Center for the Study of Traumatic Stress2008 Annual Report

The Center for the Study of Traumatic Stress has uniquely bridged
the fields of disaster and military psychiatry. Our work integrates
principles of disaster preparedness, response and recovery to foster
individual, community, organizational and public health.

Acknowledgements
The Center for the Study of Traumatic Stress (CSTS)
would like to acknowledge and thank each of theseorganizations for their continued support, guidance,and leadership throughout the past year.
■■ Uniformed Services University of the Health Sciences■■ Defense Centers of Excellence for Psychological
Health and Traumatic Brain Injury■■ The Henry M. Jackson Foundation for the
Advancement of Military Medicine■■ The National Center for PTSD■■ Deployment Health Clinical Center■■ Army Community Service■■ CSTS Scientific Advisory Board!

Director’s Message

Message from the Director
Dear Colleagues and Friends,
This Annual Report marks our Center’s
completion of 20 years of dedicated service to
Uniformed Services University of the Health
Sciences, the Department of Defense, and ournation in advancing trauma knowledge andtrauma-informed care. The Center for the
Study of Traumatic Stress (CSTS) continues togrow and expand its research, education andconsultation in the domains of disaster psychiatry, the neuroscience of traumatic stress,
understanding and support of first responders,and care of our nation’s soldiers, sailors, airman and marines who experience high stress
operations on behalf of national security.
Through domestic disasters that endanger civilian communities and engage the support of ourmilitary, the Center has uniquely bridged thefields of disaster and military psychiatry. Our
work integrates principles of disaster preparedness, response and recovery to foster individual,
community, organizational and public health.
The Center has been and continues to be a pioneer in generating and disseminating knowledge
to mitigate the impact of disaster and trauma
exposure. Through the Center’s involvement andleadership with renowned disaster experts, thearsenal of early intervention for disaster now
includes Psychological First Aid. The Center was
the first to inform the Department of Defense
and the nation about stress exposure to the deadand body recovery essential in the aftermath ofserious trauma. Center scientists were the firstto identify trends of escalation in child neglect

amongst military families in times of war. The
Center with its collaborative networks is at theforefront in examining the neuroscience of posttraumatic stress disorder in the human brain
and to have confirmed its findings in animalmodels. Through the Center’s cutting edge
research, understanding of community variables
that contribute to resilience and recovery in theface of disaster and the neuroscience of posttraumatic stress disorder are closer to our grasp.
This year the Center became a component centerof the Defense Centers of Excellence (DCoE)
for Psychological Health and Traumatic Brain
Injury institutionalizing the Center as the leading academic arm and source of knowledge
around traumatic stress. The Center continues
to focus on the horizon and to identify new
and critical issues for the science and care ofthose exposed to war, traumatic events anddisasters. We invite you to read about ourwork in more depth in the following pages.
Robert J. Ursano, M.D.
Professor and Chairman		
Department of Psychiatry
Uniformed Services University
Director, Center for the Studyof Traumatic Stress
The Center for the Study of Traumatic Stress (CSTS) continues to grow andexpand its research, education and consultation in the domains of disaster
psychiatry, the neuroscience of traumatic stress, understanding and support offirst responders, and care of our nation’s soldiers, sailors, airman and marines
who experience high stress operations on behalf of national security.

12 About CSTS

The Center for the Study ofTraumatic Stress
Overview“Disasters are a prominent part of our history
and will be a part of our future. From gene toprotein, cell to organ, and individual to group,
the complexity of human responses to disastertrauma is profound. Understanding both individual and community mental health responses
to disasters is critical to developing and planningfor post disaster interventions across the biological, psychological, and sociocultural levels.”—Robert J. Ursano, MD			
Textbook of Disaster Psychiatry, 2007
The Center for the Study of Traumatic Stress(CSTS) is one of the nation’s oldest and mosthighly regarded, academic-based organizations
dedicated to advancing trauma-informed knowledge, leadership and methodologies. The Center’s
work addresses a wide scope of trauma exposure
from the consequences of combat, operations
other than war, terrorism, natural and humanmade disasters, and public health threats. CSTS
is a part of our nation’s federal medical school,
PTSD is a signature illness of our nation’s war on terrorism, and a serious mental
disorder affecting many individuals exposed to trauma in the civilian population.
Uniformed Services University (USU), and its
Department of Psychiatry, as well as a partnering
center of the newly established Defense Centersof Excellence (DCoE) for Psychological Healthand Traumatic Brain Injury. These affiliations
represent the Center’s history, mission and future
directions as a major contributor to our country’s understanding of the impact of trauma andthe advancement of trauma-informed care.

As part of the USU Department of Psychiatry,the Center conducts translational researchin neuroscience examining the neurobiologyof brain structure using animal and humanmodels to inform prevention of and treatments
for serious stress disorders such as posttraumatic stress disorder (PTSD). PTSD is a signature illness of our nation’s war on terrorism,
and a serious mental disorder affecting many
individuals exposed to trauma in the civilian
population. Center scientists provide consultation to military leadership and the military
healthcare system around the impact andtreatment of traumatic stress and the stress andhealth consequences of deployment and combat injury on service members, their families
and children. This work fosters psychologicalhealth and strength in the military community.
A unique aspect and contribution of the Centeris the bridging of military and disaster psychiatry and the integration of disaster mental healthand public health. In applying the principles
and practices for dealing with individuals andgroups exposed to extreme environments inthe military, the Center has generated anddisseminated its subject matter expertise to
inform disaster preparedness, response andrecovery principles and practices across a wide
range of traumatic events and populations.
Today and into the future, the Center is uniquely
positioned to respond to DoD mission relevant activities and issues, especially those of
the DCoE, as well as to educate regional andnational stakeholders in government, industry,healthcare, public health, and academia on miti-

About CSTS

gating the effects of disaster and trauma in thecivilian community to foster human continuity and community and national resilience.
History
The Center was established in 1987, as a centerof excellence for responding to the long-term
concerns of the Department of Defense overthe substantial health risks resulting from thetraumatic impact of: 1) the possibility, or actual
use, of weapons of mass destruction (WMD)
during combat, acts of terrorism or hostage
events; 2) combat, peacemaking, peacekeeping, and operations other than war; 3) natural
disasters such as hurricanes, tornadoes, orfloods; and, 4) more common stress producing events such as physical assaults and motor
vehicle, shipboard, or airplane accidents inboth the uniformed and civilian communities.
Prior to Desert Storm, the Center pioneered
research on exposure to WMD through its
work in Air Force simulation exercises dealing with chemical and biological terrorism.
This early work generated an unprecedented
body of research, including a database thatcurrently consists of more than 20,000 articles
on the psychological, social and behavioral
manifestations of exposure to traumatic events.
These inferences include mental health responses ranging from resilience to psychiatricillness such as post-traumatic stress disorder, acute stress disorder, and depression.
In the 1990s the Center made major contributions to the newly emerging field of disastermental health and psychiatry. The Center
published a landmark book, one of the mostscholarly and comprehensive of its time, Individual and Community Responses to Trauma
and Disaster. This book and the Center’s workon the effects of trauma on first responders
helped shape the landscape of disaster andtrauma research, education and consultation.

In response to the events of 9/11, CSTS was instrumental in educating leadership at the federal,state and local level about individual and community responses to terrorism. This knowledge
drew upon the Center’s early work in the psychological and behavioral implications of exposure
to WMD. The Center expanded its research toencompass workplace preparedness for terrorism
and disaster, and provided consultation to the
U.S. Senate, the U.S. House of Representatives,
the U.S. Department of State, the U.S. Department of Transportation, a number of Fortune 100
corporations, and numerous government leaders.
The Center’s Director, Robert J. Ursano, M.D.,
was part of an Institute of Medicine committeethat authored an influential report and publication, Preparing for the Psychological Consequencesof Terrorism. This book recommended the integration of disaster response principles into the
public health arena with significant implications
around medical and healthcare preparedness
and response to large-scale disasters including public health threats such as a pandemic.

In response to theevents of 9/11, CSTS was
instrumental in educating
leadership at the federal,state and local level about
individual and community
responses to terrorism.

3

4 About CSTS

Since the start of the war on terrorism, theCenter has generated and disseminated knowledge on the effects of deployment and combat on
soldiers, sailors, airmen and marines and theirfamilies. The Center has galvanized nationallyrenowned academics and medical leadership as
well as its own subject matter experts to contribute to new areas of trauma need, such as the impact of combat injury on military healthcare providers, service members, their families and children. The Center has also mobilized its existing
resources to examine the prevalence of deployment-related family violence, child maltreatment
and neglect that has escalated in the militarycommunity since the start of the war on terror.
The Center is positioned
to contribute to thepsychological health andstrength of the militarycommunity as a knowledge
center for the psychologicalimplications of combat
and service to our nation.

