Center for the Study of Traumatic Stress

A n n u a l R e p o rt 2 0 0 9

A number of our research projects are combining psychosocial, epidemiologic andneuroscientific methodologies that will lead to a better understanding of the vulnerability,
protective factors and treatments for trauma disorders. This approach — from laboratory
to bedside to bench — will drive both short and long-term objectives for our involvement
in U.S. Army STARRS (Studies to Assess Risk and Resilience in Service Members).

Acknowledgements
The Center for the Study of Traumatic Stress(CSTS) would like to acknowledge and thank eachof these organizations for their continued support,
guidance, and leadership throughout the past year.
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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!

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From the CSTS Director: Robert J. Ursano, M.D.
Robert J. Ursano, M.D.
Professor and Chairman
Department of Psychiatry
Uniformed Services University
Director, Center for the Studyof Traumatic Stress
Dear Colleagues and Friends,

In recognition of therise in suicide andbehavioral healthproblems among
service members who
have served in Iraq
and Afghanistan, theNational Instituteof Mental Health(NIMH) awarded CSTS
an unprecedented
grant of $50 million
to assess and developscientific approaches
to reverse this trend.

2009 has been a year of extraordinary
growth for the Center for the Study ofTraumatic Stress (CSTS) due in large partto the confluence of an issue of national
importance, and our Center’s expertise toaddress this issue and help provide needed
solutions. In recognition of the rise in suicideand behavioral health problems among
service members who have served in Iraq
and Afghanistan, the National Institute of
Mental Health (NIMH) awarded CSTS an
unprecedented grant of $50 million to assessand develop scientific approaches to reverse
this trend. In coordination with the Secretaryof the Army, the Vice Chief of Staff of theArmy, the Surgeon General of the Army,and NIMH, CSTS is positioned to lead aninterdisciplinary team including prominent
researchers from Harvard, Columbia and the
University of Michigan to support the U.S.
Army’s advancement of trauma knowledge
and trauma informed care for our nation.
Since the Center’s establishment in 1987
to address Department of Defense (DoD)
concerns around traumatic exposure to war,
operations other than war, weapons of mass
destruction, natural disasters and traumatic
events such as accidents on land, sea and air,
CSTS has shaped the landscape of disasterand military psychiatry and bridged these

disciplines to inform planning, response andrecovery of public health threats or recovery
from pandemic and H1N1 outbreaks.
As part of the Department of Psychiatry of
Uniformed Services University (USU), CSTS
also has examined traumatic stress throughlaboratory research on animals and humans.
This pioneering work in neuroscience and theneurobiology of traumatic stress resulted in
the Center’s recent identification of a potential
biomarker for post traumatic stress disorder(PTSD), a protein and its associated gene
known as p11. These findings have important
implications for prevention and treatment
of PTSD and other trauma-related disordersthat face our service members and nation.
As you will read in the following pages,
CSTS is on the cutting edge of integrating
basic science and clinical science to better
understand the effects of stress and trauma.
A number of our research projects are
combining psychosocial, epidemiologic andneuroscientific methodologies that will leadto a better understanding of the vulnerability,
protective factors and treatments for trauma
disorders. This approach — from laboratory
to bedside to bench — will drive both shortand long-term objectives for our involvement
in U.S. Army STARRS (Studies to Assess
Risk and Resilience in Service Members).
As 2009 comes to a close, our Center’s
strength to integrate trauma researchacross genes, brain, individual, family,community and policy, and our strong
collaborative networks will assist us in
helping the U.S. Army, our expanded militarycommunity, and our nation find and apply
evidence-based approaches and treatments
to prevent and minimize the impact of2

In coordination with theSecretary of the Army,
the Vice Chief of Staff of
the Army, the Surgeon
General of the Army, andNIMH, CSTS is positioned
to lead an interdisciplinary
team including prominent
researchers from Harvard,
Columbia and the
University of Michigan tosupport the U.S. Army’s
advancement of trauma
knowledge and trauma
informed care for our
nation.

traumatic disorder from depression, PTSD,
substance abuse, family violence andtraumatic brain injury (TBI) to support
the psychological health and resilience ofour military and civilian communities.
This CSTS Annual Report communicates
our story and 2009 highlights throughconversations with our leadership team.
We wish to acknowledge the many sourcesof support through national and federal
organizations, academic and scientificcollaborations and the many friends of ourCenter whose interest in and support of ourwork is greatly valued and appreciated.

History
The Center was established in 1987 toaddress concerns of the DoD around thepsychological impact and health consequences
resulting from the traumatic impact of: 1)
the possibility, or actual use, of weapons ofmass destruction (WMD) during combat,

acts of terrorism or hostage events; 2) combat,
peacemaking, peacekeeping, and operations
other than war; 3) natural disasters suchas hurricanes, tornadoes, or floods; and,4) more common stress producing events
such as physical assaults and motor vehicle,
shipboard, or airplane accidents in boththe uniformed and civilian communities.
The Center, prior to Desert Storm,
conducted pioneering research on exposure
to WMD through its work in Air Forcesimulation exercises dealing with chemicaland biological terrorism. This early work
generated an unprecedented body of research,
including a database that currently consists ofmore than 20,000 articles on the psychological,
social and behavioral manifestations of
exposure to traumatic events. These references
include mental health responses ranging
from resilience to psychiatric illness such as
PTSD, acute stress disorder, and depression.
In the 1990s the Center made major
contributions to the newly emerging field of
disaster mental health and disaster psychiatry
publishing one of the most scholarly andcomprehensive books on disaster, Individual
and Community Responses to Trauma andDisaster: The Structure of Human Chaos.
This book and the Center’s work on theeffects of trauma on first responders helped
shape the landscape of disaster and trauma
research, education and consultation.
In response to the events of 9/11, CSTS
was instrumental in educating leadershipat the federal, state and local levels about
individual and community responses toterrorism, and expanded its research toencompass workplace preparedness forterrorism and disaster. CSTS provided
consultation to the U.S. Senate, the U.S. Houseof Representatives, the U.S. Department ofState, the U.S. Department of Transportation,
a number of Fortune 100 corporations,and numerous government leaders.

3

Since the start of the war on terrorism,
the Center has generated and disseminatedknowledge on the effects of deployment
and combat on soldiers, sailors, airmen andmarines and their families. The Center has
galvanized nationally renowned academics
and medical leadership as well as its own
subject matter experts to contribute to newareas 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 theprevalence of deployment-related family
violence, child maltreatment and neglect thathave escalated in the military community
since the start of the war on terror.
Concomitant with the Center’s advances
and involvement in military and disaster
psychiatry, the Center has engaged intranslational research in neuroscience that
addresses the brain-related prevention, onset
and recovery elements of the neurobiologyof trauma-related exposures. This researchhas been and continues to be invaluable
to the Defense Centers of Excellence(DCoE) for Psychological Health andTraumatic Brain Injury of which CSTS is
the academic arm and a partnering Center.
In July 2009, NIMH awarded the Center
an unprecedented $50 million grant tocoordinate and conduct the largest study ofsuicide and mental health among military
personnel. The study is a direct response to
the Army’s request to NIMH to enlist themost promising scientific approaches foraddressing the rising suicide rate amongsoldiers. The Center will collaborate withresearchers from Harvard, Columbia
and University of Michigan to conduct
an epidemiologic study of mental health,psychological resilience, suicide risk,
suicide-related behaviors, and suicide deathsin the Army. The Center’s leadership andinvolvement in this study supports the Army
as taking the lead in trauma informed care
to benefit the military and the nation.

The Center:
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Develops and carries out research
programs to extend our knowledge of the
medical and psychiatric consequencesof war, deployment, trauma, disaster andterrorism, 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 consequencesof war, deployment, traumatic events,
disasters, and terrorism.
Consults with private and government
agencies on medical care of trauma
victims, their families and communities,
and their recovery following traumatic
events, disasters, and terrorism.
Maintains an archive of medical
literature on the health consequences oftraumatic events, disasters and terrorism
for individuals, families, organizations,and communities.
Provides opportunities for post-doctoral
training of medical scientists to respondto and research the health consequencesof trauma.

4

Conversation with Robert K. Gifford, Ph.D.
Our major studies ofGuard and Reserve
personnel, which areongoing, will make aninvaluable contribution
to understanding theeffects of military service
on health and well-being.
With involvement incommunity shielding,
the Center has become
part of a novel wayof conceptualizing
disaster preparedness.

