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Treatment of Deployment-Related Posttraumatic Stress Disorder

Chapter 19

treatment of deploymentrelated posttraumatic stress 

disorder

JOSEF I. RUZEK, PhD*; JEFFREY S. YARVIS, PhD†; and STEVEN LINDLEY, MD, PhD‡

INTRODUCTION

PSYCHOLOGICAL THEORIES OF POSTTRAUMATIC STRESS DISORDER AND

TREATMENT

TREATMENT OF DEPLOYMENT-RELATED POSTTRAUMATIC STRESS

DISORDER

ASSOCIATED PROBLEMS IN POSTTRAUMATIC STRESS DISORDER

TREATMENT

AREAS OF IMPAIRED FUNCTIONING

TREATMENT OUTCOME RESEARCH

TOWARD IMPROVEMENT OF POSTTRAUMATIC STRESS DISORDER SERVICES

Summary

*Director, Dissemination and Training Division, National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Health Care System, 

795 Willow Road, Menlo Park, California 94025

†Lieutenant Colonel, Medical Service Corps, US Army; Chief, Behavioral Health, Department of Psychiatry, Borden Pavilion, Walter Reed Army Medical 

Center, 6900 Georgia Avenue NW, Washington DC 20307; formerly, Director of Social Work, Uniformed Services University of the Health Sciences, 

Bethesda, Maryland

‡Director of Outpatient Mental Health, Department of Veterans Affairs Palo Alto Health Care System, 795 Willow Road, 116R/MHC, Menlo Park, 

California 94025; and Associate Professor, Department of Psychiatry, Stanford University, Palo Alto, California
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Combat and Operational Behavioral Health

INTRODUCTION

Posttraumatic stress disorder (PTSD) is the most 

common and conspicuous psychiatric problem associated with the stress experienced by soldiers in combat. 

By definition, diagnosis of PTSD requires exposure to 

a traumatic event that involves experiencing, witnessing, or being confronted by death or serious injury to 

self or others; a response of intense fear, helplessness, 

or horror; and development of a set of symptoms that 

persist for at least a month and cause significant impairment of functioning.1

 Some factor analytic studies 

have demonstrated four basic dimensions of PTSD 

symptoms2—(1) reexperiencing (nightmares, flashbacks), (2) avoidance (efforts to avoid thinking about 

the trauma), (3) numbing of general responsiveness 

(restricted range of affect), and (4) hyperarousal (exaggerated startle response)—but some suggest other 

complex relationships between symptoms.3

Most individuals who develop chronic PTSD experience immediate distress that then persists over 

time.4 However, a small, but significant, number of 

individuals report increases in PTSD symptoms over 

time (delayed onset PTSD5). In retrospective studies of 

the course of PTSD, three different patterns have been 

identified: (1) high levels of symptoms after the war 

followed by recovery, (2) chronic symptoms persisting 

until the time of the assessment, or (3) relapsing-remitting symptoms.6

 Heterogeneity, of course, was also 

observed in a longitudinal study of a large community 

sample of Vietnam veterans. Koenen et al7 found that 

only 5.3% of veterans met PTSD criteria in both 1984 

and 1998, whereas 6.5% and 5.2% met criteria in 1984 

and 1998, respectively.

Current data suggest that approximately 5% to 

20% of armed forces personnel deployed for combat, 

peacekeeping, or humanitarian disaster relief will 

develop PTSD following their tour of duty.8–12 Among 

Vietnam veterans, as reported in the National Vietnam 

Veteran Readjustment Study,13 the lifetime prevalence 

for full PTSD was 30.9% for male veterans and 26% 

for female veterans. At the time of that study, 15.2% 

were currently suffering from PTSD. Reanalysis of 

the survey data, applying criteria revised to reflect 

changes in diagnostic criteria, indicates that 18.7% of 

the veterans had developed war-related PTSD during 

their lifetimes and 9.1% were currently suffering from 

PTSD 11 to 12 years after the war.9

 Despite the impact 

of methodology and deployment experiences on exact 

estimates of symptomatology, these findings represent 

significant rates of distress that often persist over long 

periods of time14 and reflect a significant public health 

problem.