Concomitant with the Center’s advances andinvolvement in military psychiatry, the Center
published in 2007 a landmark book, Textbook
of Disaster Psychiatry. This project, the firstbook to focus specifically on disaster psychiatry,brought together Center colleagues in trauma
and disaster from around the globe to provide
a comprehensive review of the psychological,
biological and social responses to disaster.
Now a component center of the Defense Centers of Excellence (DCoE) on Psychological

Health and Traumatic Brain Injury, the Centeris positioned to contribute to the improved
psychological health and strength of the militarycommunity through its cutting edge researchin neuroscience and as a knowledge center forthe psychological implications of combat andservice to our nation. The Center’s Director,
Robert J. Ursano, M.D., Professor and Chairmanof USU Department of Psychiatry, is internationally regarded for his academic contributions in
the fields of trauma prevention and care, andhis leadership in bridging the principles andpractice of military and disaster psychiatry
to strengthen our nation’s health and publichealth planning and response to local, regionaland national disasters and traumatic events.
The Center:■■ Develops and carries out research programs
to extend our knowledge of the medical
and psychiatric consequences of war,
deployment, trauma, disaster and terrorism,
including weapons of mass destruction.
■■ Educates and trains health care providers,leaders, individuals and public and private
agencies on how to prevent, mitigate andrespond to the negative consequences of war,
deployment, traumatic events, disasters, andterrorism.
■■ Consults with private and government
agencies on medical care of trauma victims,
their families and communities, and theirrecovery following traumatic events,
disasters and terrorism.
■■ Maintains an archive on medical literature
related to the health consequences oftraumatic events, disasters and terrorism
of individuals, families, organizations, andcommunities.
■■ Provides opportunities for post-doctoral
training of medical scientists to respond toand research the health consequences oftrauma, disaster, and terrorism.

About CSTS

CSTS Organizational Structure
Approximately forty scientists representing multiple disciplines staff the CSTS. These
disciplines include psychiatry, military anddisaster psychiatry, social and organizational
psychology, neuroscience, research design andstatistics, social work, risk communication andpublic health communication. The Center grows
its activities through cross-disciplinary research,
teamwork and collaborations to respond rapidly
to research and education needs. The Center
provides real-time consultation (consultation at the time of or immediately following
a traumatic event) and just-in-time education (knowledge dissemination at the time ofa traumatic incident in the form of electronic
fact sheets) for critical events that face DoD and
the Nation. The Center has been involved innearly every large scale disaster the nation has
faced in the past 25 years, through its education, research and consultation activities.

The Center funds the majority of its researchthrough extramural grants and funding froma wide range of organizations. The Director of
the Center, Robert J. Ursano, M.D., has overall
responsibility for Center function, science andfiscal activities. Six Associate Directors oversee
the Center’s Scientific Research; Public Education
and Preparedness; Health Care System Education;
Child and Family Program; Consultation and
Military Psychiatry; Homeland Security Studies; and, Information Systems and Operations.
The Center moved its major location in 2007 fromthe National Naval Medical Center to the North
Campus of USUHS located on Rockledge Drivein Bethesda, Maryland. Neuroscience laboratories
are located on the main campus of USUHS. The
CSTS has a Scientific Advisory Board composedof distinguished scientists and national and international trauma experts who provide their counsel and perspective to the Center (see page 21).

CSTS disciplines include
psychiatry, military anddisaster psychiatry,social and organizational
psychology, neuroscience,research design andstatistics, social work, risk
communication and publichealth communication.

56 Neuroscience and Neurobiology

Research in Neuroscienceand Neurobiology“We directly apply our basic research in neuroscience and neurobiology to inform clinicalinterventions for posttraumatic stress disorderdiagnosis and treatment. The Center’s translational research model — from bench to
bedside to bench — helps us respond to thoseon the battlefield, as well as those exposed
to natural and human made disasters ranging from automobile accidents to terrorism.”—He Li, MD, PhD
Associate Professor
USU Department of Psychiatry
The Center conducts pioneering, translational
research in neuroscience that addresses thebrain related prevention, onset and recovery
elements of the neurobiology of trauma- related exposures. As part of the Departmentof Psychiatry of our nation’s military medical
school, and a partnering center of the Defense

Center of Excellence (DCoE) for Psychological
Health and Traumatic Brain Injury, the Center’s research in neuroscience and neurobiology is focused on solving issues of health andperformance to optimize the psychologicalhealth and resilience of the military community and the public health of our nation.
Stress, especially the extreme stress of traumatic
events encountered in combat, can permanently
alter brain neurobiology. Posttraumatic stressdisorder (PTSD) represents a serious, potentially disabling and highly prevalent healthconsequence of deployment to Iraq and Afghanistan since the start of the war on terrorism.
Pharmacological prevention and treatment ofstress-related disorders such as posttraumaticstress disorder (PTSD) is a topic of significant
medical interest. The Center’s neuroscientificresearch from July 2007 through July 2008
has made major contributions in this arena.
Building upon numerous years of prior research,Center neuroscientists have discovered two new
critical paths in the neurobiology of posttraumatic stress disorder (PTSD). These discoveries
may lead to new treatments and diagnostic tools
for PTSD. The CSTS and its collaborators, using
new neurobiologic methodologies have identified the important function of a new gene andprotein (p11) and a cellular component (themitochondria) in PTSD. The studies represent
collaborations of CSTS scientists and leading
academic and research institutions including the
National Center for PTSD of the Department
of Veterans Affairs, Stanley Medical ResearchInstitute, National Institute of Mental Health,
Yale University and the George Washington

Neuroscience and Neurobiology 7

The first study (Zhang et al., 2008) identified
a potential biomarker for PTSD, a protein andits associated gene known as p11. This finding
has significant implications for posttraumaticstress disorder (PTSD) diagnosis and treatment since it was discovered in both animalmodels and human PTSD brain tissue. Biomarkers are increasingly used to diagnose diseases
promptly and accurately, to identify individuals
at high-risk for certain diseases and to follow the course of treatment. In the absence ofclinical biomarkers for PTSD, diagnosis has
been dependant on only the assessment ofclinical symptoms. These symptoms are often
missed, misdiagnosed and/or left untreated inthousands of affected individuals (military andcivilian), thus disrupting the quality of theirlives and the lives of their families and children.
The Zhang et al. study was the first to use humanpost-mortem brain tissue from individuals who
had PTSD. Researchers discovered that p11 (aprotein present in all individuals) decreasedin patients with depression, a condition often
co-morbid with PTSD, but the new findings
from CSTS scientists indicated it is increasedin patients with PTSD. CSTS scientists further
discovered a possible molecular mechanismthat could explain the increase of p11 in PTSD
and the decrease of p11 in depression. Usingstate of the art techniques of molecular biology, they found that three glucocorticoid (stresshormones) receptor-binding sites reside in thehuman p11 gene. These sites may regulate p11
gene expression and p11 levels via their interaction with stress hormones in PTSD patients.
This research area has significant implications

for understanding and treating PTSD: 1) thelevel of p11 may be a biomarker for diagnosing PTSD, as well as for differentiating PTSD
from depression; 2) the identification of threeglucocorticoid receptor-binding sites suggests atherapeutic target for development of clinical interventions to block or alter p11 levels for PTSD
prevention and treatment; and, 3) the presenceof p11 in tissue and therefore blood may lead to
PTSD screening and monitoring for purposesof disease prediction, diagnosis, and prognosis.
In another area of work, two important research
projects involving Center scientists Dr. H Li and
L Zhang are being carried out in collaboration
with George Washington University and haveresulted in the submission of two patent applications. The Su et al. study (2008) identified PTSDspecific gene targets with implications for PTSD
detection, diagnosis, prevention and treatment.
This study was the first to examine mitochondrial genes using human post-mortem brain tissue
from individuals diagnosed with PTSD. Mitochondria are the principal energy source of cells
that convert nutrients into energy. Mitochondrial
dysfunctions are increasingly recognized as
possible key components in stress related mental
disorders. The molecular markers associatedwith mitochondrial functions underlying thepathogenesis of PTSD are poorly understood.
Lack of such detailed knowledge greatly hampers the development of effective therapeutic
approaches to prevent as well as to treat PTSD.
Using a 3rd generation mitochondria genechip containing 1,159 genes, researchers examined gene changes in the brain tissue of six
post mortem PTSD patients against a control
group of six well matched post mortem control
subjects without PTSD. Results revealed specificgene expression patterns that distinguished the
PTSD patients from the control subjects. These
gene changes could serve as a biomarker for
PTSD diagnosis as well as a therapeutic targeta

PFC area 46b
p11 mRNA (p11/beta actin)-

University School of Medicine. The collaborators work together as the Traumatic Stress
Brain Study Group (TSBSG), a unique scientificinitiative with access to the world’s first andonly Brain Bank that collects and examines
post-mortem brain tissue of PTSD patients.