Robert K. Gifford, Ph.D.
Executive Officer,
Center for the Study of Traumatic Stress
Associate Director,
Homeland Security Studies“We are successfully managing a periodof large growth in our Center and setting
the groundwork for a period in which wewill make a major contribution in thehealth and mental health of the nation.”
In March 2009, Robert K. Gifford,
Ph.D., CSTS senior scientist and Associate
Director of Homeland Security Studies,
was appointed the Center’s Executive
Officer. In this role, Dr. Gifford assists
Dr. Ursano by ensuring that the Center’s
diverse efforts are properly coordinatedand supported, and that the Center fulfills
its obligations both to Uniformed Services
University and to external agencies, such
as DCoE. This includes but is not limited
to the timely delivery of high quality
services and products that represent theCenter’s expertise in trauma research,education, consultation and training.
Dr. Gifford conducted psychologicalresearch during Operation Desert Shield/
Storm, in Somalia, and in Bosnia, as wellas in Germany and the United States. He
served as Research Psychology Consultant
to The U.S. Army Surgeon Generaland later as the Army Medical Service
Corps’ Assistant Chief for Medical Allied
Sciences. Dr. Gifford brings extensive
expertise in military research and research
management for the military to the Center.

In describing your role as CSTS Executive
Officer could you comment on highlights of2009 in terms of the Center’s growth andimpact?
The Center’s having created a new office
and role, Executive Officer, speaks directly
to the highlights and impact of 2009 — theCenter’s enhanced mission as the academic
arm and one of the partnering centers of
DCoE, and our expanded grant activity.
More specifically, the Center’s enhanced
mission is the result and confluenceof 1) our having received a number ofgrants to study PTSD and TBI involving
extensive research and resources; 2) our
dynamic and complex affiliation with
DCoE resulting in new responsibilities
in research, education and consultation,i.e. more requests for our services, and;3) having received the largest amount ofmoney ever received by USU in a single grant,$50 million to study suicide in the Army.
What about your other role as Associate
Director, Homeland Security Studies?
My role role involves work on two
important research projects. The first is alongitudinal study of health and mental
health of National Guard and Reserve service
members, being done in collaboration
with Dr. Sandro Galea of the University ofMichigan. This project is being funded bothby the U.S. Army Medical Research andMaterial Command and NIMH. I oversee
access to military populations that constituteour research base. This research will provide
a unique look at trajectories of health andillness among members of the Reserve
Component of our armed forces. The Center5is also involved in community resilience/shielding studies in collaboration with
University of Virginia (UVA). I consult on a
UVA sponsored survey of disaster, terrorist
attack and public health threat. Our current
project is to develop educational materials
for preparing for the National Capital Region(NCR) for National Planning Scenario No. 2,
an aerosolized anthrax attack, and also H1N1.
It was also a privilege to haveparticipated on the External Scientific
Advisory Board of Ohio’s Kaptur Combat
Mental Health Initiative: Risk andResilience Factors for Combat-Related
Posttraumatic Psychopathology and Post
Combat Adjustment research project.
Congresswoman Marcy Kaptur from
Ohio has been a champion of veteranscare and was instrumental in obtaining
funding for this key research initiative.
Regarding the Center’s enhanced mission, howwould you sum up 2009?
In looking at this past year, I would saythat the Center has made great strides insynchronizing our operations with DCoE andbeing a contributing center. Our impact has
been significant in science across the board.
Major studies of Guard and Reserve personnel,
which are ongoing, will make an invaluable
contribution to understanding the effects ofmilitary service on health and well-being.
With involvement in community shielding,
the Center has become part of a novel way ofconceptualizing disaster preparedness. Past
ways of looking at disaster planning havefailed to consider the human dimension in
motivating people to prepare and respond.
We are proud to be working with leaders inchanging how to think about preparedness.

Defense Centers of
Excellence (DCoE) works
with national organizations
and experts to establish
best practices and quality
standards for the treatmentof war related psychologicaldisorders includingtraumatic brain injury. CSTS
serves as DCoE’s academic
arm and is one of its partner
centers.

6

Conversation with Carol S. Fullerton, Ph.D.
Our 2009 research
represents some exciting
directions and advances.
We are combining
our methodologies inunique ways to extend
scientific boundaries
and possibilities.

CSTS hosted a screening ofa PBS special in which Dr.
Fullerton appeared on thelife and work of her father,“Herbert Hauptman: Portraitof a Laureate.” Dr. Hauptman
received the Nobel Prizein chemistry in 1985. He
has served on the Center’s
Scientific Advisory Board
since its inception (photo of
Dr. Hauptman at right).

Carol S. Fullerton, Ph.D.
Scientific Director
Center for the Study of Traumatic Stress“We’ve moved into the arena ofintervention. We are taking evidenceinformed approaches and applying themto change the behavior of populations.
We’re in the field actually implementing
what we’ve learned from our research.”
Carol S. Fullerton, Ph.D., Research
Professor in the USU Department of
Psychiatry, serves as CSTS ScientificDirector. She has the distinction of being
part of the Center for over 20 years, andhas been instrumental in its growth andexcellence. A 2005 recipient of the James
Leonard Award for Excellence in ClinicalResearch, Dr. Fullerton is widely publishedin the areas of PTSD and the behavioral andpsychological effects of exposure to terrorism,
bioterrorism, natural disasters and combat.
Her roots in science run deep. In
September, 2008, Uniformed Services
University hosted a screening of a PBS special
in which Dr. Fullerton appeared on the life
and work of her father, “Herbert Hauptman:
Portrait of a Laureate.” Dr. Hauptman
received the Nobel Prize in chemistry in
1985. He has served on the Center’s Scientific
Advisory Board since its inception.
In describing your role as CSTS ScientificDirector, how would you characterize 2009in terms of the Center’s contributions andadvances in trauma research?
As Scientific Director, I oversee theCenter’s research portfolio, core resources,
and postdoctoral training. The Center’s
research on traumatic stress encompasses
epidemiology (the study of the causes,
distribution and control of disease inpopulations), laboratory work with animals
and humans, and clinical and translational
research in neuroscience that informs theprevention and treatment for serious stressdisorders including depression, PTSD
and the risks and actuality of suicide.
Our 2009 research represents someexciting directions and advances. We are
combining our methodologies in uniqueways to extend scientific boundaries andpossibilities. An example of this trend is
our study, P11, a Biomarker for Memory
Retrieval: A Possible Role in TraumaticStress that uniquely combines psychosocial
measures and neuroscience. We plan

7

to survey service members for PTSD,
depression and prior trauma history,
while simultaneously collecting bloodand saliva samples to look for genetic
biomarkers for PTSD and depression.
We are also applying our research to
impact the behavior and psychologicalwell being of populations who have been
exposed or will be exposed to trauma. This isexemplified by our Mortuary Affairs Soldiers:
Early Intervention and Altering Barriers
to Care for Traumatic Stress and PTSD(TEAM: Troop Education for Army Morale).
Could you describe TEAM and its
significance?
TEAM (Troop Education for Army
Morale) is an educational program
designed to help U.S. Army Mortuary
Affairs Soldiers and their spouses (one of
the few programs to target this population)
deal post-deployment with the complex
challenges that often result from traumatic
exposure. The TEAM intervention focuses
on “natural support systems” such as
spouses and buddies while providing a“stepped care” individualized approach.
TEAM utilizes Psychological First Aid,an evidence-informed resiliency building
approach to help people in the aftermathof disasters and traumatic events. TEAM
includes soldier and spouse workshops,
educational materials, a toll-free help line,
email services and a dedicated interactive
website. The significance of TEAM is its
protective and preventive implications.
Rather than diagnosing and treating, weare using resources from the environment(spouses, buddies), which conserves
healthcare resources. The study will
follow-up both soldiers and spouses overa period of 9 months post-deployment.

TEAM (Troop Education
for Army Morale) is an
educational program
designed to help U.S. Army
Mortuary Affairs Soldiersand their spouses deal
post deployment with thecomplex challenges that
often result from traumatic
exposure.

