic reminders
B5. Physiological reactivity when exposed to traumatic reminders
C. Avoidant/Numbing Symptoms (requires three or more of):
C1. Avoidance of thoughts, feelings, or conversations associated with the stressor
C2. Avoidance of activities, places, or people associated with the stressor
C3. Inability to recall important aspects of traumatic event
C4. Diminished interest in significant activities
C5. Detachment from others
C6. Restricted range of affect
C7. Sense of foreshortened future
D. Hyperarousal Symptoms (requires two or more of):
D1. Sleep problems
D2. Irritability
D3. Concentration problems
D4. Hypervigilance
D5. Exaggerated startle response
E. Duration of the disturbance is at least 1 month
Acute—when the duration of symptoms is less than 3 months
Chronic—when symptoms last 3 months or longer
With Delayed Onset—at least 6 months have elapsed between the traumatic event
and onset of symptoms
F. Requires significant distress or functional impairment
SOURCE: American Psychiatric Association (2000) with permission.
(VA) both use these criteria in diagnosing the condition in service members
and veterans.
PTSD is unique among psychiatric disorders in that it is linked to a spe-
cific trigger: a traumatic event (Criterion A1). Traumatic events known to
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28 PTSD IN MILITARY AND VETERAN POPULATIONS
trigger PTSD include combat, natural and accidental disasters (for example,
tsunamis, earthquakes, and vehicle and airplane crashes), and victimization
or abuse (for example, sexual assault, armed robbery, and torture) (Basile et
al., 2004; Harrison and Kinner, 1998; Hoge et al., 2004; Neria et al., 2007;
Punamaki et al., 2010). PTSD may be of acute, chronic, or delayed onset.
In acute PTSD, symptoms develop immediately or soon after experiencing
a traumatic event and persist longer than a month but less than 3 months.
If symptom duration is longer than 3 months, a person has chronic PTSD.
In delayed-onset PTSD, a person does not express symptoms for months
or even years after the traumatic event (APA, 2000). The condition is con-
sidered partial or subthreshold PTSD if a person does not meet the full diag-
nostic criteria—exposure to a traumatic event and at least six symptoms: at
least one B criterion of re-experiencing, at least three C criteria of numbing
or avoidance, and at least two D criteria of hyperarousal—or if symptoms
are not in the correct distribution. Changes to the diagnostic criteria for
PTSD proposed for the next version of the DSM are shown in Box 2-2.
BOX 2-2
Proposed Changes in Diagnostic Criteria for PTSD in DSM-5
Research on PTSD and acute stress reactions has progressed, and diagnostic
criteria are expected to change to reflect the updated version of DSM-5. One of
the changes affects Criterion A1: it is proposed to expand it from experiencing
or witnessing threatened or actual death or serious injury to oneself or others to
include learning about such an event that happened to a relative or close friend
and to include first responders or others who are continuously exposed to or
experience details of traumatic events (Friedman et al., 2010). Because of the
characteristics of the statistical association and predictive value of experiencing
intense fear, helplessness, or horror during the event and onset of PTSD (Brewin
et al., 2000a) and because some persons—for example, military personnel, who
are trained to not have an emotional response during such an event—it has been
proposed that Criterion A2 be eliminated (Friedman et al., 2010).
Other proposed changes for PTSD in DSM-5 include replacing the current
three-pronged model with a four-pronged model. In the proposed model, Criterion
B would become “Intrusion Symptoms,” Criterion C “Persistent Avoidance,” Cri-
terion D “Alterations in Cognition and Mood,” and Criterion E “Hyperarousal and
Reactivity Symptoms.” Although all 17 symptoms of DSM-IV would be kept in the
proposed DSM-5, some of them would be revised or regrouped (such as includ-
ing anger and aggressive behavior with irritability), and three symptoms would be
added: erroneous self-blame or other blame regarding the cause or consequences
of trauma, pervasive negative emotional states, and reckless and self-destructive
behavior. The final proposed change in DSM-5 is to omit the distinction between
acute and chronic PTSD. There is no proposal to include cases of subthreshold,
or subsyndromal, PTSD as a distinct disorder in DSM-5 (Friedman et al., 2010).
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HISTORY, DIAGNOSTIC CRITERIA, AND EPIDEMIOLOGY
EPIDEMIOLOGY OF PTSD IN THE GENERAL POPULATION
This section begins with a brief discussion of factors associated with the
experience of trauma in the general population, inasmuch as this is a main
criterion in the diagnosis of PTSD, before considering the epidemiology of
PTSD in the general population. The next major section deals with trauma
and epidemiology specific to military and veteran populations.
Men are more likely than women to experience potential traumatic
events overall, although the types of traumatic events differ by sex (Tolin
and Foa, 2006). Studies assessing the role of race and ethnicity have had
mixed results but have found that whites have higher risks of exposure to
any traumatic event than Hispanics and blacks (Noris, 1992; Roberts et
al., 2011). Other factors found to be associated with increased risk of ex-
periencing traumatic events include lower education attainment (less than
a 4-year college degree), lower annual income (less than $25,000), and
nonheterosexual orientation (Breslau et al., 1998; Roberts et al., 2010).
Three prospective studies have documented that externalizing behavioral
problems (for example, difficult temperament and antisocial behavior) in
early childhood increase the risk of traumatic-event exposure—particularly
assaultive violence—over a lifetime (Breslau et al., 2006; Koenen et al.,
2007; Storr et al., 2007).
Trauma type and severity are central determinants of the risk of devel-
opment of PTSD. Experiencing physical injuries (penetrating and assault),
viewing the event as a true threat to one’s life, and suffering major losses are
all associated with a higher risk of PTSD (Holbrook et al., 2001; Ozer et al.,
2003). The occurrence of dissociation itself during a traumatic event does
not appear to predict development of PTSD as much as dissociation that
persists after the event (Panasetis and Bryant, 2003) or the experience of
perievent emotional reactions (Galea et al., 2003). As recognized by the VA/
DoD Clinical Practice Guideline for Management of Post-Traumatic Stress
(2010), lack of social support, trauma severity, and ongoing life stress in-
crease the risk of PTSD. Lack or loss of social support (for example, spouse,
friends, or family) after a traumatic event and ongoing life stress—including
loss of employment, financial strain, and disability—have been associated
with increased risk of PTSD (Brewin et al., 2000a; Ozer et al., 2003).
Several large, nationally representative surveys have provided estimates
of the prevalence of PTSD in the general population. The National Comor-
bidity Survey (NCS), conducted from 1990 to 1992, was one of the first
large-scale surveys to examine the distribution of and factors associated
with psychiatric disorders in the United States. Using a structured diag-
nostic interview, the NCS found that the lifetime prevalence of PTSD was
7.8% overall (Kessler et al., 1995). In the National Comorbidity Survey–
Replication (NCS–R) conducted 10 years after the original, the prevalence
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30 PTSD IN MILITARY AND VETERAN POPULATIONS
of lifetime PTSD was estimated to be 6.8% overall and that of current
(12-month) PTSD 3.6% overall (Kessler et al., 2005). The 2004–2005 Na-
tional Epidemiologic Survey on Alcohol and Related Conditions estimated
lifetime prevalence of PTSD to be 7.3% overall (Roberts et al., 2011).
Sex and trauma type are two risk factors associated with PTSD (protec-
tive factors are discussed in Chapter 5). PTSD prevalence has consistently
been shown to differ by sex in the civilian population (Kessler et al., 1995,
2005; Tolin and Foa, 2006). The original NCS found PTSD prevalence to
be twice as great in women as in men, and the NCS–R estimated it to be
2.7 times greater in women than in men (Harvard Medical School, 2007b;
Kessler et al., 1995). The type of trauma experienced may lead to the dis-
crepancy between the sexes. For example, Tolin and Foa (2006) found no
sex differences associated with PTSD in persons who experienced assaultive
violence or nonsexual child abuse or neglect, but there were marked differ-
ences between men and women who experienced combat, accidents, and
disasters. Men were more likely to report having experienced a traumatic
event over their lifetimes, but women were more likely to meet criteria for
PTSD (Tolin and Foa, 2006), have PTSD symptoms four times as long as
men (48 months vs. 12 months) (Breslau et al., 1998), have a poorer quality
of life if they have PTSD (Holbrook et al., 2001; Seedat et al., 2005), and
develop more comorbid psychiatric disorders (Seedat et al., 2005).