5
4
3
*

2
1
0

Control

PTSD

p11 mRNA expression in postmortem PFC is significantly increased inpatients with PTSD compared to ageand sex-matched controls. (a) A perspective of the human brain to locate
area 46 in the prefrontal cortex (PFC).
(b) P11 mRNA in PFC (area 46) issignificantly greater in PTSD patientsat postmortem compared to age-andsex –matched controls (n=6 pergroup, 2 cases died of suicide and 4
died of other causes in PTSD group).
Data are shown as means +/- SEM,
*p<0.05 (control vs PTSD) and havebeen analyzed by the student’s t test.

8 Neuroscience and Neurobiology

for PTSD treatment. These findings of PTSDspecific gene expression patterns are of major
significance in understanding the molecularbasis underlying the pathogenesis of PTSD,
and may serve as the basis for further development of strategies and methods for detection,
diagnosis, prognosis, prevention and treatment of PTSD. A patent for hMitChip3 hasbeen filed and is currently being processed.

some suggestion that they may be less effective
in war-related PTSD, which involves chronic
exposure rather than single event exposure totraumatic events. The development of more
specific pharmacological agents with potentially less significant side effects as a therapeuticstrategy aimed at prevention and/or treatment ofdisorders such as PTSD constitutes an important step in the treatment of these illnesses.

Most of the research performed thus far addressing pharmacological prevention and treatmentof stress-related disorders has focused on theeffectiveness of serotonin reuptake inhibitors inalleviating the symptoms of stress-related disorders. Although clinical research has shown thatthese agents are useful in alleviating symptoms,
their overall efficacy is limited and hindered bytheir less selective pharmacological targets, serious side effects and lower efficacy. There is also

To further address these issues the CSTS has
another important research area examining theimpact of stress on brain structure that regulates
the fear response. From these studies, Centerscientists discovered that the 5-HT2A receptor
is the primary receptor mediating serotonergic
facilitation of GABA release and modulatingneuronal excitability in the amygdala circuitry,
which is the key brain structure that controls thefear response. 5-HT2A receptor-mediated effects
in the amygdala were found to be substantially
impaired by exposure to traumatic stress using
a traumatic stress rat model. In this model, thestress-induced behavioral and neurobiologicalalterations were very similar to those found in
PTSD patients. Researchers hypothesized thatpre- or post-treatment of subjects exposed totraumatic stress with selective 5-HT2A receptor
antagonists may be expected to prevent stressprovoked long-lasting serotonin overflow in
the amygdala neuronal circuitry and therefore
protect 5-HT2A receptors from impairment due
to receptor desensitization and down-regulation.

Researchers discovered that p11 (a protein present in all individuals) decreasedin patients with depression, a condition often co-morbid with PTSD, but the new
findings from CSTS scientists indicated it is increased in patients with PTSD.

In ongoing research the Center is focused on
the investigation of the efficacy of pre- andpost- stress administration of a selective
third generation 5-HT2A receptor antagonist
MDL 11,939 (α-Phenyl-1-(2-phenylethyl)-4piperidinemethanol) in an animal model of
PTSD. This study, for the first time, has demonstrated that both pre- and post-stress administration of 5-HT2A receptor antagonists are effective
in preventing traumatic stress-induced exaggerated fear response, suggesting that 5-HT2A

Neuroscience and Neurobiology 9

receptor signaling may play a key role inmodulating the traumatic stress response in thecentral nervous system (Jiang et al., 2008). Thus,
the use of 5-HT2A receptor antagonists to prevent, treat and promote resilience in traumaticstress-induced neuron pathogenesis represents a
novel therapeutic strategy for PTSD medication(a patent for this regimen is currently pending).
Other research using PET neuroimaging
completed in 2007–2008 was done by Dr.
E. Osuch in collaboration with Dr. Wayne
Drevetz at NIMH and has identified critical brain regions for “resilience” and recovery
after traumatic stress (E. Osuch et al., 2008).

In its role to educate neuroscientists, the Center hosted The 3rd Annual Conference on the
Neurobiology of Amygdala and Stress in April
2008 focused on basic neuroscience and translational research. The conference attendance
was at full capacity and featured internationallyrenowned speakers addressing topics ranging from ‘Mechanisms of Lasting Change inAnxiety Produced by Severe Stress in Animals’
to ‘Different Effects of Early Exposure andCognitive Therapies on Fear and Avoidance.’

10 Military Psychiatry

Military Psychiatry“Your Center’s participation on the Family
Forum panel during the Army Strategic Leaders
Development Program will be of great assistance to our future general officers and theirspouses as they assume key roles in our Army.
Thank you for your outstanding work and for
all you have done for our Army and Nation.”—George W. Casey, Jr.
General, United States Army
Chief of Staff
Military psychiatry addresses thepsychiatric, psychological andmental health issues that affect andoccur within the military community (service members, their families
and children) including Active Duty,
Guard and Reserve personnel andveterans. The Center advances thefield of military psychiatry through:1) translational research in neuroscience to understand and inform
treatments for traumatic stressdisorders (see Neuroscience); 2)
education of USU medical students
committed to service in our nation’s Army, Air Force, Navy andpublic health service; 3) development and dissemination of educational resources on timely issues of
military health and mental healthto educate physicians (military andcivilian) and healthcare providers
engaged in military and traumainformed care, and; 4) consultation

with DoD leadership, government, academia,
industry and the media to foster knowledge,
educational and clinical resources, and outcomes for optimizing and sustaining military
health and influencing military health policy.
Notably, the Center, through its affiliation with
the Department of Psychiatry of Uniformed
Services University, has since its establishment
in 1987 institutionalized our nation’s knowledgeof military psychiatry as a field of academic
and medical study. The Center has expanded
its contributions over the last three decades tostrengthen the performance, the health and mental health of our troops in combat and in operations other than war, and to foster the resilienceof military families and children. Today, theCenter, now a partnering center of the Defense
Centers of Excellence (DCoE) for Psychological
Health and Traumatic Brain Injury, is positioned
to further commit and utilize its resources andexpertise in military psychiatry for integrated,
multi-disciplinary research, education andconsultation around DoD mission relevance andoverall excellence in trauma-informed care.
Military Psychiatry Research
The Center is currently engaged in cutting edge
research to improve the health and psychologicalresilience of troops and their families through research in neuroscience, social epidemiology andrisk modeling of trauma, prevalence studies of
deployment stressors, and child and adolescent
psychiatry-related research. Through neuroscience and neurobiology, the Center is examining
the molecular mechanisms underlying traumatic
response disorders such as posttraumatic stressMilitary Psychiatry 11

disorder (PTSD) and translating findings to
inform clinical and therapeutic interventions fordiagnosis and treatment (see Neuroscience).
The Center’s new research projects related tothe health and mental health consequences of
deployment stress include a major collaboration with Dr. Sandro Galea of the University ofMichigan on the epidemiology and the trajectory of posttraumatic stress, deployment
stress, health risk behaviors and health careutilization in National Guard and Reserve. In
addition, the Center has established, fundedby DoD, an integrated research collaborationof USU, NIMH, Walter Reed National Military
Medical Center, DC Veterans Administration, and Armed Forces Retirement Home toprovide world-class clinical research capability
for PTSD and Traumatic Brain Injury (TBI)
aimed at improving psychiatric and psychological care to service members and veterans.
The Center continues to identify and pursue
research with vulnerable and forgotten populations exposed to trauma. The Center is conducting prevalence studies to determine deploymentrelated stressors on our nation’s Mortuary Affairs(MA) soldiers who perform necessary, but emotionally difficult tasks in times of combat. Centerscientists have conducted nearly 1,000 on site
surveys of personnel from four MA companies
in the active Army and the U.S. Army Reserve.
This work, past and present, has distinguished
the Center as a leading source of knowledge inbody recovery, an essential task in military andcivilian disasters. The Center has provided consultation and training around these issues to the
Army and other government agencies such as
the State Department concerned about mitigating stress and sustaining performance in disaster
response environments. The Center’s Family Violence and Trauma Project Director also teaches
a class on the psychological stress of mortuary
affairs operations at the U.S. Army Mortuary
Affairs Center and School at Ft. Lee, Virginia.