What about the Center’s growth in coreresources?
This year we plan to use “public accessdatabases” that will enable us to compare
data from populations we study to othercomparable populations. An example isaccessing Longscan data, which addresses
child neglect in the civilian population,and dovetails with our Family Violence
Program research of child neglect in the
military. In addition we will be working
with the Department of Defense Survey ofHealth Related Behaviors Among Military
Personnel (HRB) database to extend
our study of suicide in the military.
Another aspect of the Center’s researchis our dedication to training and educatingpromising scientists. We invest time andexpertise in building our training programfor postdoctoral professionals by providing
opportunities for growth in the area of trauma
and disaster research including grant writing,conducting empirical research, participating
in seminars and professional meetingsand publishing in professional journals.

8

Conversation with David M. Benedek, M.D.
PFA has become
an integral part

COL David M. Benedek, M.D.
Associate Director,
Consultation and Education
Center for the Study of Traumatic Stressof USU’s medical
student education
and a comprehensive
curriculum includinga ‘train the trainer’
approach with wide
ranging applications
as a trauma andresiliency building
intervention for militaryand civilian responder
populations.

“Increasingly the Center is turning its attention
towards answering critical military healthissues such as understanding the uniquerisk factors for suicide and developing
evidence-based interventions. Our scientificinitiatives continue to address not only PTSD
and TBI within military populations, butalso neglect, abuse, and reintegration into
garrison or civilian life after deployment.”
As Deputy Chairman of the USU
Department of Psychiatry and CSTS Associate
Director for Consultation and Education, Dr.
Benedek plays an active role in the Center’s
training, education and outreach, as well as
the Center’s research in neuroscience. Dr.
Benedek was instrumental in developing theAmerican Psychiatric Association’s Practice
Guideline for the treatment of Acute Stress
Disorder and Posttraumatic Stress Disorder(American Psychiatric Association, 2004),
and the APA’s PTSD Guideline Watch(American Psychiatric Association, 2009).
He has authored or co-authored over 75
scientific publications, and has presented on
numerous aspects of military, disaster, andforensic psychiatry at regional, national, andinternational professional conferences.
Dr. Benedek’s 2009 contributions on behalfof the CSTS include national recognition fora Centers for Disease Control and Prevention(CDC) first-responder resiliency officer
training program incorporating principles
of PFA and peer support, and leadership as

both a team member and PI for some major
research initiatives that build upon theCenter’s pioneering work in the neurobiology,
as well as, prevention and recovery
elements of trauma-related disorders.
In describing your role and activities at CSTS,
how would you characterize 2009 in termsof the Center’s contributions and advances intrauma research, education and consultation?
The Center is currently engaged in threenoteworthy research projects addressing theneurobiology of trauma with implications
for PTSD and related brain injury prevention
and treatment. The first involves theCongressionally Directed Medical Research
Program’s (CDMRP) INTRuST Clinical
Consortium; I serve as principal investigatorfor one of its sites, the National Capital Area
Integrated Clinical Study Site (NCAICSS).
The second is the VA-DoD PTSD CNS Tissue
Repository, formerly referred to as Brain Bank.
The third builds on the work of our prior
p11 studies and is referred to as our Stress &Biomarkers in a Military Population study.
The NCAICSS is a collaboration of DoD,
U.S. Department of Veterans Affairs (VA), andcivilian clinicians and researchers within the
National Capital region that comprise oneof the ten sites with the CDMRP’s clinicalconsortium for Psychological Health and
TBI. Dr. Murray Stein at the University ofCalifornia San Diego directs this 10 site
clinical consortium. Our site has establisheda network of clinician-researchers at Walter
Reed Army Medical Center (WRAMC),
National Naval Medical Center (NNMC),
the DC VA Hospital, and the Armed Forces
Retirement Home that will initiate clinical9trials for novel medications and psychotherapy
treatment for PTSD and other combat-relateddisorders including mild traumatic brain
injury (mTBI). The Study Site includes CSTS
neuroscientist Connie Duncan, whose 5-year, 2million dollar neuro imaging, cognitive testing,and electrophysiological profiling study ofservice members with mTBI will be one of
the first studies initiated by the consortium.
What are the activities of the DoD-VA
Collaborative Tissue Repository?
The DoD-VA Collaborative Tissue
Repository represents a renewed direction
for Brain Bank, a group led by the CSTS andthe National Center for PTSD (NCPTSD).
This group previously studied a small
sample of PTSD and matched control
brains (from the Stanley Medical ResearchInstitute and NIH collections) that resulted
in the identification of candidate biomarkers
for PTSD and the p11 study (described
below). DCoE has provided CSTS withadditional funding to establish ethical andregulatory advisory groups to insure that
donor identification, consent, assessment,
and processes related to specimen collection
and distribution are conducted in accordancewith relevant ethical considerations andlegal standards and with the highest degreeof respect for donors and their families.
Could you describe the p11 study that builds on
the Center’s work in the neurobiology of stress?
Our Stress and Biomarker study willenroll, survey and collect blood samples
from approximately 1,200 soldiers fromhighly operational, frequently deployed units
at a large Army base. Of this group, 80%
are likely to have experienced significant
combat exposure. Anonymous surveys will beadministered to encourage accurate selfreporting, and will screen for probable PTSD,
depression, mTBI, substance use disorders
and previous trauma history. Blood andPsychological First Aid Principles
Psychological first aid (PFA) includes five core principles: safety,
calming, connectedness, self-efficacy, hope, and optimism. The
actions taken when administering PFA include the following:■■ Contact and engagement with members of the team■■ Physical and psychological safety assessments■■ Calming and stabilizing distressed persons■■ Gathering information about issues or concerns■■ Offering practical assistance■■ Making connections■■ Helping others cope■■ Linking distressed people with collaborative services

saliva samples will also be taken. We will
analyze data to determine if p11 or otherprotein biomarkers can discriminate between
vulnerability for PTSD or other mental
disorders, or serve as a marker for diseasestatus. Among our Center’s research advances

CSTS in the News (see CDC
Website above): Virtual
Reality Helps CDC Staff
Deployed for Outbreak
Response Prepare for Stress.
Published: May 14, 2009.

10

in 2009 are the unique combining of two
distinctly different scientific methodologies— psychosocial measures (the survey
was created by CSTS Scientific Director,
Dr. Fullerton) and genetic biomarkers.

1. Zhang: p11 mRNA levels in
PBMCs of controls, PTSD, BP,
MDD & SCZ (top image, left).
2. Zhang: Relationshipbetween PBMC p11 mRNA
expression levels andsymptoms of PTSD (topimage, right).
3. ZhangL 5-HT2A receptors
were highly expressed on
the Parvalbumin-labeledInterneurons in the amygdala(bottom image, left).
4. Johnson: Stress Signaling at
the Synapse (bottom image,right).

Your work in the training and application of
PFA is very exciting. How was the Center
involved in helping CDC’s first responders?
Our work with CDC represents anothernew direction for our Center – applying
evidence-informed approaches to real world
trauma response training. For decades, CDC
professionals have deployed around theworld to control disease outbreaks, collect
health knowledge, and improve response
strategies. In addition to protecting physicalsafety, there has been recognition of themental stressors that responders experiencefrom traumatic exposure to events suchas the Sumatran Tsunami and Hurricane
Katrina. To address this, CDC provided
funding to CSTS to develop and implement
training for their Deployment Safety and
Resiliency Team (DSRT) officers. The key
component of this training is Psychological

1

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3

4

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First Aid (PFA). We taught DSRT its basic
concepts (see PFA Principles on page 9) tobuild resiliency among colleagues throughpeer support. PFA has become an integral
part of USU’s medical student education
and a comprehensive curriculum includinga ‘train the trainer’ approach with wide
ranging applications as a trauma andresiliency building intervention for militaryand civilian responder populations.

Neuroscience Activity at Center for the
Study of Traumatic StressCenter neuroscientists have discovered
two new critical components in theneurobiology of post traumatic stress disorder(PTSD). In addition to characterizing thefunction of serotonin (5-HT2A) receptors instress response, the CSTS and its collaborators
have identified changes in the levels of the p11
gene and protein (p11) and have measured
gene expression within cellular mitochondria.
These observations may lead to newtreatments and diagnostic tools for PTSD.
The posters on this page illustratesome of the translational research
conducted by Center neuroscientists.
The fourth annual Amygdala, Stressand PTSD Conference, sponsored by
CSTS and the USU Graduate Programin Neuroscience, was held on April 28th,
2009 at USU. The conference, which brings
together scientists and clinicians working
towards solving the biological basis of posttraumatic stress disorder, featured Nobel
Laureate, Dr. Paul Greengard’s work on
neuronal function and memory processes/
intracellular components of synaptictransmission. He presented on his work: p11
as a predictor of vulnerability to depression.