There is some evidence on the effect of race and ethnicity on the devel-
opment of PTSD although findings are inconsistent among studies. Results
from the 2004–2005 wave of the National Epidemiologic Survey on Alcohol
and Related Conditions showed that whites were more likely to have expe-
rienced any trauma, and lifetime prevalence of PTSD was highest in blacks
and lowest in Asians. Even after adjustment for characteristics related to
trauma, the risk of PTSD was significantly higher in blacks and lower in
Asians than in whites in the sample (Roberts et al., 2011). Marshall et al.
(2009) found that in a sample of survivors of physical trauma, Hispanic
whites reported greater symptoms related to cognitive and sensory percep-
tion (for example, hypervigilance and emotional reactivity) and overall
symptom severity than non-Hispanic whites. Other work has shown that
Hispanic whites are more likely to report PTSD after a traumatic event than
are non-Hispanic whites (Galea et al., 2004). In a study of adults 18–45
years old in the Detroit area, Breslau et al. (1998) found that nonwhites
were not at higher risk for PTSD than whites.
PTSD can affect people of any age. In the NCS–R, people were divided
into four cohorts: 18–29, 30–44, 45–59, and older than 59 years old. The
highest lifetime and 12-month prevalences of PTSD were in the group
45–59 years old (9.2% and 5.3%, respectively), and the lowest preva-
lences (2.8% and 1.0%, respectively) were in the group over 59 years old
(Harvard Medical School, 2007a,b). Results from the earlier NCS showed
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HISTORY, DIAGNOSTIC CRITERIA, AND EPIDEMIOLOGY
a different distribution of lifetime prevalence of PTSD by age group. The
lowest prevalence was in men 15–24 years old (2.8%) and women 45–54
years old (8.7%) (Kessler et al., 1995). However, most of those studies ex-
amined the association between current age of the participants and PTSD
symptoms or diagnostic threshold, and the strength of association between
age and development of PTSD is unknown. Prevalence estimates of PTSD
by age groups may also be confounded by historical events, such as the
Vietnam War.
Sexual orientation has been associated with risk of PTSD. The National
Epidemiologic Survey of Alcohol and Related Conditions found that the
risk of PTSD was significantly higher in lesbians and gays, bisexuals, and
heterosexuals with any same-sex partners than it was in the heterosexual
reference group. After adjusting for demographic factors, the higher risk
of PTSD was largely explained by nonheterosexuals’ greater exposure to
violence, exposure to more potentially traumatic events, and earlier age at
trauma exposure (Roberts et al., 2010).
Cognitive reserve—individual differences in brain structure and function
that are thought to provide resilience against damage from neuropathology—
is thought to be one important etiologic factor in the development and se-
verity of PTSD and other neuropsychiatric disorders (Barnett et al., 2006).
Intelligence quotient (IQ), a marker of cognitive reserve, has been shown to
be inversely related to risk of PTSD and other psychiatric disorders (Batty et
al., 2005; Walker et al., 2002). In a 17-year prospective study of randomly
selected newborns in southeastern Michigan, Breslau et al. (2006) found
that children who at the age of 6 years had an IQ of greater than 115 had a
decreased conditional risk of PTSD after trauma exposure; however, the risk
increased for children that experienced anxiety disorders and whom teachers
rated as high for externalizing problems. Overall, the authors found that high
IQ (115 or higher) protected exposed persons from developing PTSD in this
cohort (Breslau et al., 2006).
Similarly, Koenen et al. (2007) examined the association between early
childhood neurocognitive factors and risk of PTSD in a New Zealand birth
cohort that was followed through the age of 32 years. The authors found
that IQ assessed at the age of 5 years was inversely associated with risk
for developing PTSD by the age of 32 years. No associations were found
between PTSD and other neurodevelopmental factors assessed in the co-
hort, suggesting that the IQ–PTSD association was not a marker of broader
neurodevelopmental deficits.
The findings on the strength of association between family psychiatric
history and PTSD are mixed. In one analysis of NCS data, after controlling
for previous traumatic events, parental mental health disorders were associ-
ated with increased risk of PTSD in both men and women (Bromet et al.,
1998). Although Breslau et al. (1991) found statistically significant associa-
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32 PTSD IN MILITARY AND VETERAN POPULATIONS
tions between PTSD after a traumatic event and family psychiatric history
of depression, anxiety, and psychosis, a meta-analysis of risk factors for
PTSD did not find this association in either civilian or military population
studies (Brewin et al., 2000b). A family history of psychiatric disorders may
be indicative of adverse family environment, which may increase the risk of
experiencing a traumatic event, such as abuse, during childhood (Breslau
et al., 1995; Brewin et al., 2000b). A positive association was found be-
tween reported family history of psychopathologic conditions and higher
rates of PTSD symptoms or diagnosis, but the strength of this relationship
differed by the type of traumatic experience of the target event (stronger
after noncombat interpersonal violence than after combat exposure) and
method of PTSD assessment (stronger when symptoms were determined in
interviews than in self-reports) (Ozer et al., 2003). In a study that followed
a New Zealand birth cohort and assessed for PTSD at the age of 26 years
and again at the age of 32 years, maternal depression before the age of 11
years was associated with increased risk of PTSD through the age of 32
years (Koenen et al., 2007).
Family and twin studies of PTSD have produced two major findings.
First, PTSD has a genetic component. Modern genetic studies of PTSD be-
gan with the observation that relatives of probands (persons serving as in-
dex cases in genetic investigations of families) who had PTSD had a higher
risk of the disorder than relatives of similarly trauma-exposed controls who
did not develop PTSD. Twin studies established that genetic influences ex-
plain much of the vulnerability to PTSD, from about 30% in male Vietnam
veterans (True et al., 1993) to 72% in young women (Sartor et al., 2011),
even after genetic influences on trauma exposure are accounted for. Second,
both family and twin studies suggest that there is strong overlap for genetic
influences on PTSD and those of other mental disorders including major
depression, generalized anxiety disorder, and alcohol and drug dependence.
For example, in a sample of Vietnam veterans, common genetic influences
explained 63% of the major depression–PTSD comorbidity and 58% ge-
netic variance in PTSD (Koenen et al., 2008a). Other studies using the
Vietnam Era Twin Registry found genetic influences of generalized anxiety
disorder and panic disorder symptoms (Chantarujikapong et al., 2001),
alcohol dependence and drug dependence (Xian et al., 2000), and nicotine
dependence (Koenen et al., 2005b) account for a substantial proportion of
the genetic variance for PTSD. Those results suggest that most of the genes
that affect the risk of PTSD also influence the risk of these psychiatric dis-
orders and vice versa. A more complete discussion of genetic influences on
PTSD is found in Chapter 3.