In collaboration with the University of Virginia, the Center has examined “community
shielding” for military installations in casesof bioterrorism, nuclear or pandemic events.
The Center’s Child and Family Program area isengaged in clinical and therapeutic interventions
research for children and families of injured
soldiers (see Child and Family Program).
The Center’s research literature on military
medicine is extensive and its database isrich in important historical and contemporary publications. These references informand guide current research and policy.
Research of Center Scientists is funded by
DoD, U.S. Army, Centers for Disease Control
and Prevention, National Institute of Mental Health, National Institute on Drug Abuseand other public and private foundations.
The Center is currently engaged in cutting edge research to improve the healthand psychological resilience of troops and their families through research inneuroscience, social epidemiology and risk modeling of trauma, prevalence studies
of deployment stressors, and child and adolescent psychiatry-related research.
Military Psychiatry Education
The Center educates and trains providers in
the military health care system, which includes
doctors, nurses, psychologists and family
outreach professionals, military leadership as
well as civilian providers and organizations who
serve military members and their families. This
education focuses on preventing, mitigating andresponding to the negative consequences of war,
deployment, combat injury and other trauma
related issues. Center experts serve as faculty
for undergraduate medical student educationin general and military psychiatry, and also
oversee clinical psychiatry clerkships and residency programs in the major military medical
centers in the National Capital region. Center
educators provide continuing medical education in military trauma, disaster and terrorism

12 Military Psychiatryas Visiting Professors at civilian and military
medical training centers throughout the country
as well as through distance learning programs.
The Center also sponsors military psychiatry fellowships that have brought international scholars and clinicians to the Center
expanding its academic influence globally.
In 2008, the CSTS graduated its second Preventive/Disaster Psychiatry Fellow, Major Art
Therakopian, M.D. who spent two weeks in
Afghanistan during his practicum year with
the CSTS after receiving his Master in Public
Health. He also served as an appointed fellow to the American Psychiatric Association’s
Disaster Psychiatry Committee and published an important article on measurementof PTSD in the Journal of Traumatic Stress.
The Center educates and trains providers in the military health caresystem, which includes doctors, nurses, psychologists and family
outreach professionals, military leadership as well as civilian providers
and organizations who serve military members and their families.
Other scholarly articles and papers of impact
in military psychiatry include editorials andcommentaries in JAMA written by Dr. Ursano
with Dr. Jon Shaw of the University of Miami,
a commentary on recent work in the UK on
deployment by Drs. Ursano, Engel and Benedek
in the distinguished British Medical Journal,
and a commentary by Drs. Ursano and Benedek
in one of the leading science journals, Public
Library of Science (PLoS) on the first study
to examine the epidemiology of war related
mental illness in Palestine, which was written by Dr. Elie Karem and Dr. Ron Kessler.
A highly successful educational product drawing
upon the Center’s expertise in military psychiatry is its Courage to Care initiative. Launched in
2004, Courage to Care is an ongoing, electronic
health communication campaign addressing

important and timely topics of military health,as well as issues pertaining to homeland security and the nation’s health. It is intended for
medical leadership and practitioners, as well
as military families throughout the globe. This
year’s installments included the following provider resources: ‘Alcohol Misuse through Brief
Screening and Counseling’, ‘Healthcare Continuity of Military Families’, and ‘Fostering Recovery from Medical Illness, Injury and Disease.’
Military family fact sheets included: ‘Alcohol
and Your Health’ and ‘Military Families on theMove: Tips for Keeping Your Family Healthy.’Child and Family Program
The Center has a robust Child and Family
Program (CFP) that has expanded the Center’sreach and expertise on the effects of trauma on
families and children from war, natural disaster,
terrorism and bioterrorism. Dr. Stephen Cozza,
former Chief of Psychiatry at Walter Reed
Medical Center (WRMC), joined the CSTS in2006 as an Associate Director to head up CFP.
The Center’s contributions this year in advancing the health and mental health of militaryfamilies and children have been extensive.
Seed funding from DoD Military Communityand Family Policy and DoD Health Affairs
supports research and education related tomilitary children and families, the impact ofparental combat deployment on children, andthe work of the Center as a Category II site of
the National Child Traumatic Stress Network(NCTSN). As part of the NCTSN, the Center
serves as a knowledge development and dissemination center providing expertise in the impactof trauma on military children and families.
Through Congressionally Directed Medical Research Program (CDMRP) funding the Center’s
CFP is assessing the impact of parental combat
injury on children and families as part of a collaborative grant with WRAMC, Brooke Army
Medical Center and the 2nd Infantry Division

Military Psychiatry 13

at Ft. Stewart, Georgia. Research is also being
carried out to examine the relationship between
military family and community characteristics,
and the prevalence of child neglect in the Army.
In December of 2007, the Center hosted a Workgroup on Intervention with Combat Injured Families bringing together national experts in adolescent and child psychiatry, military medicine
and trauma to create guidelines of care aroundthe impact of combat injury on military children
and families. The Center produced an importanteducational document, Principles for Caring for
Combat Injured Families, a set of ten core principles that are evidence informed and serve to
guide the practice of both health care and community providers serving this special populationof military families. The principles were developed to encourage scientific study that will further inform evidence-based approaches to care.
In July 2008, the Center introduced a newhealth communication campaign, Resources
for Recovery, to further disseminate its knowledge around the impact of combat injury on
our nation’s military children and families. The
first installment, “The Combat Injured Family: Guidelines for Care,” is based upon the
Principles for Caring document. Future installments of Resources for Recovery will cover the
principles of communicating about injury, bothwithin the family and between family members
and health care/community service providers,
understanding child and family distress as aresult of combat injury, and sustaining parental availability during the recovery process.
Another important contribution of the Centerand its CFP is the Parent Guidance AssessmentCombat Injured (PGA-CI). The PGA-CI wasdeveloped to assist skilled mental health professionals in the development of family assistancestrategies and plans. While it is not specificallyintended for other populations, the PGA-CI
has applicability for other families with an

injured parent such as might appear in a trauma
center after a major motor vehicle accident.
Family Violence and Trauma Project
The Center’s Family Violence and Trauma Project (FVTP), now in its thirteenth year, represents
another domain of military psychiatry. Throughresearch to develop evidence for practice, the
FVTP addresses the prevalence and trends of
spouse abuse and child maltreatment in the U.S.
Army. Funded by the U.S. Army, the FVTP provides support via briefings, papers, staff studies
and a quarterly newsletter, Joining Forces Joining
Families, to inform Army leadership and the Army’s Family Advocacy Program of the scientificand medical aspects of child and spouse abuse.
Program Director Dr. James McCarroll and CSTS
scientists examined long-term trends in childmaltreatment and made the first observations on
increased rates of child neglect in the US Army
since the onset of the war on terrorism. These
early observations were independently con-

14 Military Psychiatry

firmed in two subsequent published papers. The
Center’s original findings were published recently
in Child Abuse Review. This research has highlighted the importance of child neglect in the
Army during periods of high family stress due torapid and frequent deployments. In addition to
the research on child maltreatment trends, the
FVTP has continued to perform regular analysesof the rates of spouse and child maltreatmentin the Army for each Army installation andperforms special studies for Army leadership.
Additional highlights of 2007-2008 include thepublishing of a book, Building Bridges to Research, a collection of statistics articles previously
featured in the Joining Forces Joining Families
newsletter. This book was disseminated to the
Army Community Service, the Army Family Advocacy Programs, and other military and civilian
consumers such as graduate schools of social
work. During this period, the FVTP also collaborated in a research project with the Fordham
University Graduate School of Social Service todevelop a training curriculum for Army social
workers. This training curriculum was developed using an evidence-based methodology forthe assessment of domestic violence victims.
Additionally, FVTPs has contributed to the Center’s literature database to improve the development of family violence research protocols andto further military and civilian social workers’
research education. From continuous analysesof child and spouse maltreatment statistics, to collaborations
with academic institutions todevelop evidence-based training,to publication of scholarly papers
and books, to on site research,
FVTP demonstrates the Center’s unique ability to go frombench to bedside to bench.
The Center also developed an
e-education campaign for Army