11

Conversation with John A. Stuart, Ph.D.

The Center’s grantfunding has gone from$4 million in February
08, to $21 million inJune 09, to over $70
million in July 09. Ourorganizational structure
must reflect and respondto these changes andthe challenges posed.”

John A. Stuart, Ph.D.
Director, Resource Management
Center for the Study of Traumatic Stress“We’re trying to accommodate our facilities
to meet unprecedented demand and growththat has resulted from a dramatic increasein grants. The Center’s grant funding hasgone from $4 million in February 08,
to $21 million in June 09, to over $70
million in July 09. Our organizational
structure must reflect and respond to thesechanges and the challenges posed.”In his role as Director, Resource
Management, Dr. Stuart oversees the Center’shuman resources, information technology,
operations and grants. Prior to year 2004,
he served 21 years in the U.S. Army as a
Research Psychologist with assignments
at the U.S. Army Medical Research andMaterial Command, Ft. Detrick, Maryland,
the Walter Reed Army Institute of Research,
Washington DC, and U.S. Army Academy ofHealth Sciences, San Antonio, Texas. Dr. Stuart
has published on a variety of stress related
research topics covering recent military
deployments, stress indices and measures,and reports in belief to toxic exposures.

In your role as CSTS Director for Resource
Management, how would you characterize theCenter’s highlights and growth in 2009?
My role involves acquisition andmaintenance of computer related hardware,
software, accessories or any device, which
promotes knowledge, data processing
and retrieval. This includes the Center’s
large literature database with over 20,000
publications and extensive research datasets.
I supervise a staff that includes a Computer
Scientist and support staff. The most complex,
time-intensive aspect of my work at theCenter is oversight and administrative
support of all of our submitted and accepted
grants. One could generally characterize
the process in terms of months — that
include development, award, and post award
periods of performance. Research grants
are designed to answer questions of scienceand behavior and as such involve a dynamic
system of personnel, technology, expenses
and other support to effect the process.
A review of the grants — ongoingand new as of 2009 — is an excellent
way to understand the Center’s impact
and growth in 2009 (see next page).

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Active Grants
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CSTS Health Education Conference Series
Trauma Health Education: Psychological and Behavioral Response, Recovery,
and Mitigation
Development of the Child and Family Trauma Program
Family Violence and Trauma Project III
Neuroscience Education and Training*Protecting the Health, Safety & Resilience of Deployed Staff*Safety and Health at Work for all People
Amphetamine Challenge: A Marker of Brain Function that Mediates Risk for Drug
Abuse and Alcohol Abuse
Inhibitory Control: Toward a Vulnerability Phenotype*Clinical Study Site for PTSD and TBI (sub-award)
Addressing the Needs of Children and Families of Combat Injured*Mortuary Affairs Soldiers: Early Intervention and Altering Barriers to Care forTraumatic Stress and PTSD
Deployment Family Stress: Child Neglect and Maltreatment in U. S. Army Families
Mental Health and Service Utilization Among Reserve and National Guard Forces(sub award)*PTSD Trajectory, Co-morbidity, and Utilization of Mental Health Services among
Reserve Forces (sub award)*PTSD Trajectory, Co-morbidity, and Utilization of Mental Health Services among
National Guard Soldiers
Stress and Resiliency in U. S. Army Mortuary Affairs Soldiers*P11, a Biomarker for Memory Retrieval: A Possible Role in Traumatic Stress
Corticosterone Administration to Promote Fear Memory Forgetting Process in an
Animal Model of PTSD
Neurobiological Evaluation of Novel Targets for Therapeutic Intervention in PTSD
Identification of Gene Expression Patterns in Brain Tissues and Peripheral White
Blood Cells of Rat Model of PTSD
Community Shielding Applications to the National Capital Region (Sub award)*Guidelines for Assessing and Measuring Community Resilience*CSTS - Program Grant*FOCUS-CI Preventive Intervention with Children and Families of Combat Injured*U.S. Army STARRS (Studies to Assess Risk and Resilience in Servicemen)* Indicates grants received in 2009.

13

Conversation with Stephen J. Cozza, M.D.
The work of theCenter’s Child andFamily Program is
especially focusedon the impact of war
including deployment
stress, parenting andfamily function, andthe impact of war
injuries on militarychildren and families.

Stephen J. Cozza, M. D.
Associate Director, Child and Family Program
Center for the Study of Traumatic Stress“We have laid the groundwork for collecting
scientifically-based data from militaryfamilies. Our findings will help us develop
evidence-based approaches and interventions
that are responsive to families under stressand change. Supporting the psychologicalhealth and resilience of our military families
also fosters our nation’s national security.”
Dr. Cozza, CSTS Associate Director,
oversees the Child and Family Program(CFP), which provides national leadershipin advancing scientific knowledge andclinical interventions that address the needsof children and families affected by trauma.
The work of the Center’s Child and Family
Program is focused in large part on the impact
of war including deployment stress, parenting
and family function, and the impact of war
injuries on military children and families. Thisoutreach is accomplished through research
programs, education of military andcivilian leadership, and consultation
to diverse stakeholders in children’s
health and welfare including
national media outlets, professionalorganizations, and projects dedicatedto helping children and families
affected by traumatic events.
Could you describe some of thehighlights and contributions of
CFP in 2009?
The CFP has contributed
its expertise in understanding

and responding to child and family
trauma in the arenas of national disaster
preparedness, as well as in military health— advancing the care and resilienceof military children and families.
In the area of national preparedness,
the Center served on the Advisory Boardof Sesame Workshop’s “Let’s Get Ready:Planning Together for Emergencies.” The
U.S. Department of Homeland Security isusing this educational resource to assist
young children and families in preparing fordisasters as part of their Ready.gov campaign.
I also had the opportunity to chair theDisaster Committee and Disaster Task
Force of the American Academy of Childand Adolescent Psychiatry, as well as topresent, “The Role of Child Psychiatrists in
Disaster Response,” at their annual meeting.
What about your work with military children
and families?
The Center has been a leader inunderstanding, studying and educating
the nation around the unique challenges

14

CFP contributed to thebook, For Children ofValor, and published thefirst document on caring forcombat injured families.

and needs of military children that result
from the ongoing deployment to Iraq and
Afghanistan. This year, in addition to ourcurrent military child and family research
projects, we received $6 million in funding
from Congressionally Directed Medical
Research Programs (CDMRP) to adapt anintervention that has been used successfully
with high-risk traumatized children andfamilies. The grant, referred to as FOCUS-CI
Preventive Intervention with Children andFamilies of Combat Injured, is supported by
the Center’s collaboration with prominent
child and adolescent psychiatrists andresearchers at Harvard, UCLA and Universityof Washington. We are adapting this familycentered intervention, FOCUS (originallynamed Families Overcoming and Coping
under Stress), for use with military children
affected by parental injury. Importantly, ourresearch initiatives have laid the groundwork
for collecting scientifically based data frommilitary families. Our findings will further
inform and help develop approaches andclinical interventions that are evidencebased. Supporting the psychological healthand resilience of our military families also
fosters our nation’s national security.

What has been the role of the Center’sChild and Family in public education andconsultation?
We strive to communicate our knowledge
to important professional audiences as wellas to the general public. We published an
important document, the first of its kind,outlining the issues and challenges of caring
for military families and children affectedby parental, war-related injury. Proceedings:
Workgroup on Intervention with Combat
Injured Families also contains Principles
of Caring for Combat Injured Families
and their Children and two Resources for
Recovery fact sheets for military healthcare providers and military families.
A consultation highlight, the result of
several years involvement as an advisor to
Sesame Workshop, was our work on the
Sesame Street PBS Special, “Coming Home:
Military Families Cope with Change” where
I explain PTSD to Elmo, the muppet. This
television special was a phenomenal tributeto the needs and valuing of military children.
I also had the honor of helping write a book,
For Children of Valor, which Arlington
National Cemetery will provide to young
children who have lost a parent in war.
CSTS CFP continues its collaborations
with National Child Traumatic Stress Network(NCTSN), Zero to Three, Military Child
Education Coalition (MCEC) and National
Military Family Association (NMFA). We
worked collaboratively with NMFA to
study families of injured service members
attending their Operation Purple (Healing
Adventures) Camps, another opportunity
to learn about the effect of these profound
events on military children and families.