Several prospective studies have implicated pretrauma psychopathology
in increasing the risk of PTSD. In a cohort of randomly selected newborns
in southeastern Michigan followed for 17 years, children who at the age of
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HISTORY, DIAGNOSTIC CRITERIA, AND EPIDEMIOLOGY
6 years were rated as having externalizing problems above the normal range
were more likely to develop PTSD than children who were rated as normal
externalizers; young adults who had received a diagnosis of any anxiety
disorder at the age of 6 years were significantly more likely to develop
PTSD than those who had not (Breslau et al., 2006). Another prospective
study in a cohort of children of similar age entering first grade over a 2-year
period and followed for 15 years, those who in first grade were categorized
as highly anxious or having depressive mood were at higher risk for PTSD
among those exposed to traumatic events than their peers who did not have
these psychologic problems; exhibiting aggressive or disruptive behaviors,
concentration problems, and low social interaction were not found to be
associated with increased risk of PTSD in this cohort (Storr et al., 2007). A
third prospective study, which followed a New Zealand birth cohort and
assessed for trauma exposure and PTSD at the ages of 26 and 32 years,
found several childhood risk factors to be associated with PTSD. Childhood
temperament ratings were made at the ages of 3 and 5 years, and behavior
ratings were made by teachers biannually from the ages of 5 through 11
years. Children who had difficult temperaments or antisocial behavior and
who were unpopular were statistically more likely to develop PTSD than
their peers who did not have these characteristics. Antisocial behavior as-
sessed before the age of 11 years predicted development of PTSD at the age
of 26 years and at the age of 32 years. Childhood poverty and high levels of
internalizing symptoms in mothers were also associated with development
of PTSD (Koenen et al., 2007).
Childhood abuse may have an effect on the development of PTSD. A
meta-analysis that considered nine studies suggests that abuse during child-
hood is a risk factor for PTSD (Brewin et al., 2000b). Desai et al. (2002)
found that physical or sexual childhood victimization or both increased
the risk of adult victimization by an intimate partner. This aligns with NCS
findings that women who experienced physical abuse during childhood had
the highest risk of lifetime PTSD (Kessler et al., 1995).
In addition to pretrauma psychopathology or childhood abuse, prior
trauma has been shown to increase the risk of PTSD. Ozer et al. (2003)
found a significant association between a history of prior trauma and PTSD
symptoms or diagnosis. Persons who experienced a traumatic event before
the target stressor reported higher levels of PTSD symptoms on the average
than persons who did not. Prior trauma was more strongly associated with
PTSD in connection with traumatic experiences of noncombat interpersonal
violence than with combat exposures (Ozer et al., 2003). However, more
recent data from prospective studies offer evidence against the hypothesis
that prior trauma alone increases the risk of PTSD. Using a random sample
from a large health maintenance organization in southeastern Michigan,
Breslau et al. (2008) found that prior experience of trauma does not neces-
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34 PTSD IN MILITARY AND VETERAN POPULATIONS
sarily increase the risk of PTSD in response to a subsequent trauma. Only
those persons who developed PTSD in response to a prior trauma had an
increased risk of PTSD after a later trauma. A follow-up study on assaultive
violence found that it was the development of prior PTSD after a trauma
that was predictive of the development of current PTSD after a later trauma
(Breslau and Peterson, 2010).
Trajectory of PTSD
The course of PTSD may remit with time, with steepest remission in
the first 12 months after diagnosis. In a nonrandomized, observational,
retrospective analysis based on the NCS, the median time until diagnostic
criteria were no longer met in those who received treatment was 36 months
compared with 64 months in those who did not receive treatment (Kessler
et al., 1995). However, approximately one-third of PTSD cases do not remit
even after many years of treatment. A prospective study of PTSD in rape
victims found that half recovered spontaneously, with the steepest declines
from the first to the fourth assessment (mean, 35 days after the assault),
whereas victims who had a diagnosis of PTSD 2 months or more after the
trauma (rape) were unlikely to recover without treatment (Rothbaum et al.,
1992). Other studies have shown remission of PTSD after particular trau-
matic events, such as disasters, in the first 6 months after exposure to the
event (Galea and Resnick, 2005). Although PTSD is triggered by the initial
exposure to a traumatic event, several studies have shown that exposure to
ongoing stressors and other traumatic events throughout life contributes
to the persistence of PTSD in the general population (Galea et al., 2008).
Few studies have investigated the chronicity of PTSD, most conducted
before some current therapies were available; therefore, they are rela-
tively dated. Two similarly designed prospective observational studies of
people who had diagnosed PTSD and who were seeking care in tertiary
care psychiatric practices (Zlotnick et al., 1999) or primary care practices
(Zlotnick et al., 2004) had similar findings. Over the 5-year follow-up of
the 54 persons in the tertiary care study, the probability of experiencing full
remission was 18%. Chronicity of PTSD was associated with a history of
alcohol abuse or dependence and childhood trauma (Zlotnick et al., 1999).
In the primary care study, the authors considered full and partial remission
separately. The findings were similar to those of the tertiary care study:
over the 2-year follow-up of the 84 primary care subjects, the probability
of full remission was 18% and the probability of partial remission 69%.
Both full remission and partial remission were associated with fewer co-
morbid anxiety disorders and a smaller degree of psychosocial impairment.
The authors also evaluated the type, dose, and duration of treatment. The
treatment was not randomized, but there was no association between the
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HISTORY, DIAGNOSTIC CRITERIA, AND EPIDEMIOLOGY
use of selective serotonin reuptake inhibitors or serotonin norepinephrine
reuptake inhibitors and PTSD status at any point during the follow-up
period (Zlotnick et al., 2004).
Men who reported combat as their worst trauma in the NCS were
more likely to have lifetime PTSD, delayed onset of PTSD symptoms, and
unresolved PTSD symptoms than men who named other types of trauma as
their worst (Prigerson et al., 2001). Veterans enrolled in the NVVRS who
had ever had full or partial PTSD reported they had experienced symptoms
63% of the time during the preceding 5 years (data collected between
1994–1996); 55% reported having symptoms every month, and 17% re-
ported having no symptoms. In the 3 months before assessment, 78% had
been symptomatic (Schnurr et al., 2003).
PTSD is associated with several adverse outcomes, including lower
quality of life, work-related impairment, and medical illness throughout
its course (Marshall et al., 2001; Resnick and Rosenheck, 2008; Zatzick
et al., 1997). Several studies have shown an adverse effect of PTSD on
physical health (Weiss et al., 2011), and others have found that exposure
to a traumatic event increases the risk of adverse physical health, includ-
ing many of the leading causes of premature death, such as cardiovascular
disease and stroke (Boscarino, 2008; Cohen et al., 2009, 2010; Dirkzwager
et al., 2007; Dong et al., 2004; Kubzansky et al., 2007, 2009). The asso-
ciations are thought to be mediated in part by health behaviors, such as
smoking, alcohol use, and physical inactivity (Breslau et al., 2003; Dobie
et al., 2004). Because it would be unethical to expose humans to major
trauma experimentally, randomized studies of the trajectory of PTSD are
not feasible. The only available studies of trajectory of PTSD are natural
history and observational studies, so the inference of findings to the general
populaton is limited, and this makes it difficult to project future care and
treatment needs.
Comorbidities of PTSD
People who have PTSD often have co-occurring psychologic disorders,
such as depressive disorders, substance dependence, panic disorder, agora-
phobia, generalized anxiety disorder, social phobia, bipolar disorder, and
somatization (APA, 2000). People who have diagnoses of more than one
mental health disorder have greater impairment than those who have a
single diagnosis (IOM, 2008b). Those additional disorders can precede or
present simultaneously with PTSD, and they may also resolve before, after,
or simultaneously with PTSD. A prospective study that used data from a
New Zealand birth cohort found that 96.3% of all adults who at the age
of 32 years had a diagnosis of PTSD in the preceding year and 93.5% of
those meeting criteria for lifetime diagnosis of PTSD at the age of 26 years
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48 PTSD IN MILITARY AND VETERAN POPULATIONS
physical health are unlikely to join the armed forces or to complete basic
training, and the same should be true of people who have poor mental
health. If such people are not medically discharged early in their military ca-
reers, they may be excluded from some deployments (Wilson et al., 2009).