Community Support, Joining Forces Joining
Families: Helping, Caring and Learning. Thisbi-monthly e-education program is directedto advancing and supporting the work of the
Army Community Support leadership.
Military Psychiatry Consultation
The Center provides real-time consultation to
the military healthcare system and its leadership as well as to government and state agencies,
industry and academic institutions regarding military unique health and mental healthissues. Drs. Ursano, Benedek and Cozza presented the Center’s work on traumatic stressin soldiers and families to the four star generals of the U.S. Army and their wives at the
U.S. Army Chief of Staff ’s (General Casey’s)
meeting. A letter of appreciation from GEN
Casey supported the excellent reception of thepresentation. The success of the presentation
resulted in requests to present to the “generals school” conference in Washington DC.
Center scientists also consult with national andlocal media and educational organizations to inform their risk communication and educational
outreach around military unique health issues.
Dr. Cozza has served as a consultant to Sesame
Workshop to assist their production of an innovative DVD series to support the children of
deployed military personnel. He participatedin the development of their second installment,
Talk, Listen, Connect: Deployments, Homecomings, Changes, launched in April 2008. The materials help families cope with multiple deployments and the return of a parent who has been
injured in combat. Dr. Cozza also consulted ona book on bereavement for children, sponsored
by Arlington Cemetery, with a focus on helping children of military families deal with loss.
The Center’s work in military psychiatry research, education and consultation spans a vast
terrain. This work encompasses research on theneurobiology of brain structure to understandDisaster Psychiatry 15

human responses to fear, studies to evaluate
the stressors of combat operations on soldiers
who fight, even those who must recover andreturn our fallen heroes, resources that address the impact of deployment, reintegrationand combat injury on our military families andchildren, education for our military leadershipon the complexity of trauma, and consultation
with national media on the production of valuable and sensitive resources that foster strengthand resilience in our military community. The
Center’s work and strength is its capacity to gofrom bench to bedside to bench. We use thismetaphor to illustrate how the Center’s research
informs practical applications in the form ofdisaster preparedness recommendations toclinical care of trauma victims, and how thesereal world experiences in turn help the Center
identify new and advanced research needs.

As part of Uniformed Services University’s military medical school and a partnering center of the
Defense Centers of Excellence (DCoE) for Psychological Health and Traumatic Brain Injury, theCenter for the Study of Traumatic Stress is proud toserve our nation and provide consummate leadership in the field and practice of military psychiatry.

Disaster Psychiatry“The Center’s work has always focused onthemes of individual and community responses
to trauma and traumatic events, and has helped
shape and re-shape the landscape of disaster andtrauma research, education and consultation.”—Carol S. Fullerton, PhD, Professor,
Department of USU Psychiatry,
Science Director, Center for the
Study of Traumatic Stress
Disaster psychiatry examines the psychologicaland behavioral effects of traumatic events on
individuals and populations to inform disaster
preparedness, response and recovery. Disaster
psychiatry brings together the knowledge andpractice of psychiatry to inform approaches
aimed at preventing, mitigating and responding to the psychological and behavioral out-

comes of disasters on individuals, families andcommunities. The Center is one of the leading
institutions in the world to address the fieldof disaster psychiatry and disaster behavioral
health, bringing lessons learned from studying
human behavior under extreme stress in the
military to individual and population-based
impact on civilian lives and organizations.

Disaster psychiatry

Disaster Psychiatry Research
The Center’s Scientific Director, Carol S. Fullerton, PhD, leads an innovative public health study
partnering with Centers for Disease Control andPrevention (CDC), the National Institute of Occupational Safety and Health, and the Universityof Miami and Florida Department of Health. The
study involves longitudinal research to understand the vulnerability and resilience of our na-

disaster preparedness,examines the psychologicaland behavioral effectsof traumatic eventson individuals andpopulations to inform

response and recovery.

16 Disaster Psychiatrytion’s public health responders and their work in
the hurricanes of 2004 and 2005. This study also
demonstrates a partnership across federal, state
and academic organizations helping to prepare
our nation’s health care personnel. Dr. Fullerton
provides invaluable leadership as the recipientof the prestigious, James Leonard Award for
Excellence in Clinical Research for her researchon the acute and long-term effects of trauma
exposure on disaster workers that was a featurearticle in the American Journal of Psychiatry.

educate medical leadership and medical professional organizations. Dr. Ursano delivered theDistinguished Scientist Lecture at the American
Psychiatric Association meeting to psychiatric clinicians and scientists. Drs. Benedek and
Ursano also presented a clinical symposium on
treatment of PTSD. This distinguished panel,chaired by Dr. Ursano, included Dr. Doug
Zatzick from the University of Washington and
Dr. Patti Resick, Ph.D. from Boston University
and the National Center for PTSD of the VA.

Research on civilian disasters includes the impact
of disaster and rescue work on first responders as well as its long-term effects on healthcare
providers. The CDC engaged CSTS to conduct
an organizational assessment of its deployment
operations, policy and practices in an effort toidentify factors to sustain resilience in emergency
responders. The CSTS completed its work andDrs. Benedek and Ursano presented the Center’s report to the senior leadership of CDC.

In advancing the integration of disaster mental health, preparedness and public health, theCenter’s work also has an impact on national
security. Dr. Ursano was appointed a memberof the Institute of Medicine Committee on
Nuclear Preparedness. In addition, Drs. Flynn
and Ursano were appointed to the National
Biodefense Science Board subcommittee on
Mental Health for the Department of UnitedStates Department of Health and Human Services (HHS). The subcommittee was establishedby Homeland Security Presidentially Directed
Activity (HSPD 21), and reports to the Secretaryof HHS. Dr. Ursano received several important
appointments representing his and the Center’s
expertise and contributions in disaster psychiatry. Dr. Ursano was appointed to the first major
scientific advisory board of CDC for terrorism
response and preparedness. As the only federal
employee member of this Board, this appointment required a Secretarial waiver. Dr. Ursano
was also asked to be part of a committee thatwill oversee the formation of a USUHS Center
for Disaster Medicine and Preparedness. The
Center through Drs. Flynn and Gifford, represented USUHS in meetings with HHS on HSPD
21 planning for disaster education needs.

Disaster Psychiatry Education
In 2007, the Center published with Cambridge
University Press, a landmark book, Textbook
of Disaster Psychiatry (Eds., Ursano, Fullerton,
Weisaeth, Raphael), the first book to focus
specifically on disaster psychiatry. The Center’s
involvement brought together international
experts to provide a comprehensive review of thepsychological, biological and social responses todisaster. Chapters address the epidemiology ofdisaster response, the neurobiology of disaster
exposure, socio-cultural issues, the role of nongovernmental organizations, workplace policies
and implications for public health planning at
the level of the individual and the community.
Disaster psychiatry ensures that principles of
behavioral health and mental health care arein the medical arsenal supporting the public health response to disaster management.
To advance this, Center scientists continuallyDrs. Benedek and Ursano headed up a reviewof the present American Psychiatric Association
treatment guidelines for PTSD and ASD. Drs.
Benedek and Fullerton also had critical publica-

Disaster Psychiatry 17

tions on the now established early interventionof Psychological First Aid. Dr. Ursano, as acollaborator with Dr. Ron Kessler of Harvard’s
Department of Health Care Policy, publishedthe follow up of the Hurricane Katrina disasterregion, showing that the rates of mental illness
have remained high 18 months after the disaster.
A follow up article has proposed methodologicalneeds for future disaster population assessments.
The Center also develops disaster education
resources in real time and in response to organization needs that are national and international. In response to the 2008 earthquakes in
China, the Center translated a health assessment inventory and four critically important
disaster response fact sheets into Chinese foruse by the WHO, APA and disaster responders.
Cambridge University is translating the Textbook
of Disaster Psychiatry into Chinese to meet theneeds of health care responders in China. The
Center’s fact sheets are in continual demand bygovernment leaders, industry, academia and the
media (see CSTS Educational Materials, p. 23).
The Center created and runs the nation’s firstand only Fellowship in Disaster Psychiatry
and Public Health. CSTS graduated its second
Preventive/Disaster Psychiatry Fellow, Major
Art Therakopian, M.D. Major Therakopian
also served as an appointed fellow to the APA
Disaster Psychiatry Committee and published an important article on measurementof PTSD in the Journal of Traumatic Stress.

18 Selected Publications

Selected Publications
Selected Publications by Center Scientists(2007–2008)

Soldiers, Archives of Physical Medicine and Rehabilitation(in press).

Abraham PA, Xing GQ, Zhang L, Yu EZ, Post R, Gamble
EH, and Li H,: β1 and β2 adrenoceptor induced synaptic
facilitation in rat basolateral amygdala. Brain Research,
2008.

Hamaoka D., Fullerton C.S., Gifford R., Nam T.,
Benedek, D.M., and Ursano R.J., Medical students’
responses to an inpatient suicide: opportunities foreducation and support, Academic Psychiatry, Sept–
Oct:31(5):350–3 , 2007.