15

How would you sum up 2009 as aspringboard to the growth and impact
of CFP?
We have laid the groundwork forcollecting scientifically based data frommilitary families. Our findings will help
us develop evidence-based approaches
and interventions that are responsive
to families under stress and change.
Supporting the psychological health andresilience of our military families also
fosters our nation’s national security.
We are contributing our knowledge
to enhance national preparedness for all
children and families. Through strong
collaborations that strengthen our researchand educational outreach, CFP is positioned
to continue to shape and advance thefield of child and family trauma.

Center for the Study of Traumatic Stress
Understanding the Effects of Trauma and Traumatic Events to Help Prevent, Mitigate and Foster Recovery for Individuals, Organizations and Communities

A Program of Uniformed Services University, Our Nation’s Federal Medical School, Bethesda, Maryland • www. usuhs.mil/csts/

Casualty Assistance Information:
Meeting the Needs of Military Families and Children
The death of a military parent is aThis fact sheet addresses the needs
This fact sheet addresses the needs oflife-changing event that impacts theof military families, especially children
entire family, the surviving spouse or
who experience the unthinkable loss
military families, especially children,next of kin (NOK), and any children.
of a parent through combat injury or
who experience the unthinkable loss
The casualty assistance officer (CAO)
deployment related accidents. The factof a parent through combat injury or
often meets the military family at the
sheet provides general information on
critical crossroads of grief (reaction
children’s grief upon learning of theirdeployment related accidents.
to the loss of a loved one) andparent’s death as well as details about
bereavement (working through thechildren’s understanding of death atgrief). While grief and bereavement are normal processes
different ages. There is also information on warning signsof human experience, they differ in their expression andthat may indicate a child’s need for professional help in
intensity for each individual, and often reflect a family’s
coping, as well as recommendations about the involvement
unique cultural, ethnic, spiritual and social background.
of children in funerals, especially military funerals.
Understanding Children’s Grief and Bereavement
Children are likely to be powerfully affected by thedeaths of loved ones, but may be less able to express
confusing thoughts and feelings in words. While many
children may express feeling sad, cry or become more
withdrawn, others will express their emotions throughbehaviors that may be regressed, reverting back to earlier
behaviors. Infants and toddlers are likely to experience
the death through the emotional responses or change inavailability of the important adults in their lives. Veryyoung children can demonstrate changes in sleeping or
eating patterns or develop tantrums or overactive behavior.
School aged children may express emotional concerns
through physical complaints such as stomachaches orheadaches. Teenagers often wish to present themselves as
independent and not in need of adult help. Their sullenness
or seeming disconnectedness should not be mistaken for alack of emotional response to a death. Behavioral changes
in any grieving child are better viewed as due to emotional
responses rather than disciplinary problems.
Children’s Understanding of Death
It is important to appreciate how children of different
ages understand and may react to their parent’s death. This
information can be helpful to you and the next of kin.

Ages 0–3
Children younger than 3 do not understand the concept
of death, but toddlers can understand the notion of ‘here’
and ‘not here’. Children of this age are very aware of theemotional reactions of their caretaker and will react to the
NOK’s level of distress. Children of this age experienceanxiety if separated from their caretakers. They do not needverbal explanations, so much as needing to be held by andclose to their caretakers and maintaining a normal routine.
Ages 3–7
Children at this stage have limited understanding
and need to be told that death is permanent. Simple facts
should be explained such as who died, where and how.
They understand that the body stops functioning when aperson dies, but may need help to fully understand whatthat means. Examples of ways to explain death include,“Daddy no longer sees, hears, eats, talks or moves.” Likening
death to the death of a pet can also be helpful. It is unwise
to tell children that the deceased is sleeping or resting
because the child may interpret this literally causing them
to be confused and fearful.
Ages 7–11
At this stage, children need to be told more facts of who
Continued on reverse side

CSTS is a part of the Department of Psychiatry of Uniformed Services University and a partnering center of the
Defense Centers of Excellence (DCoE) for Psychological Health and Traumatic Brain Injury

One of many CSTS fact sheets
prepared for military families
and children.

16

Conversation with Nancy T. Vineburgh, M.A.
We translate theacademic and clinicalexpertise of the Centerin disaster planning,
response and recovery,
and military uniquehealth issues aroundtrauma for the benefitof our civilian andmilitary populations.

Nancy T. Vineburgh, M.A.
Associate Director, Office of Public
Education and Preparedness
Center for the Study of Traumatic Stress“The Center, as part of the USU Departmentof Psychiatry, is regarded as the trusted voice
regarding the psychological effects and healthconsequences of trauma and traumatic stressin the arena of military and public health.
OPEP develops educational resources that
communicate the Center’s voice and vision.”
Nancy Vineburgh oversees CSTS Officeof Public Education and Preparedness(OPEP). She provides communicationand public education expertise on healthand mental health topics, and works with
CSTS scientists to develop and disseminate
educational resources for military and
FAC T SHEET FOR PROVIDERS

C  CA H P C Uniformed Services University of the Health Sciences, your federal medical school, Bethesda, Maryland • www. usuhs.mil

R R
Shared Sense of Purpose
REINTEGRATION CHALLENGES
Uniformed Services University applauds
the educational efforts and programs our
Department of Defense community isproviding to assist troops and their families
in the reintegration process post deployment.
To enhance these efforts, our military trauma
experts have prepared this concise and friendly,
two-part fact sheet that is based upon recent
interviews with affected families. You may
forward this Provider Fact Sheet and theattached Fact Sheet for Couples electronically,or download them for distribution to military health andcommunity leaders, and the military families they serve.
Local contact information can be added to the Couples
Fact Sheet in the space provided by hand or using the fullversion of Adobe Acrobat. We encourage you to reachout to the many spouses of young soldiers who returned
to families of origin and other sources of support notconnected to military communities.

REAL ISSUES

Courage to Care, launched in
2004, celebrates five years of
public education service to
our nation.

The changing nature and complexity of the Iraq war
has contributed to reintegration stresses experienced byservice members, their spouses and families. The military
operation in Iraq, a conventional conﬂict between armies
for only a few weeks, became a predominantly guerilla
war with no front-line, constant threat and a disguised
enemy. Humanitarian and peace keeping missions suchas rebuilding schools, hospitals, and training police forces
have and continue to put our troops in harm’s way. Many
service members and families have encountered confusionand stress due to this variety of missions compounded byextended or open-ended return dates.

REFRAMING THE CHALLENGE:
SHARED-SENSE-OF-PURPOSE PARADIGM
The challenge of reintegration can be summed
up in three words: sense of purpose. The biggest
task for the returning service member is totransform a sense of purpose created by theintensity of war into the routines and safety of
everyday life. Similarly, the service member’sfamily has established a sense of purpose
sustaining the home and its routines in theabsence of the spouse. Helping couples respect
each other’s perspective and reestablish a sharedsense of purpose is a constructive paradigm that addresses
standard concepts such as emotional changes, expectations
and adjustments, and reframes them into an actionoriented, positive approach for moving couples forward.

ROADMAP FOR REINTEGRATION
The attached fact sheet presents a four-step guide on how
couples can reestablish a shared sense of purpose. It can be
distributed as a takeaway after educational debrieﬁngs, orused with existing programs. The four steps to achieving ashared sense of purpose are:
1. Understand common factors that have shaped theservice member’s and spouse’s sense of purpose during
separation;
2. Recognize common concerns shared by service member
and spouse resulting from the separation;
3. Be aware of relationship breakers: common, sensitive
issues that can distance couples;
4. Focus on relationship makers: ways to build sharedexperiences, shared sense of purpose and closeness.