Subthreshold PTSD
As discussed earlier in this chapter, DSM-IV lists 17 symptoms of
PTSD, at least 6 of which are required—in the correct distribution (one
re-experiencing, three numbing or avoidance, and two hyperarousal)—for
a diagnosis of PTSD. However, several studies have indicated that even sub-
threshold PTSD is impairing and that people who have it may benefit from
treatment (Grubaugh et al., 2005; Marshall et al., 2001; Stein et al., 1997;
Zlotnick et al., 2002). If the purpose of diagnosing PTSD and treating it
is to regain and maintain functioning, then it is clear that any symptoms
that are potentially attributable to prior trauma and are accompanied by
functional impairment warrant treatment. Subthreshold PTSD may also be
a signal of other pathologic conditions, such as depression or an additional
anxiety disorder, in that there is overlap in the defining symptoms of these
conditions. Subthreshold symptoms have potential implications for screen-
ing, level of functioning, degree of distress, and treatment. A full discussion
of the implications of subthreshold PTSD is beyond the scope of this report,
but it merits mention as a subject of further inquiry.
Compensation Issues and Secondary Gain
PTSD in military and veteran populations is complicated by concerns
about malingering and attempts to receive the diagnosis for secondary
gain. This issue has become particularly important in military populations
inasmuch as its presence is formally recognized as making someone eligible
for DoD and VA benefits. Thus, a diagnosis of PTSD is problematic in both
active-duty and veteran populations, and can lead to underreporting (for
example, to remain in one’s position) or to overreporting (for example, to
gain benefits or to be excused from duty). A previous Institute of Medicine
report on PTSD compensation and military service (IOM, 2007) noted that,
apart from problems with the current procedures for assigning a disability
rating to PTSD, other considerations include “barriers or disincentives to
recovery, the effect of disability compensation on recovery, and the advis-
ability of periodic re-examination of PTSD compensation beneficiaries.”
Although that committee found that compensation does not appear to serve
as a disincentive to seeking treatment, periodic re-examinations for veterans
who have a PTSD service-connected disability were regarded as inappropri-
ate because research on misreporting and exaggeration of symptoms had
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49
HISTORY, DIAGNOSTIC CRITERIA, AND EPIDEMIOLOGY
not found evidence supporting a singling out of PTSD (IOM, 2007). This
is an important and complicated issue, and the present committee will re-
consider it if any new literature becomes available during phase 2.
SUMMARY
PTSD is prevalent in the general population in which it has a lifetime
prevalence of about 8% in adults, but military and veteran populations
are exposed to many more traumatic events than the general population,
and service members who have served in OEF and OIF have a lifetime
PTSD prevalence of 13% to 20%. Many factors increase a service mem-
ber’s risk of PTSD, some demographic—such as age; sex; prior exposure
to trauma, particularly sexual assault and childhood maltreatment; lower
education attainment; and lower IQ—and some combat-specific—such as
killing someone, seeing someone killed, and being in an explosion or being
badly injured. PTSD is often comorbid with other psychologic or medical
conditions, such as depression, substance use (particularly alcohol use)
disorder, and traumatic brain injury. Special considerations in the diagno-
sis of and treatment for PTSD in military and veteran populations include
subthreshold PTSD, underreporting and overreporting of PTSD symptoms,
the role of stigma in seeking care for PTSD, the healthy warrior effect, and
compensation. The next chapter provides a discussion of the biologic basis
of and factors that affect the development of PTSD.
REFERENCES
APA (American Psychiatric Association). 1980. DSM-III: Diagnostic and statistical manual of
mental disorders. 3rd ed. Washington, DC: American Psychiatric Association.
APA. 2000. Diagnostic and statistical manual of mental disorders, fourth edition, text revision
(DSM-IV-TR). Washington, DC: American Psychiatric Association.
Arrighi, H. M., and I. Hertzpicciotto. 1994. The evolving concept of the healthy worker sur-
vivor effect. Epidemiology 5(2):189-196.
Barnett, J. H., C. H. Salmond, P. B. Jones, and B. J. Sahakian. 2006. Cognitive reserve in
neuropsychiatry. Psychological Medicine 36(8):1053-1064.
Basile, K. C., I. Arias, S. Desai, and M. P. Thompson. 2004. The differential association of
intimate partner physical, sexual, psychological, and stalking violence and posttraumatic
stress symptoms in a nationally representative sample of women. Journal of Traumatic
Stress 17(5):413-421.
Batty, G. D., E. L. Mortensen, and M. Osler. 2005. Childhood IQ in relation to later psychi-
atric disorder: Evidence from a Danish birth cohort study. British Journal of Psychiatry
187:180-181.
Birmes, P., L. Hatton, A. Brunet, and L. Schmitt. 2003. Early historical literature for post-
traumatic symptomatology. Stress and Health 19(1):17-26.
Boscarino, J. A. 2008. A prospective study of PTSD and early-age heart disease mortality
among Vietnam veterans: Implications for surveillance and prevention. Psychosomatic
Medicine 70(6):668-676.
OCR for page 50
50 PTSD IN MILITARY AND VETERAN POPULATIONS
Breslau, N., and E. L. Peterson. 2010. Assaultive violence and the risk of posttraumatic
stress disorder following a subsequent trauma. Behaviour Research and Therapy 48(10):
1063-1066.
Breslau, N., G. C. Davis, P. Andreski, and E. Peterson. 1991. Traumatic events and post-
traumatic stress disorder in an urban population of young adults. Archives of General
Psychiatry 48(3):216-222.
Breslau, N., G. C. Davis, and P. Andreski. 1995. Risk factors for PTSD-related traumatic
events: A prospective analysis. American Journal of Psychiatry 152(4):529-535.
Breslau, N., R. C. Kessler, H. D. Chilcoat, L. R. Schultz, G. C. Davis, and P. Andreski. 1998.
Trauma and posttraumatic stress disorder in the community—the 1996 Detroit area
survey of trauma. Archives of General Psychiatry 55(7):626-632.
Breslau, N., G. C. Davis, and L. R. Schultz. 2003. Posttraumatic stress disorder and the in-
cidence of nicotine, alcohol, and other drug disorders in persons who have experienced
trauma. Archives of General Psychiatry 60(3):289-294.
Breslau, N., S. P. Novak, and R. C. Kessler. 2004. Daily smoking and the subsequent onset of
psychiatric disorders. Psychological Medicine 34(2):323-333.
Breslau, N., V. C. Lucia, and G. F. Alvarado. 2006. Intelligence and other predisposing factors
in exposure to trauma and posttraumatic stress disorder: A follow-up study at age 17
years. Archives of General Psychiatry 63(11):1238-1245.
Breslau, N., E. L. Peterson, and L. R. Schultz. 2008. A second look at prior trauma and the
posttraumatic stress disorder effects of subsequent trauma. Archives of General Psychia-
try 65(4):431-437.
Brewin, C. R., B. Andrews, and S. Rose. 2000a. Fear, helplessness, and horror in posttraumatic
stress disorder: Investigating DSM-IV criterion A2 in victims of violent crime. Journal of
Traumatic Stress 13(3):499-509.
Brewin, C. R., B. Andrews, and J. D. Valentine. 2000b. Meta-analysis of risk factors for post-
traumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical
Psychology 68(5):748-766.
Bromet, E., A. Sonnega, and R. C. Kessler. 1998. Risk factors for DSM-III-R posttraumatic
stress disorder: Findings from the national comorbidity survey. American Journal of
Epidemiology 147(4):353-361.
Brown, P. J., and J. Wolfe. 1994. Substance abuse and post-traumatic stress disorder comorbid-
ity. Drug & Alcohol Dependence 35(1):51-59.
Carter-Visscher, R., M. A. Polusny, M. Murdoch, P. Thuras, C. R. Erbes, and S. M. Kehle.
2010. Predeployment gender differences in stressors and mental health among U.S.
National Guard troops poised for Operation Iraqi Freedom deployment. Journal of
Traumatic Stress 23(1):78-85.
Chantarujikapong, S. I., J. F. Scherrer, H. Xian, S. A. Eisen, M. J. Lyons, J. Goldberg, M.