Benedek, DM, Ursano, RJ and Fullerton CS: First
responders: mental health consequences of natural andhuman made disasters for public health and public
safety workers, Annual Review of Public Health, 28:55–78,
2007.
Benedek DM, and Fullerton CS: Translating Five Essential Elements into Programs and Practice. A commentaryon ‘Five Essential Elements of Immediate and Mid-Term
Mass Trauma Intervention: Empirical Evidence,’. Psychiatry, 70(4), 2007.
Blumenfield, M and Ursano, RJ, (Eds). Early Intervention After Mass Violence, Cambridge University Press,
London, U.K. (in press)
Cozza SJ and Lieberman AF,: The young military child:
our modern Telemachus. Zero to Three Journal, 2007.
Davis JD, Engel CC, Mishkind M, Jaffer A, Sjoberg T,
Tinker T, McGough M, Tipton S, Armstrong DW, O’Leary
T: Provider and patient perspective regarding health carefor war-related health concerns. Patient Education andCounseling, 68:52–60, 2007.
Engel, CC, Locke S, Reissman DB, DeMartino R, Kutz I,
McDonald M, Barsky AJ: How might We Solve the latest
Mind-Body Problem? Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, 5(2): 155–63, 2007.
Galea, S, Brewin, C.R., Gruber, M., Jones R.T., King
D.W., King L.A., McNally, R.J., Ursano R.J., Petukhova
M., Kessler R. Exposure to Hurricane Related Stressors
and Mental Illness after Katrina, Arch Gen Psych, 64(12) :1427–1434, 2007
Grieger TA, Benedek DM, and Ursano R.J. PosttraumaticStress Disorder, Aggression and Violence, In Simon, RI
and Tardiff, K, eds, Agression and Mental Health , APPI,
Washington, D.C., 2008: 123–140.
Grieger, T.A., Benedek, D.M., Ursano RJ, Cozza SJ andEngel CC, Pain, Posttraumatic Stress Disorder, Depression, and Health Related Quality of Life in Battle-Injured

Hamaoka, D., Benedek, D. M., Grieger, T., & Ursano,R. J.: Crisis Intervention, In Encyclopedia of Stress, Editedby G Fink, 2nd edition, Elsevier/Academic Press, London
2007.
Hamaoka, D., Benedek, D. M.., & Ursano, R. J., Managing Psychological Consequences in Disaster Populations,
In Psychiatry 3rd Ed , A. Tasman, J. Kay and J. Lieberman(Eds.), William & Wilkins, (in press).
Hobfoll, S., Watson, P., Bell, C.C., Bryant, R.A., Brymer,
M.J., Friedman, M.J., Friedman, M., Gersons, B.P.R., deJong, J., Layne, C.M., Maguen, S., Neria, Y., Norwood,
A.E., Pynoos, R.S., Reissman, D., Ruzek, J I., Shalev, A. Y.,
Solomon, Z., Steinberg, A.M., Ursano, R.J.: Five Essential
Elements of Immediate and Mid-Term Mass Trauma Intervention: Empirical Evidence. Psychiatry: Interpersonaland Biological Processes 70(4):283–315 (2007).
Hoge, C.W., Terhakopian, A., Castro, C.A., Messer, S,C,,
Engel, C.C.. Association of Posttraumatic Stress Disorderwith Somatic Symptoms, Health Care Visits, and Absenteeism Among Iraq War Veterans. American Journal of
Psychiatry, 164(1):150–153, 2007.
Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC,
Castro CA: Mild Traumatic Brain Injury Among U.S.
Soldiers Returning from Iraq. New England Journal of
Medicine, 358(8): 453–463, 2008.
Howe, E.G.: Taking Patients’ Values Seriously, The Journalof Clinical Ethics 18(1): 4–11, 2007.
Howe EG: “I’m Still Glad You Were Borm” — Careproviders and Genetic Counseling, The Journal of Clinical Ethics
18 (2) (Sum 2007): 99–110.
Howe EG: Initial Screening of Patients for Alzheimer’s
Disease and Minimal Cognitive Impairment Psychiatry
2007 4 (7) (July 2007): 24–27.
Howe EG: Ethics in Psychiatry/ Five Ethical Questions
Involving Alzheimer’s Disease, Psychiatry 2007 (Aug2007): 31–4.

Selected Publications 19

Howe EG: Alzheimer’s Therapies, Commentary , Psychiatry 2007 (Aug 2007):29–30.

in Non-Mutual and Mutual Domestic Violence in the U.S.
Army: 1998–2004. Violence and Victims.

Howe EG: How Should Careproviders Respond Whenthe Medical System Leaves a Patient Short? The Journalof Clinical Ethics18 (3) (Fall 2007): 195–205.

McCarroll JE, Castro S, Nelson EM, Fan Z, Evans PK,& Rivera A. (2008). Establishing and Maintaining a
Volunteer Victim Advocate Program to Assist Victims ofDomestic Violence in the U.S. Army. Military Medicine,
173:860–864.

Howe EG: When Family Members Disagree, The Journalof Clinical Ethics 18 (4) (Win 2007): 331–339.
Howe EG: Key Psychosocial Interventions for Alzheimer’s
Disease — An Update on Alzheimer’s Disease, Psychiatry
2008 (Feb 2008): 23–26.
Jiang X, Xing G, Yang C, Verma A, Zhang L and Li H,:
Stress Impairs 5-HT2A Receptor-Mediated Serotonergic
Facilitation of GABA Release in Juvenile Rat Basolateral
Amygdala. Neuropsychopharmacology, (in press), 2008.
Kessler RC, Galea S, Gruber MJ, Simpson NA, Ursano
RJ, and Wessley S: Trends in mental illness and suicidality after Hurricane Katrina. Molecular Psychiatry, 13(4):374–384, 2008.
Kessler, R, Lane, M, North, C.S., Schnurr. P.P., Tuma, F.,
Colpe, L., Norris, F., Reissman, D.B., Stein, B.D., Ursano,R.J., Identifying Patterns and Predictors of DSM-IV PostTraumatic Stress Disorder Using a Common Interview
Protocol Across Three Small-Scale Disasters, Psychological
Medicine, (in press)
Kessler, R.C., Keane, T. M., Mokdad, A.H., Petukhava, M,
Ursano R.J., Zaslavsky, A.M., Measuring Vulnerability in
Post Disaster Mental Health Needs Assessments. Health
Affairs (in press)
Kolko, T.T., Spira, J.L., Morse, J.S., and Grieger, T.A.,
Posttraumatic Stress Disorder and Depression in HealthCare Providers Returning from Deployment in Iraq and
Afghanistan. Military Medicine, 172(5) 451–455, 2007.
Litz BT, Engel CC, Bryant R, Papa A: A Randomized
Controlled Proof of Concept Trial of Internetbased
Therapist-assisted Self-management Treatment for Posttraumatic Stress Disorder. American Journal of Psychiatry,
164(11): 1676–1683, 2007.
Manion, S.T., Gamble, E.H. and Li, H., Prazosin Administered Prior to Inescapable Stressor Blocks Subsequent
Exaggeration of Acoustic Startle Response in Rats, Pharmacol Biochem Behav, 86(3):559–65, 2007.
Mastroianni G, Mabry T, Benedek, D and Ursano R.
The Stresses of Modern War, In Biobehavioral Resilienceto Stress edited by Brian Lukey and Victoria Tepe, CRC
Press, 2008
McCarroll JE, Fan Z, & Bell NS. (In press). Alcohol use

McCarroll JE, Castro S, Nelson EM, Fan Z, Evans PK, &Rivera A. (2008). Characteristics of Domestic Violence
Incidents Reported at the Scene by Volunteer Victim
Advocates. Military Medicine, 173:865–870.
McCarroll, JE, Fan Z, Newby JH, and Ursano RJ. Trends
in U.S. Army Child Maltreatment Reports: 1990–2004.
Child Abuse Review, 17:108–118, 2008.
McCarroll JE, Newby JH, Dooley-Bernard M. (2007).
Responding to Domestic Violence in the U.S. Army: The
Family Advocacy Program. In Kendall-Tackett. K. & Sarah
Giacomoni S. (Eds.), Intimate Partner Violence. Kingston,
NJ: Civic Research Institute, 12–10—12–12.
Power, T.E., Adams, P.C., Barton, J.C., Acton, R.T., Howe,
E.G., Palla, S., Walker, A.P., Anderson, R., Harrison, B.:
Psychosocial Impact of Genetic Testing for Hemochromatosis in the HEIRS Study: A Comparison of Participants
Recruited in Canada and in the United States, Genetic
Testing, 11(1): 55–64, 2007.
Reissman, D, Schreiber, M.D., Shultz,J.M., Ursano, R.J.
Disaster Mental and Behavioral Health. In Disaster
Medicine Edited by KL Koenig & CH Schultz, Cambridge
University Press (in press)
Riddle, J.R., Smith, T.C., Smith, B., Corbeil, T.E., Engel,
C.C., Wells, T.S., Hoge, C.W., Adkins, J., Zamorski, M.,
Blazer, D. for the Millennium Cohort Study Team. Millennium Cohort: The 2001–2003 baseline prevalence ofmental disorders in the US military. Journal of Clinical
Epidemiology, 60:192–201, 2007. Pub 2006 Sep 28
Robichaux RJ & McCarroll JE. (In press). Family Maltreatment and Military Deployment. In EC Ritchie (Ed.)
Textbook of Combat and Operational Psychiatry.
Schnurr, P.P., Friedman, M.J., Engel, C.C., Foa, E.B., Shea,
M.T., Chow, B.K., Resick, P.A., Thurston,V., Orsillo, S.M.,
Haug, R,, Turner, C., Bernardy, N.. Cognitive-behavioral
therapy for Posttraumatic Stress Disorder in Women:a Randomized Controlled Trial. JAMA, 297:820–830,
2007.
Shibley, H, Benedek D, and Ursano, RJ, Emergency
Personnel, in Encyclopedia of Stress, Edited by Marshall
F et al (in press.)