Courage TO Care is a new health promotion campaign of Uniformed Services University.
Its purpose is two-fold: to provide quality health information reﬂecting our University’s
excellence in military medicine and to present it in a friendly, appealing format for
immediate distribution for the health promotion needs in your community.

civilian audiences. Under her leadership,
the Center spearheaded Courage toCare, an electronic fact sheet initiativethat is distributed to military healthcare
providers and service members andfamilies nationally and internationally.
She has conducted research and publishednumerous articles on workplace
preparedness for terrorism and disaster.
In your role as CSTS Associate Director of
Public Education and Preparedness, could
you describe the Center’s 2009 highlights
and contributions in public education andoutreach around the impact of trauma?
The OPEP was established in 2004 totranslate the academic and clinical expertiseof the Center in both disaster planning,
response and recovery, and militaryunique health issues around trauma forthe benefit of our civilian and military
populations. This includes stakeholders
in government, industry and academia,
healthcare providers as well as individuals,
families and communities. Among our first,
highly successful projects was Courage toCare, an electronic campaign on timely
topics of military health that is a valued
resource for providers and families who
experience the impact of deployments,
war injuries and the challenges ofparenting under stress. Courage to Care
has sustained its visibility and relevancefor five years, and continues to support
the psychological health and resilience of
our service members and their families.
For the second consecutive year, theCSTS received the American Graphic DesignAward for excellence in graphic presentation

17of its public education resources. This year
the CSTS 2008 Annual Re­port received
the award. Last year’s award winningpre­sentation was the Center’s Cour­age to
Care for Me campaign, introduced during
April’s Month of the Military Child.
Have you reached out to any new audiences
this year?
Yes, Courage to Care has been expanded
to include a new, yet to be launchedcampaign, Courage to Care Courage to Talk.
This campaign is designed to facilitatecommunication around war injuries in
hospital settings between affected families
and healthcare professionals as well as
within the family itself, especially aroundthe impact on children whose parent hassustained serious injury. OPEP developed
a poster for November’s DoD Warrior Care
Month highlighting the Center’s resources
around warrior care, and assisted in the
production of an important document,
Proceedings Workgroup on Intervention
with Combat Injured Families.
How does OPEP assist other programs andprojects within the Center?
We provide editorial, design andproduction assistance for many projects
including, Joining Forces Joining Families,
a quarterly newsletter on family violence
research for the U.S. Army Family
Advocacy Program and leadership.
How would you sum up the Center’s public
education contributions for 2009 and going
forward?
The Center, as part of the USU
Department of Psychiatry, is regarded
as the trusted voice regarding thepsychological effects and healthconsequences of trauma and traumaticstress in the arena of military and publichealth. OPEP develops resources that
communicate the Center’s voice andvision. The Center, as the academic
arm and a partnering center of DCoE,
continues to be responsive to the needs
for public education that supports thehealth and mental health of militaryfamilies, especially those affected bydisorders such as depression, PTSD,
substance abuse, family violence and
TBI. Importantly, we are capable ofdeveloping public education resources inreal time on important topics that affectour nation such as H1N1. Going forward,
we hope to align our public education
outreach with the Center’s suicide related
research activities and initiatives.

Representative CSTS public
education products —posters, fact sheets, andwebsites.

18

Conversation with Brian Flynn, Ed.D.
Dr. Flynn represents
the Center at national

Brian Flynn, Ed.D.
Associate Director,
Health Systems
Center for the Study of Traumatic Stressand international
conferences on
the integration of
behavioral healthprinciples in planning,
response and recovery
around traumatic
events, publichealth issues andhealthcare systems.

“The Center has helped ensure thatbehavioral health is at the table arounddiscussion for disaster planning, response andrecovery, as well as for public health threats.
Educating health systems helps us sustain
and enhance this important dialogue.”In his role as Associate Director for
Health Systems, Dr. Flynn represents
the Center at national and international
conferences on the integration of
behavioral health principles in planning,
response and recovery around traumatic
events, public health issues and healthcare
systems. Prior to retiring from federal
service in 2002 as a Rear Admiral/Assistant
Surgeon General in the United States
Public Health Service (USPHS), Dr. Flynn
supervised the operation of the Federal
Government’s domestic disaster mental
health program (including terrorism), as
well as programs involving suicide andyouth violence prevention, child trauma,
refugee mental health, women’s andminority mental health concerns, andrural mental health. He accompanied Vice
President and Mrs. Gore to Columbine
following the school shootings to meetwith the families of those who were killed.
He served as a special consultant to theUnited States Agency for International
Development and the State Department
following the bombings of the U.S.
Embassies in Kenya and Tanzania.

What have been the 2009 highlights of yourinvolvement in education and training for
behavioral health issues in disasters andemergency?
This has been a year of international
outreach and an expanded direction
in public health issues. As part of ourdisaster preparedness and education
efforts, I co-presented a preconference
workshop prior to the National Forum on
Emergency Preparedness and Response,“The Right Stuff at the Right Place:
Building Surge Capacity in Canada.”
I also conducted a one-day workshop
with James Shultz, Ph.D. of Universityof Miami, Disaster and Extreme Event
Preparedness (DEEP) Center in Winnipeg,
Manitoba, Canada. The content wasawareness level behavioral health issues
in disasters and emergency. The Public
Health Agency of Canada, with ourconsultation, is in the process of adaptingthat workshop into an online course
to be available throughout Canada.
I was very privileged to present the
keynote address in Jerusalem at theInternational Conference on Organizational

19

and Professional Responses to Disasters
sponsored by the Schools of Social Workat Rutgers and Ben-Gurian University.
How has your work encompassed new
directions in public health?
An important emerging topic is the
behavioral health factors in understanding
childhood vaccine hesitation. I provided
a keynote, Understanding Psychosocial
Factors, at the Childhood Vaccine Safety
Development Workshop in Washington
sponsored by Oak Ridge Institute for
Science and Education, part of the U.S.
Department of Energy. This led to anotherpresentation, “Addressing Vaccine Hesitancy:
Psychosocial Considerations,” deliveredat CDC’s 43rd National Immunization
Conference, in Dallas, Texas.
How do you envision building uponand expanding the Center’s work 		
going forward?
Along with Dr. Ursano, I was
privileged to be appointed to serveon the Mental Health Subcommitteeof the National Biodefense Science
Board (NBSB). This subcommittee wasestablished under the requirements ofHomeland Security Presidential Directive#21 (HSPD-21) whose goal is to enhance
all elements of the nation’s health caresystem to respond to extraordinary events
that impact the public’s health. I haveprovided special consultation on issues
involving communication opportunities
and challenges. The subcommittee
anticipates continuing to advise the
NBSB on behavioral health elements ofa variety of topics including H1N1.
The Center has helped ensure thatbehavioral health is at the table arounddiscussion for disaster planning, response
and recovery as well as for public healththreats. Educating health systems helps
us sustain this important dialogue andcontribution. Helping the Center achieve
this continued visibility and the ongoingprovision of content expertise is my
primary objective going forward.

20

Publications
Department of Psychiatry
Recent Publications
Benedek DM and Ursano RJ: Exposure
to war as a risk factor for mental disorders. Public Library of Science: Medicine,5(4): e82, 2008.
Benedek DM, Friedman MJ, Zatzick D,
and Ursano RJ: Guideline watch: Practiceguidelines for the treatment of patientswith acute stress disorder and posttraumatic stress disorder, 2009.
Benedek DM and Ursano RJ: Understanding PTSD: From phenomenology toclinical practice. Focus, 7: 160–175, 2009.
Braga M, Aroniadou-Anderjaska V, Li
H, and Rogawski M: Topiramate reduces
excitability in the basolateral amygdala
selectively inhibiting GluK1 (GluR5)
Kainate receptor on interneurons andpositively modulating GABAA receptors
on principal neurons. Journal of Pharmacology and Experimental Therapeutics,(in press).
Donaldson LP, Ahearn FL, Fullerton CS,
Gifford RK, and Ursano RJ: Resiliency
among people who are homeless during
the Washington-area sniper attacks ofOctober 2002. Journal of Poverty, 13(1):20–39, 2009.
Engel CC, Oxman T, Yamamoto C, Gould
D, Barry S, Stewart P, Kroenke K, Williams JW Jr, and Dietrich AJ: RESPECTMil: Feasibility of a systems-level collaborative care approach to depression andpost-traumatic stress disorder in militaryprimary care. Military Medicine, 173(10):935–940, 2008.
Fullerton CS, Gifford RK, Flynn BW,
Peterson K, Ahearn F, Donaldson L, andUrsano RJ: Effects of the 2002 sniper
attacks on the homeless population in
Washington, DC. Disaster Medicine andPublic Health Preparedness, 3(4): 1–5,
2009.