Tsuang, and W. R. True. 2001. A twin study of generalized anxiety disorder symptoms,
panic disorder symptoms and post-traumatic stress disorder in men. Psychiatry Research
103:133-145.
Chilcoat, H. D., and N. Breslau. 1998. Investigations of causal pathways between PTSD and
drug use disorders. Addictive Behaviors 23(6):827-840.
Cohen, B. E., C. Marmar, L. Ren, D. Bertenthal, and K. H. Seal. 2009. Association of cardio-
vascular risk factors with mental health diagnoses in Iraq and Afghanistan war veterans
using VA health care. Journal of the American Medical Association 302(5):489-492.
Cohen, B. E., P. Panguluri, B. Na, and M. A. Whooley. 2010. Psychological risk factors and
the metabolic syndrome in patients with coronary heart disease: Findings from the heart
and soul study. Psychiatry Research 175(1-2):133-137.
OCR for page 51
51
HISTORY, DIAGNOSTIC CRITERIA, AND EPIDEMIOLOGY
Coyle, B. S., D. L. Wolan, and A. S. Van Horn. 1996. The prevalence of physical and sexual
abuse in women veterans seeking care at a Veterans Affairs medical center. Military
Medicine 161(10):588-593.
De Bellis, M. D. 2001. Developmental traumatology: The psychobiological development of
maltreated children and its implications for research, treatment, and policy. Development
and Psychopathology 13:539-564.
Desai, S., I. Arias, M. P. Thompson, and K. C. Basile. 2002. Childhood victimization and
subsequent adult revictimization assessed in a nationally representative sample of women
and men. Violence & Victims 17(6):639-653.
Dirkzwager, A. J., P. G. van der Velden, L. Grievink, and C. J. Yzermans. 2007. Disaster-
related posttraumatic stress disorder and physical health. Psychosomatic Medicine
69(5):435-440.
Dobie, D. J., D. R. Kivlahan, C. Maynard, K. R. Bush, T. M. Davis, and K. A. Bradley. 2004.
Posttraumatic stress disorder in female veterans: Association with self-reported health
problems and functional impairment. Archives of Internal Medicine 164(4):394-400.
DoD (Department of Defense). 2008. Active duty demographic profile: Assigned strength,
gender, race, marital, education and age profile of active duty force. Defense Manpower
Data Center.
DoD. 2010. Demographics 2010: Profile of the military community. Washington, DC: Office
of the Deputy Under Secretary of Defense.
Dohrenwend, B. P., J. B. Turner, N. A. Turse, B. G. Adams, K. C. Koenen, and R. Marshall.
2006. The psychological risks of Vietnam for U.S. veterans: A revisit with new data and
methods. Science 313(5789):979-982.
Dohrenwend, B. P., J. B. Turner, N. A. Turse, R. Lewis-Fernandez, and T. J. Yager. 2008.
War-related posttraumatic stress disorder in black, Hispanic, and majority white Viet-
nam veterans: The roles of exposure and vulnerability. Journal of Traumatic Stress
21(2):133-141.
Dong, M., W. H. Giles, V. J. Felitti, S. R. Dube, J. E. Williams, D. P. Chapman, and R. F.
Anda. 2004. Insights into causal pathways for ischemic heart disease: Adverse childhood
experiences study. Circulation 110(13):1761-1766.
Farberow, N. L., H. K. Kang, and T. A. Bullman. 1990. Combat experience and postservice
psychosocial status as predictors of suicide in Vietnam veterans. Journal of Nervous &
Mental Disease 178(1):32-37.
Fontana, A., and R. Rosenheck. 1995. Attempted suicide among Vietnam veterans: A model
of etiology in a community sample. American Journal of Psychiatry 152(1):102-109.
Frayne, S. M., K. M. Skinner, L. M. Sullivan, T. J. Tripp, C. S. Hankin, N. R. Kressin, and
D. R. Miller. 1999. Medical profile of women Veterans Administration outpatients who
report a history of sexual assault occurring while in the military. Journal of Women’s
Health & Gender-Based Medicine 8(6):835-845.
Friedman, M., P. A. Resick, R. A. Bryant, and C. R. Brewin. 2010. Considering PTSD for
DSM-5. Depression and Anxiety 1(20).
Fu, Q., K. C. Koenen, M. W. Miller, A. C. Heath, K. K. Bucholz, M. J. Lyons, S. A. Eisen,
W. R. True, J. Goldberg, and M. T. Tsuang. 2007. Differential etiology of posttraumatic
stress disorder with conduct disorder and major depression in male veterans. Biological
Psychiatry 62(10):1088-1094.
Gale, C. R., I. J. Deary, S. H. Boyle, J. Barefoot, L. H. Mortensen, and G. D. Batty. 2008.
Cognitive ability in early adulthood and risk of 5 specific psychiatric disorders in middle
age: The Vietnam experience study. Archives of General Psychiatry 65(12):1410-1418.
Galea, S., and H. Resnick. 2005. Posttraumatic stress disorder in the general population after
mass terrorist incidents: Considerations about the nature of exposure. CNS Spectrums
10(2):107-115.
OCR for page 52
52 PTSD IN MILITARY AND VETERAN POPULATIONS
Galea, S., D. Vlahov, H. Resnick, J. Ahern, E. Susser, J. Gold, M. Bucuvalas, and D. Kilpatrick.
2003. Trends of probable post-traumatic stress disorder in New York City after the Sep-
tember 11 terrorist attacks. American Journal of Epidemiology 158(6):514-524.
Galea, S., D. Vlahov, M. Tracy, D. R. Hoover, H. Resnick, and D. Kilpatrick. 2004. Hispanic
ethnicity and post-traumatic stress disorder after a disaster: Evidence from a general
population survey after September 11, 2001. Annals of Epidemiology 14(8):520-531.
Galea, S., J. Ahern, M. Tracy, A. Hubbard, M. Cerda, E. Goldmann, and D. Vlahov. 2008.
Longitudinal determinants of posttraumatic stress in a population-based cohort study.
Epidemiology 19(1):47-54.
Gregory, A. M., A. Caspi, T. E. Moffitt, K. Koenen, T. C. Eley, and R. Poulton. 2007. Juvenile
mental health histories of adults with anxiety disorders. American Journal of Psychiatry
164(2):301-308.
Grubaugh, A. L., K. M. Magruder, A. E. Waldrop, J. D. Elhai, R. G. Knapp, and B. C. Frueh.
2005. Subthreshold PTSD in primary care: Prevalence, psychiatric disorders, healthcare
use, and functional status. Journal of Nervous & Mental Disease 193(10):658-664.
Harrison, C. A., and S. A. Kinner. 1998. Correlates of psychological distress following armed
robbery. Journal of Traumatic Stress 11(4):787-798.
Harvard Medical School. 2007a. 12-month prevalence of DSM-IV/WMH-CIDI disorders
by sex and cohort (n=9282). http://www.hcp.med.harvard.edu/ncs/ftpdir/NCS-R_12-
month_Prevalence_Estimates.pdf (accessed January 10, 2011).
Harvard Medical School. 2007b. Lifetime prevalence DSM-IV/WMH-CIDI disorders by
sex and cohort (n=9282). http://www.hcp.med.harvard.edu/ncs/ftpdir/NCS-R_Lifetime_
Prevalence_Estimates.pdf (accessed January 10, 2011).
Helmus, T. C., and R. W. Glenn. 2004. Steeling the mind: Combat stress reactions and their
implications for urban warfare. Santa Monica, CA: RAND Corporation.
Hendin, H., and A. P. Haas. 1991. Suicide and guilt as manifestations of PTSD in Vietnam
combat veterans. American Journal of Psychiatry 148(5):586-591.
Himmelfarb, N., D. Yaeger, and J. Mintz. 2006. Posttraumatic stress disorder in female veter-
ans with military and civilian sexual trauma. Journal of Traumatic Stress 19(6):837-846.