20 Selected Publications

Shibley, H, Benedek D, and Ursano, RJ, Grotesque
Death, in Encyclopedia of Stress, Edited by Marshall F et
al (in press).
Smith TC, Zamorski M, Smith B, Riddle JR, LeardMann
CA, Wells TS, Engel CC, Hoge CW, Adkins J, Blazer D:
The physical and mental health of a large military cohort:baseline functional health status of the Millennium Cohort. BMC Public Health, 7: 340, 2007.
Stuart, J., Ursano, R. J., Fullerton, C. S., and Wessley S.:
Belief in exposure to chemical and biological agents in
Persian Gulf War soldiers. JNMD, 196(2): 122–7, 2008
Terhakopian, A. and Benedek, D.M.: “Hospital Disaster
Preparedness: Mental and Behavioral Health Interventions for Infectious Disease Outbreaks and Bioterrorism
Incidents,” American Journal of Disaster Medicine, 1(2):43–50, 2007.
Ursano AM, Kartheiser PE and Ursano RJ. The teachingalliance. Psychiatry : Interpersonal and Biological Processes,
70:3 Pg 1–87–194, 2007.
Ursano R.J, McCarroll J.E. and Fullerton C.S.: Traumatic
Death in Terrorism and Disasters, In Textbook of Disaster Psychiatry, Edited by R.J. Ursano., C.S. Fullerton, L.
Weisaeth. and B. Raphael, Cambridge University Press,
London, (2007)
Ursano R.J., Fullerton C.S., Norwood A.E. and Holloway H.C.: Weapons of Mass Destruction and Pandemics: Global Disasters with Mass Destruction and Mass
Disruption, In Textbook of Disaster Psychiatry, Edited by
R.J. Ursano., C.S. Fullerton, L. Weisaeth. and B. Raphael,Cambridge University Press, London, (2007)
Ursano R.J., Fullerton C.S., Weisaeth L. and RaphaelB.: Individual and Community Responses to Disaster,
In Textbook of Disaster Psychiatry, Edited by R.J. Ursano,
C.S. Fullerton, L. Weisaeth. and B. Raphael, Cambridge
University Press, London (2007)
Ursano R.J., Fullerton C.S., Weisaeth L. and Raphael
B.: Public Health and Disaster Mental Health: Preparing, Responding and Recovering, In Textbook of Disaster
Psychiatry, Edited by R.J. Ursano., C.S. Fullerton, L.
Weisaeth. and B. Raphael, Cambridge University Press,
London (2007)
Ursano RJ, Benedek DM, Hanaoka, DA, Fullerton,
CS, Kessler RC, World disasters and mental health: Acommentary on: “Prevalence of and gender disparities inposttraumatic stress disorder in an internally-displaced
population six months after the 2004 Tsunami in Sri
Lanka, Disaster Medicine and Public Health Preparedness,
1:41–43, 2007.

Ursano RJ., Shaw, JA. Children of war and opportunities
for peace (Editorial), JAMA 298:567–568, 2007.
Ursano, A. M., Sonnenberg S, and Ursano, R. J.: The
doctor-patient relationship, In Psychiatry 3rd Ed , A. Tasman, J. Kay and J. Lieberman (Eds.), William & Wilkins,(in press).
Ursano, R. J. and Ursano, A. M.: Brief individual psychodynamic psychotherapy, in Oxford Textbook of Psychiatry
2nd Edition, Vol. 2. M. Gelder, J. Lopez and N. Andreasen(Eds.). Oxford University Press, Oxford, UK, (in press)
Ursano, R. J., Fullerton, C. S., Raphael, B., and Weisaeth,
L. (Eds.). Textbook of Disaster Psychiatry. Cambridge
University Press, London, U.K. (2007).
Ursano, R. J., Sonnenberg, S. M., and Lazar, S. G. Psychodynamic Psychotherapy In 4 th ed. Textbook of Psychiatry,(Eds Hales R, Yudofsky S) American Psychiatric Press,
Inc., Washington, DC, (in press).
Ursano, R.J., Fullerton, C.S., & Benedek, D.M: Peritraumatic Dissociation: Time Perception and Cerebellar
Regulation of Psychological, Interpersonal and Biological
Processes, In Vermetten E, Dorahy M, Spiegel D, eds:
Traumatic Dissociation, American Psychiatric Press, Inc.,
Washington, DC (in press).
Ursano, R.J., Fullerton, C.S., Benedek, D.M., andHamaoka, D.A.: Hurricane Katrina: Disasters Teach Us
and We Must Learn (Commentary), Academic Psychiatry,
31(3): 1802–2, 2007
Ursano, RJ, Benedek DM, and Engel CC. Mental illness
in deployed soldiers. BMJ 335(7620) :571–572, 2007.
Ursano, AM, Kartheiser, PE, & Ursano, RJ : The teachingalliance : a perspective on the good teacher and effective
learning. Psychiatry, 70(3) : 187–194,2007.
Ursano, RJ and Engel, CC : The importance of assessing exposure to trauma. Psychiatric Services,59(3) :229,2008.
Ursano RJ, Li H, Zhang L, Hough CJ, Fullerton CS,
Benedek DM, Gieger TA, Holloway HC : Models
of PTSD and traumatic stress: the importance of research ‘from bedside to bench to bedside’. Progress in Brain
Research, 167 :203–15,2008.
Vineburgh N, Benedek DM, Fullerton, CS, Gifford RK,
and Ursano RJ, Workplace Resources for Crisis Management: Implications for Public Private Sector Planning,
Policy and Response to Disasters, International Journal of
Public Policy, (in press)

Scientific Advisory Board 21

Vineburgh N.T., Gifford R.K., Ursano R.J., Fullerton
C.S., and Benedek D.M.: Workplace Disaster Preparedness and Response, In Textbook of Disaster Psychiatry,
Edited by R.J. Ursano., C.S. Fullerton, L. Weisaeth. and B.
Raphael, Cambridge University Press, London, (2007)
Vineburgh NT, Ursano RJ, Hamaoka D, and Fullerton
CS: Public health communication for disaster planningand response, International Journal of Public Policy (inpress)
Vineburgh, N.T., Benedek, D,M,, Fullerton, C,S,, Gifford, R,K,, Ursano, R.J.,: Workplace Resources for Crisis
Management: Implications for Public Private Sector
Planning, Policy and Response to Disasters, International
Journal of Public Policy, (in press)

Warner, C., Warner, C., Matuszak, T., Flynn, J., Rachal, J.,
Grieger, T.,: Disordered Eating in Entry Level Military
Personnel, Military Medicine 172:147–151, 2007
Zhang HT, Huang Y, Masood A, Stolinski LR, Li Y, Zhang
L, Dlaboga D, Jin SL, Conti M, O’donnell JM,: AnxiogenicLike Behavioral Phentype of Mice Deficient in Phosphodiesterase 4B (PDE4B). Neuropsychopharmacology, 2007
Zhang L, Li H, Su TP, Barker JL, Maric D, Fullerton CS,
Webster MJ, Hough CJ, Li XX: p11 is upregulated in
the forebrain of stressed rats by glucocorticoid acting via
two specific glucocorticoid response elements in the p11
promoter. Neuroscience, 153: 1126–34, 2008

CSTS Scientific Advisory Board
James E. Barrett, Ph.D.
Department of Pharmacology and Physiology
Drexel University, College of Medicine
245 N. 15th Street
Mail Stop 488, Room 8213
Philadelphia, PA 19102-1192
jbarrett@drexelmed.edu
BG William T. Bester
351 Huck Finn Trail
Dripping Springs, TX 78620
wllmbester@yahoo.com
Robert G. Darling, M.D., FACEP, CAPT, MC, USN(RET)
Director, Center for Disaster and Humanitarian
Assistance Medicine
F. Edward Hebert School of Medicine
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799
rdarling@usuhs.mil
M. Richard Fragala, M.D.
P.O. Box 182
Malverne, NY 11565
Richarf0@ucia.gov