Flynn BW and Lane CF: Integratingorganizational and behavioral healthprinciples to promote resilience in extreme events, in International Terrorism
and Threats to Security: Managerial andOrganizational Challenges. C. Cooper, R.
Burke (eds.) Edward Elgar Publishing,
2008.
Gore KL, Engel CC, Freed MC, Liu
X, and Armstrong DW III: Test of asingle-item posttraumatic stress disorderscreener in a military primary care setting. General Hospital Psychiatry, 30(5):391–397, 2008.
Hoge CW, McGurk D, Thomas JL, Cox
AL, Engel CC, and Castro CA: Mild traumatic brain injury among U.S. soldiers
returning from Iraq. New England Journal of Medicine, 358(5): 453–463, 2008.
Howe EG: Improving the quality of life
for patients with Alzheimer’s disease. Psychiatry (Edgemont), 5(8): 51–56, 2008.
Howe EG: When, if ever, should careproviders share their moral views withpatients? The Journal of Clinical Ethics,
19(1): 3–10, 2008.
Howe EG: Red towels: Maximizing thecare of patients who are dying. The Journal of Clinical Ethics, 19(2): 99–109, 2008.
Howe EG and Gross ML: Medical ethics
during war. Medical Ethics, 15(2): 6–7,
2008.
Howe EG and Howe C: Three keys totreating inmates and their application in
ethics consultation. The Journal of Clinical Ethics, 19(3): 195–203, 2008.
Howe EG: Beyond informed consent:
The ethics of informing, anticipating, andwarning. Psychiatry (Edgemont), 5(10):42–47, 2008.
Howe EG: Child abuse: How society
and careproviders should respond. The
Journal of Clinical Ethics, 19(4): 307–315,
2008.
Howe EG, Kosaju A, Laraby PR, andCasscells SW: Guantanamo: Ethics interrogation, and forced feeding. Military
Medicine, 174(1): iv–xiii, 2009.

Howe EG: Using nonevidence-based approaches to treat patients with Alzheimer’s disease. Psychiatry (Edgemont), 6(3):20–25, 2009.
Howe EG: Increasing consensus with inpatients and their loved ones. The Journalof Clinical Ethics, 20(1): 1-12, 2209.
Howe EG: Review of Michael L Gross,bioethics and armed conflict/moral dilemmas in medicine and war. The American Journal of Bioethics, 8(10): 82-84,
2008.
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,
34(2): 410–423, 2009.
Jiang X, Zhanj Z-j, Zhang S, Gamble
E, Jia M, Ursano RJ, and Li H: 5-HT2A
receptor antagonism by MDL 11,939
administered prior to inescapable stressor prevents subsequent exaggerationof acoustic startle response and reduced
body weight in rats. Journal of Psychopharmacology, (in press).
Kang HK, Li B, Mahan CM, Eisen SA,
and Engel CC: Health of U.S. veteransof 1991 Gulf War: A follow-up survey
in 10 years. Journal of Occupational andEnvironmental Medicine, 51(4): 401–410,
2009.
Kessler RC, Galea S, Gruber MJ, Sampson
NA, Ursano RJ, and Wessely S: Trends
in mental illness and suicidality after
Hurricane Katrina. Molecular Psychiatry,
13(4): 374–384, 2008.
Kessler RC, Keane TM, Ursano RJ, Mokdad AH, and Zaslavsky AM: Sample anddesign considerations in post-disastermental health needs assessment tracking
surveys. International Journal of Methods in Psychiatric Research, 17(Suppl 2):
S6–S20, 2008.
Kessler RC, Keane TM, Mokdad AH,
Petukhava M, Ursano RJ, and Zaslavsky
AM: Measuring vulnerability in post disaster mental health needs assessments.
Health Affairs, (in press).

21

Liu X, Engel CC, Armstrong DW, andKang H: Survival convergence and thepreceding mortality crossover for two
population subgroups. Population Researchand Policy Review, 27(3): 293–306, 2008.
McCarroll JE, Fan Z, Newby JH, Ursano RJ, and Fullerton CS: Trends in
U.S. army child maltreatment reports:
1990–2004. Child Abuse Review, 17(2):108–118, 2008.
McCarroll JE, Castro S, Nelson EM, FanZ, Evans PK, and Rivera A: Establishing and maintaining a volunteer victim
advocate program to assist victims of domestic violence in the U.S. army. Military
Medicine, 173(9): 860-864, 2008.
McCarroll JE, Castro S, Nelson EM,
Fan Z, Evans PK, and Rivera A: Characteristics of domestic violence incidents
reported at the scene by volunteer victim
advocates. Military Medicine, 173(9):865–870, 2008.
Osuch EA, Willis M, Bluhm R, CSTS
Neuroimaging Study Group, Ursano RJ,
and Drevets WC: Neurophysiologicalresponses to traumatic reminders in theacute aftermath of serious motor vehicle
collisions using [15O]-H2O positronemission tomography. Biological Psychiatry, 64(4): 327–335, 2008.
Robinson R, Davis JD, Krueger M, Gore
KL, Freed MC, Kuesters P, Dube S, andEngel CC: Acceptability of adverse childhood experiences questions for healthsurveillance in U.S. armed forces. Military
Medicine, 173(9): 853–859, 2008.
Stuart J, Ursano RJ, Fullerton CS, andWesley S: Belief in exposure to chemicaland biological agents in Persian Gulf War
soldiers. Journal of Nervous and Mental
Disease, 196(2): 122–127, 2008.
Su YA, Wu J, Zhang L, Zhang Q, Su DM,
He P, Wang BD, Li H, Traumatic Stress
Brain Study Group, Rennert OM, andUrsano RJ: Dysregulated mitochondrial
genes and networks with drug targets inpostmortem brain of patients with posttraumatic stress disorder (PTSD) re-vealed by human mitochondria-focused
cDNA microarrays. International Journalof Biological Science, 4(4): 223–235, 2008.
Su T, Zhang L, Chung M, Chen Y, Bi Y,
Chou Y, Barker JL, Barrett JE, Maric D, Li
XX, Li H, Webster MJ, Benedek DM, Carlton JR, and Ursano RJ: Levels of the potential biomarker p11 in peripheral blood
cells distinguish patients with PTSD
from those with other major psychiatricdisorders. Journal of Psychiatric Research,
43(13): 1078–1085, 2009.
Terhakopian A, Sinaii N, Engel CC,
Schnurr PP, and Hoge CW: Estimating
population prevalence of posttraumaticstress disorder: An example using the
PTSD checklist. Journal of TraumaticStress, 21(3): 290–300, 2008.
Ursano RJ, Li H, Zhang L, Hough CJ,
Fullerton CS, Benedek DM, Grieger
TA, and Holloway HC: Models of PTSD
and traumatic stress: The importanceof research “from bedside to bench to
bedside.” Progress In Brain Research, 167:
203–215, 2008.
Ursano RJ, Benedek DM, and Fullerton
CS: Posttraumatic stress disorder: Neurobiology, psychology, and public health.
Psychiatric Times, 25(3): 16–20, 2008.
Ursano RJ and Engel CC: The importance of assessing exposure to trauma.
Psychiatric Services, 59(3): 229, 2008.

Ursano RJ, Zhang L, Li H, Johnson L,
Carlton JR, Fullerton CS, and Benedek
DM: PTSD and traumatic stress: Fromgene to community and bench to bedside. Brain Research, 1293: 2–12, 2009.
Vineburgh NT, Ursano RJ, Hamaoka
DA, and Fullerton CS: Public healthcommunication for disaster planning andresponse. International Journal of Public
Policy, 3(5/6): 292–301, 2008.
Yuan P, Salvadore G, Li XX, Zhang L,
Du J, Chen G, and Manji HK: Vaproate
actives the Notch 3/c-FLIP signalingcascade: A strategy to attenuate whitematter hyperintensities in bipolar disorder in late life? Bipolar Disorders, 11(3):256–269, 2009.
Zhang L, Li H, Su TP, Barker JL, Maric
D, Fullerton CS, Webster MJ, Hough
CJ, Li XX, Traumatic Stress Brain Study
Group, and Ursano RJ: p11 is up regulated in the forebrain of stressed rats by
glucocoricoid acting via two specific glucocorticoid response elements in the p11
promotor. Neuroscience, 153(4): 11261134, 2008.
Zhang L, Li H, Carlton JR, and Ursano
RJ: The injury profile after the 2008
earthquakes in China. Injury, 40(1):84–86, 2008.
Zhang L, Li H, Benedek DM, Li XX, andUrsano RJ: A strategy for the development of biomarker tests for PTSD. Medical Hypotheses, (in press).