Hoge, C. W., C. A. Castro, S. C. Messer, D. McGurk, D. I. Cotting, and R. L. Koffman. 2004.
Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New
England Journal of Medicine 351(1):13-22.
Holbrook, T. L., D. B. Hoyt, M. B. Stein, and W. J. Sieber. 2001. Perceived threat to life
predicts posttraumatic stress disorder after major trauma: Risk factors and functional
outcome. Journal of Trauma-Injury Infection & Critical Care 51(2):287-292; discussion
292-283.
Howden, L. M., and J. A. Meyer. 2011. Age and sex composition: 2010. Washington, DC:
U.S. Department of Commerce.
IOM (Institute of Medicine). 2007. PTSD compensation and military service. Washington,
DC: The National Academies Press.
IOM. 2008a. Gulf War and health: Physiologic, psychologic, and psychosocial effects of
deployment-related stress. Washington, DC: The National Academies Press.
IOM. 2008b. Treatment of posttraumatic stress disorder: An assessment of the evidence.
Washington, DC: The National Academies Press.
IOM. 2010. Gulf War and health: Update of health effects of serving in the Gulf War. Wash-
ington, DC: The National Academies Press.
Jakupcak, M., J. Cook, Z. Imel, A. Fontana, R. Rosenheck, and M. McFall. 2009. Posttrau-
matic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan war
veterans. Journal of Traumatic Stress 22(4):303-306.
Jeavons, S., K. M. Greenwood, and D. J. Horne. 2000. Accident cognitions and subsequent
psychological trauma. Journal of Traumatic Stress 13(2):359-365.
OCR for page 53
53
HISTORY, DIAGNOSTIC CRITERIA, AND EPIDEMIOLOGY
Jones, E. 2006. Historical approaches to post-combat disorders. Philosophical Transactions
of the Royal Society B: Biological Sciences 361(1468):533-542.
Kang, H. K., B. H. Natelson, C. M. Mahan, K. Y. Lee, and F. M. Murphy. 2003. Post-
traumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War
veterans: A population-based survey of 30,000 veterans. American Journal of Epidemiol-
ogy 157(2):141-148.
Kessler, R. C., A. Sonnega, E. Bromet, M. Hughes, and C. B. Nelson. 1995. Posttrau-
matic stress disorder in the national comorbidity survey. Archives of General Psychiatry
52(12):1048-1060.
Kessler, R. C., P. Berglund, O. Demler, R. Jin, K. R. Merikangas, and E. E. Walters. 2005.
Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national
comorbidity survey replication. Archives of General Psychiatry 62(6):593-602.
Khantzian, E. J. 1985. The self-medication hypothesis of addictive disorders: Focus on heroin
and cocaine dependence. American Journal of Psychiatry 142(11):1259-1264.
Kim, P. Y., J. L. Thomas, J. E. Wilk, C. A. Castro, and C. W. Hoge. 2010. Stigma, barriers to
care, and use of mental health services among active duty and National Guard soldiers
after combat. Psychiatric Services 61:572-588.
Kimerling, R., A. E. Street, J. Pavao, M. W. Smith, R. C. Cronkite, T. H. Holmes, and
S. M. Frayne. 2010. Military-related sexual trauma among Veterans Health Administra-
tion patients returning from Afghanistan and Iraq. American Journal of Public Health
100(8):1409-1412.
Koenen, K. C., R. Harley, M. J. Lyons, J. Wolfe, J. C. Simpson, J. Goldberg, S. A. Eisen, and
M. Tsuang. 2002. A twin registry study of familial and individual risk factors for trauma
exposure and posttraumatic stress disorder. Journal of Nervous and Mental Disease
190(4):209-218.
Koenen, K. C., Q. J. Fu, M. J. Lyons, R. Toomey, J. Goldberg, S. A. Eisen, W. True, and M.
Tsuang. 2005a. Juvenile conduct disorder as a risk factor for trauma exposure and post-
traumatic stress disorder. Journal of Traumatic Stress 18(1):23-32.
Koenen, K. C., B. Hitsman, M. J. Lyons, R. Niaura, J. McCaffery, J. Goldberg, S. A. Eisen,
W. True, and M. Tsuang. 2005b. A twin registry study of the relationship between post-
traumatic stress disorder and nicotine dependence in men. Archives of General Psychiatry
62(11):1258-1265.
Koenen, K. C., B. Hitsman, M. J. Lyons, L. Stroud, R. Niaura, J. McCaffery, J. Goldberg,
S. A. Eisen, W. True, and M. Tsuang. 2006. Posttraumatic stress disorder and late-onset
smoking in the Vietnam Era Twin Registry. Journal of Consulting & Clinical Psychology
74(1):186-190.
Koenen, K. C., T. E. Moffitt, R. Poulton, J. Martin, and A. Caspi. 2007. Early childhood fac-
tors associated with the development of post-traumatic stress disorder: Results from a
longitudinal birth cohort. Psychological Medicine 37(2):181-192.
Koenen, K. C., Q. J. Fu, K. Ertel, M. J. Lyons, S. A. Eisen, W. R. True, J. Goldberg, and M. T.
Tsuang. 2008a. Common genetic liability to major depression and posttraumatic stress
disorder in men. Journal of Affective Disorders 105(1-3):109-115.
Koenen, K. C., T. E. Moffitt, A. Caspi, A. Gregory, H. Harrington, and R. Poulton. 2008b.
The developmental mental-disorder histories of adults with posttraumatic stress disor-
der: A prospective longitudinal birth cohort study. Journal of Abnormal Psychology
117(2):460-466.
Kramer, T. L., J. D. Lindy, B. L. Green, M. C. Grace, and A. C. Leonard. 1994. The comor-
bidity of posttraumatic-stress-disorder and suicidality in Vietnam veterans. Suicide and
Life-Threatening Behavior 24(1):58-67.
OCR for page 54
54 PTSD IN MILITARY AND VETERAN POPULATIONS
Kremen, W. S., K. C. Koenen, C. Boake, S. Purcell, S. A. Eisen, C. E. Franz, M. T. Tsuang, and
M. J. Lyons. 2007. Pretrauma cognitive ability and risk for posttraumatic stress disorder:
A twin study. Archives of General Psychiatry 64(3):361-368.
Kubzansky, L. D., K. C. Koenen, A. Spiro, 3rd, P. S. Vokonas, and D. Sparrow. 2007. Prospec -
tive study of posttraumatic stress disorder symptoms and coronary heart disease in the
normative aging study. Archives of General Psychiatry 64(1):109-116.
Kubzansky, L. D., K. C. Koenen, C. Jones, and W. W. Eaton. 2009. A prospective study of
posttraumatic stress disorder symptoms and coronary heart disease in women. Health
Psychology 28(1):125-130.
Kulka, R. A. 1990. Trauma and the Vietnam War generation: Report of findings from the
National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel.
Lasser, K., J. W. Boyd, S. Woolhandler, D. U. Himmelstein, D. McCormick, and D. H. Bor.
2000. Smoking and mental illness: A population-based prevalence study. Journal of the
American Medical Association 284(20):2606-2610.
Lewis-Fernandez, R., J. B. Turner, R. Marshall, N. Turse, Y. Neria, and B. P. Dohrenwend.
2008. Elevated rates of current PTSD among Hispanic veterans in the NVVRS: True
prevalence or methodological artifact? Journal of Traumatic Stress 21(2):123-132.
Lewis-Fernandez, R., D. E. Hinton, A. J. Laria, E. H. Patterson, S. G. Hofmann, M. G. Craske,
D. J. Stein, A. Asnaani, and B. Liao. 2010. Culture and the anxiety disorders: Recom-
mendations for DSM-V. Depression & Anxiety 27(2):212-229.
MacGregor, A. J., R. A. Shaffer, A. L. Dougherty, M. R. Galarneau, R. Raman, D. G.