Matthew J. Friedman, M.D.
Executive Director
National Center for Posttraumatic Stress Disorder(116D)
VAM & ROC
215 North Main Street
White River Junction, VT 05001-3833
Matthew.j.friedman@dartmouth.edu
Carol S. Fullerton, Ph.D.
Science Director, Center for the Study of TraumaticStressDepartment of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799
cfullert@erols.com
David S. Krantz, Ph.D.
Chair, Department of Medical and Clinical Psychology
F. Edward Hebert School of Medicine
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799
dskrantz@usuhs.mil

22 Selected Publications

Larry W. Laughlin, M.D., Ph.D.
Dean
F. Edward Hebert School of Medicine
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799
llaughlin@usuhs.mil
Craig H. Llewellyn, M.D.
Professor
Department of Military and Emergency Medicine
F. Edward Hebert School of Medicine
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799
cllewellyn@usuhs.mil
Husseini K. Manji, M.D., F.R.C.P.C.
Chief, Lab of Molecular Pathophysiology
NIMH, Building 49, Room B1EE16
49 Convent Drive, MSC 20892-4405
Manji@nih.gov
David H. Marlowe, Ph.D.
Senior Lecturer
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799
Dmarlow06@comcast.net

Robert M. Post, M.D.
Head, Bioplar Collaborative Network
3502 Turner Lane
Chevy Chase, MD 20815
Robert.post@speakeasy.net
CAPT Gerald V. Quinnan, Jr., MC, USN
Professor
Department of Preventive Medicine/Biometrics
F. Edward Hebert School of Medicine
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799
gquinnan@usuhs.mil
ArikY. Shalev, M.D.
Professor and Chairman
Department of Psychiatry
Hadassah University School of Medicine
Jerusalem, Israel
Ashalev@cc.huji.ac.il
Captain Trueman Sharp, MC, USN
Department Chair, Military and Emergency Medicine
F. Edward Hebert School of Medicine
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799
tsharp@usuhs.mil
BG Loree K. Sutton
Director,
Defense Centers of Excellence for Psychological Healthand Traumatic Brain Injury
Loree.Sutton@ha.osd.mil
Robert J. Ursano, M.D.
Chairman, Department of Psychiatry
Professor of Psychiatry and Neuroscience
F. Edward Hebert School of Medicine
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799
rursano@usuhs.mil
Lars Weisaeth, M.D.
Professor and Chairman
Division of Disaster Psychiatry
University of Oslo
Oslo, Norway
Lars.weisath@medisin.uio.no

Educational Materials 23

CSTS Educational Materials(2007–2008)
Center scientists advance trauma knowledge
and trauma-informed care to a wide variety
of audiences, military and civilian, on timely
and relevant topics using diverse media:

Courage to Care, a healthcommunication campaign for
military providers and families
to improve and sustain our
military’s health and resilience.

the Center’s website, electronic fact sheets,
e-communications, newsletters, briefings
and academic papers and publications. Hereare some examples of the Center’s work.

A newsletter for Army Family
Advocacy Program and family
outreach professionals toadvance research knowledge
and evidence-informed
practice in family violence, childneglect and maltreatment.

An e-communication campaign
to educate and reinforce
knowledge within the Army
Community Support networkon the stressors experienced
by military families due todeployment and redeployment.

Leadership document
resulting from Workgroupon Intervention with Combat
Injured Families setting
forth guidelines of care forfamilies and children of ournation’s wounded soldiers.

A book, marking 13 years ofcontinuous publication of
Joining Forces Joining Families
newsletter, which advances
knowledge of statistics for family
program research in militaryand civilian communities.

The Center’s website,which provides
information andresources on a wide
range of trauma anddisaster subjects forresearch scientists,
health care providers,
government
leaders, educators,
industry and thegeneral public.

24 Directors and Scientists

CSTS CENTER DIRECTORS
Robert J. Ursano, M.D.
Director, Center for the Studyof Traumatic Stress
Chairman, Department of Psychiatry
Professor of Psychiatry
and Neuroscience
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
rursano@usuhs.mil
LTC David M. Benedek, MC, USA
Associate Director, Consultation and
Military Psychiatry, Center for
the Study of Traumatic Stress
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
dbenedek@usuhs.mil
Carol S. Fullerton, Ph.D.
Associate Director, Scientific
Research, Center for the
Study of Traumatic Stress
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
cfullerton@usuhs.mil
Brian W. Flynn, Ed.D.
Associate Director, Health Care
System Education, Center for
the Study of Traumatic Stress
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
BrianWFlynn@aol.com
COL Stephen J. Cozza, MC, USA
Associate Director, Child andFamily Program, Center for
the Study of Traumatic Stress
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciencesscozza@usuhs.mil

Robert K. Gifford, Ph.D.
Associate Director, Homeland
Security Studies, Center for the
Study of Traumatic Stress
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciencergifford@usuhs.mil
Nancy T. Vineburgh, M.A.
Associate Director, Public Education
and Preparedness, Center for
the Study of Traumatic Stress
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Science
nvineburgh@usuhs.mil
John Stuart, Ph.D.
Associate Director, Information
Systems, Center for the
Study of Traumatic Stress
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
jstuart@usuhs.mil
CSTS CENTER SCIENTISTS
LTC David M. Benedek, MC, USA
Associate Professor
Consultant to the U.S. Army Surgeon
General for Forensic Psychiatry
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
Quinn M. Biggs, Ph. D., M.P.H.
Research Psychologist (Post Doc)
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
Maria Braga, D.D.S., Ph.D.
Research Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences

Janis Carlton, CDR, USN
Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences

Michael C. Freed, Ph.D.
Assistant Professor (Research)
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences

Stephen Cozza, M.D.
Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences

Carol S. Fullerton, Ph.D.
Research Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences

Brian Crowley, M.D.
Clinical Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences

Frances Gabbay, Ph.D.
Research Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences

Connie Duncan, Ph.D.
Research Associate Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences

COL Gary Gackstetter, USAF
Associate Professor
Department of Preventive
Medicine/Biometrics
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences

Richard S. Epstein, M.D., P.A.
Clinical Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
COL Charles Engel,
MC, USA, M.P.H.
Associate Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
Martha Faraday, Ph.D.
Assistant Professor
Department of Medical andClinical Psychology
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
Brian W. Flynn, Ed.D.
Associate Director, Center for the
Study of Traumatic Stress
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences

Robert Gifford, Ph.D.
Associate Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
Krisitie Gore, Ph.D.
Research Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
Thomas A. Grieger, M.D.
Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
Jennifer Guimond, Ph.D.
Associate Child Psychologist
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health SciencesDerrick Hamaoka, M.D.
Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
Harry C. Holloway, M.D.
Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
Tomoko I. Hooper, M.D.
Assistant Professor
Department of Preventive
Medicine/Biometrics
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
Christopher Hough, Ph.D.
Research Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
Luke Johnson, Ph. D.
Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
Elie Karam, M.D.
Professor and Chair
Department of Psychiatry
American University – Beirut
Beirut, Lebanon
Joceyln Kilgore, M.D.
Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
He Li, M.D., Ph.D.
Associate Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences

Xian Liu
Research Assistant Professor
Deployment Health Clinical Center
Walter Reed Army Medical Center
Washington, DC
David Marlowe, Ph.D.
Senior Lecturer
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
James E. McCarroll, Ph.D.
Research Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
Jodi McKibben, Ph.D.
Research Psychologist
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences

Robert J. Ursano, M.D.
Professor and Chairman
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
Nancy T. Vineburgh, M.A.
Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences
Maree J. Webster, Ph.D.
Assistant Research Professor
Stanley Foundation
Bethesda, MD 20889
Lars Weisaeth, M.D.
Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences

John Newby, Ph.D.
Research Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences

Kathleen Wright, Ph.D.
Deputy Chief,
Department of Military Psychiatry
Division of Neuropsychiatry
Walter Reed Army Instituteof Research
Washington, DC

Janet A. Schmidt, Ph.D.
Senior Scientist
Center for the Study ofTraumatic Stress
Uniformed Services Universityof the Health Sciences

Guoquiang Xing, Ph.D.
Research Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences

John A. Stuart, Ph.D.
Research Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences

Lei Zhang, M.D.
Associate Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services Universityof the Health Sciences

E. Fuller Torrey, M.D.
Executive Director
Stanley Foundation
Bethesda, MD

Center for the Study of Traumatic Stress
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road, Bethesda, MD 20814-4799
Tel: 301-295-2470 | Fax: 301-319-6965 | www.usuhs.mil/csts | www.CSTSonline.org