22
22

CSTS Scientific Advisory Board
James E. Barrett, Ph.D.
Department of Pharmacology andPhysiology
Drexel University, College of Medicine
245 N. 15th Street
Mail Stop 488, Room 8213
Philadelphia, PA 19102-1192
BG (ret) William T. Bester, RN, MSN,
CNAA, BC
Vice President for Distributed Learning;
Acting Vice President of External Affairs
F. Edward Hebert School of Medicine
Uniformed Services University
4301 Jones Bridge Road
Bethesda, MD 20814-4799
Robert G. Darling, M.D., FACEP, CAPT,MC, USN (RET)
Director, Center for Disaster andHumanitarian Assistance Medicine
F. Edward Hebert School of Medicine
Uniformed Services University
4301 Jones Bridge Road
Bethesda, MD 20814-4799
M. Richard Fragala, M.D.
P.O. Box 182
Malverne, NY 11565
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

Carol S. Fullerton, Ph.D.
Scientific Director, Center for the Study ofTraumatic Stress
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
4301 Jones Bridge Road
Bethesda, MD 20814-4799
David S. Krantz, Ph.D.
Chair, Department of Medical and ClinicalPsychology
F. Edward Hebert School of Medicine
Uniformed Services University
4301 Jones Bridge Road
Bethesda, MD 20814-4799
Larry W. Laughlin, M.D., Ph.D.
Dean
F. Edward Hebert School of Medicine
Uniformed Services University
4301 Jones Bridge Road
Bethesda, MD 20814-4799
Craig H. Llewellyn, M.D.
Professor
Department of Military and Emergency
Medicine
F. Edward Hebert School of Medicine
Uniformed Services University
4301 Jones Bridge Road
Bethesda, MD 20814-4799
David H. Marlowe, Ph.D.
Senior Lecturer
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
4301 Jones Bridge Road
Bethesda, MD 20814-4799
Robert M. Post, M.D.
Head, Bioplar Collaborative Network
3502 Turner Lane
Chevy Chase, MD 20815
CAPT Gerald V. Quinnan, Jr., MC, USN
Professor and Chair, Preventive Medicine &Biometrics
RADM, USPHS (Ret)F. Edward Hebert School of Medicine
Uniformed Services University
4301 Jones Bridge Road
Bethesda, MD 20814-4799

ArikY. Shalev, M.D.
Professor and Chairman
Department of Psychiatry
Hadassah University School of Medicine
Jerusalem, Israel
CAPT Trueman Sharp, MC, USN
Department Chair, Military and Emergency
Medicine
F. Edward Hebert School of Medicine
Uniformed Services University
4301 Jones Bridge Road
Bethesda, MD 20814-4799
BG Loree K. Sutton, MC, USA
Director,
Defense Centers of Excellence for Psychological
Health and Traumatic Brain Injury
Robert J. Ursano, M.D.
Chairman, Department of Psychiatry
Professor of Psychiatry and Neuroscience
F. Edward Hebert School of Medicine
Uniformed Services University
4301 Jones Bridge Road
Bethesda, MD 20814-4799
Lars Weisaeth, M.D.
Professor and Chairman
Division of Disaster Psychiatry
University of Oslo
Oslo, Norway

23
23

CSTS Directors and Scientists
CSTS DIRECTORSCSTS SCIENTISTS

Robert J. Ursano, M.D.
Director, CSTS
Chairman, Department of Psychiatry
Professor of Psychiatry and Neuroscience
F. Edward Hebert School of Medicine
Uniformed Services University

COL David M. Benedek, M.D., MC, USA
Professor
Consultant to the U.S. Army Surgeon
General for Forensic Psychiatry
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University

COL David M. Benedek, M.D. MC, USA
Associate Director, Consultation and
Education, CSTS
Professor/Deputy Chair, Department of
Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
Stephen J. Cozza, M.D.
Associate Director, Child and Family
Program, CSTS
Professor, Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
Brian W. Flynn, Ed.D.
Associate Director, Health Systems, CSTS
Adjunct Professor, Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
Carol S. Fullerton, Ph.D.
Director, Scientific Research, CSTS
Professor, Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
Robert K. Gifford, Ph.D.
Executive Officer, andAssociate Director, Homeland Security
Studies, CSTS
Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
John A. Stuart, Ph.D.
Director, Resource Management, CSTS
Assistant Professor, Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
Nancy T. Vineburgh, M.A.
Associate Director, Public Education andPreparedness, CSTS
Assistant Professor, Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University

Quinn M. Biggs, Ph. D., M.P.H.
Research Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
Maria Braga, D.D.S., Ph.D.
Associate Professor
Department of Anatomy, Physiology 		and Genetics
F. Edward Hebert School of Medicine
Uniformed Services University
CDR Janis Carlton, M.D., MC, USN
Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
Stephen J. Cozza, M.D.
Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
Brian Crowley, M.D.
Clinical Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
Connie Duncan, Ph.D.
Research Associate Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
Richard S. Epstein, M.D., P.A.
Clinical Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
COL Charles Engel, M.D., M.P.H. MC, USA
Associate Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University

Martha Faraday, Ph.D.
Assistant Professor
Department of Medical and Clinical Psychology
F. Edward Hebert School of Medicine
Uniformed Services University
Brian W. Flynn, Ed.D.
Adjunct Professor, Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
Michael C. Freed, Ph.D.
Research Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
Carol S. Fullerton, Ph.D.
Research Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
Frances Gabbay, Ph.D.
Research Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
COL Gary Gackstetter, USAF
Associate Professor
Department of Preventive Medicine/Biometrics
F. Edward Hebert School of Medicine
Uniformed Services University
Robert K. Gifford, Ph.D.
Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
Krisitie Gore, Ph.D.
Research Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
Christine Gray, M.P.H.
Public Education Program Manager
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
Thomas A. Grieger, M.D.
Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University

24
24

Jennifer Guimond, Ph.D.
Research Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University

Jodi McKibben, Ph.D.
Research Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University

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

Maj. Derrick Hamaoka, M.D., USAF, MC, FS
Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University

Jamie Naifeh, Ph.D.
Research Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University

Lei Zhang, M.D.
Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University

Harry C. Holloway, M.D.
Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University

John Newby, Ph.D.
Research Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University

Tomoko I. Hooper, M.D.
Assistant Professor
Department of Preventive Medicine/Biometrics
F. Edward Hebert School of Medicine
Uniformed Services University

LCDR Patcho Santiago, M.D., M.P.H., 		
MC, USN
Assistant Professor
CSTS
F. Edward Hebert School of Medicine
Uniformed Services University

Luke Johnson, Ph. D.
Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
Elie Karam, M.D.
Professor and Chairman
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 University

Janet A. Schmidt, Ph.D.
Senior Scientist
CSTS
F. Edward Hebert School of Medicine
Uniformed Services University
John A. Stuart, Ph.D.
Research Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
E. Fuller Torrey, M.D.
Executive Director
Stanley Medical Research Institute
Bethesda, MD

He Li, M.D., Ph.D.
Associate Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University

Robert J. Ursano, M.D.
Chairman, Department of Psychiatry
Professor of Psychiatry and Neuroscience
F. Edward Hebert School of Medicine
Uniformed Services University

Xian Liu, Ph.D.
Research Assistant Professor
Deployment Health Clinical Center
Walter Reed Army Medical Center

Nancy T. Vineburgh, M.A.
Assistant Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University

David Marlowe, Ph.D.
Senior Lecturer
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University
James E. McCarroll, Ph.D., M.P.H.
Research Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University

Maree J. Webster, Ph.D.
Assistant Research Professor
Stanley Medical Research Institute
Bethesda, MD 20889
Lars Weisaeth, M.D.
Professor
Department of Psychiatry
F. Edward Hebert School of Medicine
Uniformed Services University

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!

DEFENSE CENTERS
OF EXCELLENCEFor Psychological Health& Traumatic Brain Injury

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