Baker, S. P. Lindsay, B. A. Golomb, and K. S. Corson. 2009. Psychological correlates of
battle and nonbattle injury among Operation Iraqi Freedom veterans. Military Medicine
174(3):224-231.
MacGregor, A. J., P. P. Han, A. L. Dougherty, and M. R. Galarneau. 2012. Effect of dwell time
on the mental health of U.S. military personnel with multiple combat tours. American
Journal of Public Health 102(Suppl 1):S55-S59.
Macklin, M. L., L. J. Metzger, B. T. Litz, R. J. McNally, N. B. Lasko, S. P. Orr, and R. K.
Pitman. 1998. Lower precombat intelligence is a risk factor for posttraumatic stress
disorder. Journal of Consulting and Clinical Psychology 66(2):323-326.
Maguen, S., L. Ren, J. O. Bosch, C. R. Marmar, and K. H. Seal. 2010. Gender differences in
mental health diagnoses among Iraq and Afghanistan veterans enrolled in Veterans Af-
fairs health care. American Journal of Public Health 100(12):2450-2456.
Marshall, G. N., T. L. Schell, and J. N. Miles. 2009. Ethnic differences in posttraumatic dis-
tress: Hispanics’ symptoms differ in kind and degree. Journal of Consulting and Clinical
Psychology 77(6):1169-1178.
Marshall, R. D., M. Olfson, F. Hellman, C. Blanco, M. Guardino, and E. L. Struening. 2001.
Comorbidity, impairment, and suicidality in subthreshold PTSD. American Journal of
Psychiatry 158(9):1467-1473.
McDevitt-Murphy, M. E., J. L. Williams, K. L. Bracken, J. A. Fields, C. J. Monahan, and J. G.
Murphy. 2010. PTSD symptoms, hazardous drinking, and health functioning among
U.S. OEF and OIF veterans presenting to primary care. Journal of Traumatic Stress
23(1):108-111.
MHAT VII (Mental Health Advisory Team VII). 2011. Joint mental health advisory team 7
(J-MHAT 7) Operation Enduring Freedom 2010. Washington, DC: Office of the Surgeon
General, United States Army Medical Command, Office of the Command Surgeon HQ,
USCENTCOM, Office of the Command Surgeon U.S. Forces Afghanistan.
Nash, W. P., C. Silva, and B. Litz. 2009. The historic origins of military and veteran mental
health stigma and the stress injury model as a means to reduce it. Psychiatric Annals
39(8):789-794.
OCR for page 55
55
HISTORY, DIAGNOSTIC CRITERIA, AND EPIDEMIOLOGY
Neria, Y., R. Gross, B. Litz, S. Maguen, B. Insel, G. Seirmarco, H. Rosenfeld, E. J. Suh, R.
Kishon, J. Cook, and R. D. Marshall. 2007. Prevalence and psychological correlates of
complicated grief among bereaved adults 2.5-3.5 years after September 11th attacks.
Journal of Traumatic Stress 20(3):251-262.
Norris, F. H. 1992. Epidemiology of trauma: Frequency and impact of different potentially
traumatic events on different demographic groups. Journal of Consulting & Clinical
Psychology 60(3):409-418.
Ozer, E. J., S. R. Best, T. L. Lipsey, and D. S. Weiss. 2003. Predictors of posttraumatic stress
disorder and symptoms in adults: A meta-analysis. Psychological Bulletin 129(1):52-73.
Panasetis, P., and R. A. Bryant. 2003. Peritraumatic versus persistent dissociation in acute
stress disorder. Journal of Traumatic Stress 16(6):563-566.
Pitman, R. K., S. P. Orr, M. J. Lowenhagen, M. L. Macklin, and B. Altman. 1991. Pre-Vietnam
contents of posttraumatic stress disorder veterans’ service medical and personnel records.
Comprehensive Psychiatry 32(5):416-422.
Prigerson, H. G., P. K. Maciejewski, and R. A. Rosenheck. 2001. Combat trauma: Trauma
with highest risk of delayed onset and unresolved posttraumatic stress disorder symp-
toms, unemployment, and abuse among men. Journal of Nervous and Mental Disease
189(2):99-108.
Punamaki, R. L., S. R. Qouta, and E. El Sarraj. 2010. Nature of torture, PTSD, and somatic
symptoms among political ex-prisoners. Journal of Traumatic Stress 23(4):532-536.
Resnick, S. G., and R. A. Rosenheck. 2008. Posttraumatic stress disorder and employment
in veterans participating in Veterans Health Administration compensated work therapy.
Journal of Rehabilitation Research & Development 45(3):427-435.
Roberts, A. L., S. B. Austin, H. L. Corliss, A. K. Vandermorris, and K. C. Koenen. 2010.
Pervasive trauma exposure among U.S. sexual orientation minority adults and risk of
posttraumatic stress disorder. American Journal of Public Health 100(12):2433-2441.
Roberts, A. L., S. E. Gilman, J. Breslau, N. Breslau, and K. C. Koenen. 2011. Race/ethnic dif-
ferences in exposure to traumatic events, development of post-traumatic stress disorder,
and treatment-seeking for post-traumatic stress disorder in the United States. Psychologi-
cal Medicine 41(1):71-83.
Rothbaum, B., E. B. Foa, D. S. Riggs, T. Murdock, and W. Walsh. 1992. A prospective ex-
amination of post-traumatic stress disorder in rape victims. Journal of Traumatic Stress
5(3):455-475.
Sadler, A. G., B. M. Booth, D. Nielson, and B. N. Doebbeling. 2000. Health-related conse-
quences of physical and sexual violence: Women in the military. Obstetrics and Gynecol-
ogy 96(3):473-480.
Sagalyn, D. 2011. Army general calls for changing name of PTSD. http://www.pbs.org/news
hour/updates/ military/july-dec11/stress_11-04.html (accessed January 30, 2012).
Santiago, P. N., J. E. Wilk, C. S. Milliken, C. A. Castro, C. E. Engel, and C. Hoge. 2010.
Screening for alcohol misuse and alcohol-related behaviors among combat veterans.
Psychiatric Services 61(6):575-581.
Sartor, C. E., V. V. McCutcheon, N. E. Pommer, E. C. Nelson, J. D. Grant, A. E. Duncan, M.
Waldron, K. K. Bucholz, P. A. F. Madden, and A. C. Heath. 2011. Common genetic and
environmental contributions to post-traumatic stress disorder and alcohol dependence in
young women. Psychological Medicine 41(7):1497-1505.
Schnurr, P. P., C. A. Lunney, A. Sengupta, and L. C. Waelde. 2003. A descriptive analysis of
PTSD chronicity in Vietnam veterans. Journal of Traumatic Stress 16(6):545-553.
Seal, K. H., D. Bertenthal, C. R. Miner, S. Sen, and C. Marmar. 2007. Bringing the war back
home: Mental health disorders among 103,788 U.S. veterans returning from Iraq and
Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medi-
cine 167(5):476-482.
OCR for page 56
56 PTSD IN MILITARY AND VETERAN POPULATIONS
Seedat, S., D. J. Stein, and P. D. Carey. 2005. Post-traumatic stress disorder in women: Epide-
miological and treatment issues. CNS Drugs 19(5):411-427.
Shephard, B. 2000. War, medicine and modernity. Medical History 44(2):287-287.
Skinner, K. M., N. Kressin, S. Frayne, T. J. Tripp, C. S. Hankin, D. R. Miller, and L. M.
Sullivan. 2000. The prevalence of military sexual assault among female Veterans Admin-
istration outpatients. Journal of Interpersonal Violence 15(3):291-310.
Smith, T. C., M. A. Ryan, D. L. Wingard, D. J. Slymen, J. F. Sallis, D. Kritz-Silverstein, and The
Millennium Cohort Study. 2008. New onset and persistent symptoms of post-traumatic
stress disorder self-reported after deployment and combat exposures: Prospective popula-
tion based U.S. military cohort study. British Medical Journal 336(7640):366-371.
Stecker, T., J. Fortney, R. Owen, M. P. McGovern, and S. Williams. 2010. Co-occurring medi-
cal, psychiatric, and alcohol-related disorders among veterans returning from Iraq and
Afghanistan. Psychosomatics 51(6):503-507.
Stein, M. B., J. R. Walker, A. L. Hazen, and D. R. Forde. 1997. Full and partial posttraumatic
stress disorder: Findings from a community survey. American Journal of Psychiatry
154(8):1114-1119.
Stewart, S. H. 1996. Alcohol abuse in individuals exposed to trauma: A critical review. Psy-
chological Bulletin 120(1):83-112.
Storr, C. L., N. S. Ialongo, J. C. Anthony, and N. Breslau. 2007. Childhood antecedents of
exposure to traumatic events and posttraumatic stress disorder. American Journal of
Psychiatry 164(1):119-125.
Suris, A., and L. Lind. 2008. Military sexual trauma—a review of prevalence and associated
health consequences in veterans. Trauma Violence & Abuse 9(4):250-269.
Suris, A., L. Lind, T. M. Kashner, P. D. Borman, and F. Petty. 2004. Sexual assault in women
veterans: An examination of PTSD risk, health care utilization, and cost of care. Psycho-
somatic Medicine 66(5):749-756.
Tanielian, T. L., and L. Jaycox. 2008. Invisible wounds of war: Psychological and cogni-
tive injuries, their consequences, and services to assist recovery. Arlington, VA: RAND
Corporation.
Tarrier, N., and L. Gregg. 2004. Suicide risk in civilian PTSD patients—predictors of sui-
cidal ideation, planning and attempts. Social Psychiatry & Psychiatric Epidemiology
39(8):655-661.
Thomas, J. L., J. E. Wilk, L. A. Riviere, D. McGurk, C. A. Castro, C. W. Hoge. 2010. Preva-
lence of mental health problems and functional impairment among active component and
National Guard soldiers 3 and 12 months following combat in Iraq. Archives of General
Psychiatry 67(6):614-623.
Tolin, D. F., and E. B. Foa. 2006. Sex differences in trauma and posttraumatic stress disorder:
A quantitative review of 25 years of research. Psychological Bulletin 132(6):959-992.
Toomey, R., H. K. Kang, J. Karlinsky, D. G. Baker, J. J. Vasterling, R. Alpern, D. J. Reda,
W. G. Henderson, F. M. Murphy, and S. A. Eisen. 2007. Mental health of U.S. Gulf War
veterans 10 years after the war. British Journal of Psychiatry 190:385-393.
True, W. R., J. Rice, S. A. Eisen, A. C. Heath, J. Goldberg, M. J. Lyons, and J. Nowak. 1993.
A twin study of genetic and environmental contributions to liability for posttraumatic
stress symptoms. Archives of General Psychiatry 50(4):257-264.
VA (Department of Veterans Affairs). 2012. Military sexual trauma. http://www.ptsd.va.gov/
public/pages/military-sexual-trauma-general.asp (accessed January 30, 2012).
VA and DoD. 2010. VA/DoD clinical practice guideline for management of post-traumatic
stress. Washington, DC: VA and DoD.
OCR for page 57
57
HISTORY, DIAGNOSTIC CRITERIA, AND EPIDEMIOLOGY
Vasterling, J. J., S. P. Proctor, M. J. Friedman, C. W. Hoge, T. Heeren, L. A. King, and D. W.
King. 2010. PTSD symptom increases in Iraq-deployed soldiers: Comparison with non-
deployed soldiers and associations with baseline symptoms, deployment experiences, and
postdeployment stress. Journal of Traumatic Stress 23(1):41-51.
Vogt, D., R. Vaughn, M. E. Glickman, M. Schultz, M. Drainoni, R. Elwy, and S. Eisen. 2011.
Gender differences in combat-related stressors and their association with postdeployment
mental health in a nationally representative sample of U.S. OEF/OIF veterans. Journal of
Abnormal Psychology 120(4):797-806.
Walker, N., P. McConville, D. Hunter, I. Deary, and L. Whalley. 2002. Childhood mental
ability and lifetime psychiatric contact: A 66-year follow-up study of the 1932 Scottish
Mental Ability Survey. Intelligence 30:233-245.
Warner, C. H., G. N. Appenzeller, T. A. Grieger, S. Belenkly, J. Breitback, J. Parker, C. M.
Warner, and C. W. Hoge. 2011. Importance of anonymity to encourage honest report-
ing in mental health screening after combat deployment. Archive of General Psychiatry
68:1065-1071.
Weiss, T., K. Skelton, J. Phifer, T. Jovanovic, C. F. Gillespie, A. Smith, G. Umpierrez, B.
Bradley, and K. J. Ressler. 2011. Posttraumatic stress disorder is a risk factor for meta-
bolic syndrome in an impoverished urban population. General Hospital Psychiatry
33(2):135-142.
Welke, B. Y. 2001. Recasting American liberty: Gender, race, law, and the railroad revolution,
1865-1920. Cambridge, UK: Cambridge University Press.
Wieland, D., M. Hursey, and D. Delgado. 2010. Operation Enduring Freedom (OEF) and
Operation Iraqi Freedom (OIF) military mental health issues. Information on the wars’
signature wounds: Posttraumatic stress disorder and traumatic brain injury. Pennsylvania
Nurse 65(3):4-11.
Wilson, J., M. Jones, N. T. Fear, L. Hull, M. Hotopf, S. Wessely, and R. J. Rona. 2009. Is
previous psychological health associated with the likelihood of Iraq war deployment?
An investigation of the “healthy warrior effect.” American Journal of Epidemiology
169(11):1362-1369.
Wolf, E. J., M. W. Miller, R. F. Krueger, M. J. Lyons, M. T. Tsuang, and K. C. Koenen. 2010.
Posttraumatic stress disorder and the genetic structure of comorbidity. Journal of Abnor-
mal Psychology 119(2):320-330.
Xian, H., S. I. Chantarujikapong, J. F. Shrerrer, S. A. Eisen, M. J. Lyons, J. Goldberg, M.
Tsuang, and W. True. 2000. Genetic and environmental influences on posttraumatic stress
disorder, alcohol, and drug dependence in twin pairs. Drug and Alcohol Dependence
61:95-102.
Yaeger, D., N. Himmelfarb, A. Cammack, and J. Mintz. 2006. DSM-IV diagnosed post-
traumatic stress disorder in women veterans with and without military sexual trauma.
Journal of General Internal Medicine 21:S65-S69.
Zatzick, D. F., C. R. Marmar, D. S. Weiss, W. S. Browner, T. J. Metzler, J. M. Golding, A.
Stewart, W. E. Schlenger, and K. B. Wells. 1997. Posttraumatic stress disorder and
functioning and quality of life outcomes in a nationally representative sample of male
Vietnam veterans. American Journal of Psychiatry 154(12):1690-1695.
Zlotnick, C., M. Warshaw, M. T. Shea, J. Allsworth, T. Pearlstein, and M. B. Keller. 1999.
Chronicity in posttraumatic stress disorder (PTSD) and predictors of course of comorbid
PTSD in patients with anxiety disorders. Journal of Traumatic Stress 12(1):89-100.
Zlotnick, C., C. L. Franklin, and M. Zimmerman. 2002. Does “subthreshold” posttraumatic
stress disorder have any clinical relevance? Comprehensive Psychiatry 43(6):413-419.
Zlotnick, C., B. F. Rodriguez, R. B. Weisberg, S. E. Bruce, M. A. Spencer, L. Culpepper, and
M. B. Keller. 2004. Chronicity in posttraumatic stress disorder and predictors of the
course of posttraumatic stress disorder among primary care patients. Journal of Nervous
and Mental Disease 192(2):153-159.
OCR for page 58