In considering the problem of PTSD, it should also 

be acknowledged that problematic reactions to trauma 

are not limited to full-blown disorder. A considerable 

percentage (ie, 10%–25%) of those not meeting threshold diagnostic criteria for PTSD experience significant 

subsyndromal symptoms15 that may require treatment. 

Subthreshold, or partial, PTSD is associated with significant levels of impairment of social, occupational, 

and family functioning,15–19 often similar to those reported in individuals with full PTSD. (Yarvis et al18

conservatively defined subthreshold PTSD as having 

met the Diagnostic and Statistical Manual, 4th edition, 

criteria for the re-experiencing cluster and at least one 

other symptom cluster). Subthreshold presentations 

of PTSD are also associated with rates of help-seeking 

behaviors similar to those found with individuals 

who meet all the diagnostic criteria.16,20,21 These findings raise questions about the clinical significance of 

subthreshold PTSD and the diagnostic cutoffs. Those 

being diagnosed with PTSD may fall on the upper end 

of a stress-response continuum instead of representing 

a discrete clinical syndrome.22

Individuals diagnosed with PTSD almost always 

experience additional concurrent mental health disorders, such as substance use disorder, other anxiety 

disorders, and major depressive disorder.13,23–25 In the 

National Comorbidity Survey,25 88% of men and 79% 

of women with a lifetime history of PTSD met criteria 

for at least one other disorder. PTSD is also associated 

with significant levels of functional impairment and 

disability in civilian and veteran populations.10,11,20,26–37

The extent and number of symptoms can often predict 

physical and mental health problems.38 The persistence 

of PTSD as much as 30 years after trauma exposure 

is associated with continuing family problems and 

reduced happiness and life satisfaction.39

Risk factors for development of PTSD include 

characteristics of the traumatic event itself, pretrauma 

factors, and posttrauma factors. Event characteristics 

that increase the risk for chronic PTSD include type of 

trauma, greater amount of exposure, injury, involvement in atrocities, and perceived life threat.13,40–43

Degree of exposure to potentially traumatic combat 

events during deployment is strongly associated with 

development of PTSD.44 Military sexual trauma is more 

strongly associated with PTSD than premilitary or 

postmilitary sexual trauma45 or other traumas.46 In a 

sample of female veterans seeking treatment for stress 

disorders, sexual stress was found to be almost four 

times as influential in the development of PTSD as 

duty-related stress.47 In veterans, predisposing factors 
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Treatment of Deployment-Related Posttraumatic Stress Disorder

have included non-Caucasian ethnicity, lower intelligence or education, younger age at exposure, lower 

socioeconomic status, family problems in childhood, 

pretrauma psychopathology, and childhood behavior 

problems.13,40,41,48 Postevent factors that predict chronic 

PTSD in veterans include low levels of social support, 

negative homecoming experiences, poor coping, and 

adverse life events posttrauma.40,41,48,49 Although many 

risk factors exert a similar effect in military and civilian 

populations, trauma severity and posttrauma social 

support may be more important in military than in 

civilian samples.50 

PSYCHOLOGICAL THEORIES OF POSTTRAUMATIC STRESS DISORDER AND TREATMENT

Conceptions of the etiology of PTSD, both psychosocial and biological, have implications for the understanding of treatment. Many theories have focused on 

the intense fear often experienced during traumatic 

events and the impact of fear on conditioned emotional reactions and encoding of traumatic memories. 

According to emotional processing theory as applied 

to PTSD,51 impaired “emotional processing” of traumatic experiences can result in creation of memories 

of the trauma (“pathological fear structures”) that are 

disruptively intense, contain unrealistic elements (in 

which harmless stimuli are associated with escape or 

avoidance responses), and include erroneous evaluations or interpretations (eg, “anxiety will persist until 

escape” or “fear will cause harm”). The Ehlers and 

Clark52 Cognitive Theory of PTSD is similar to emotionprocessing theory in drawing attention to the nature of 

trauma memories (and their links to other memories), 

to appraisals of the trauma and its sequelae, and to the 

behavioral and cognitive responses that prevent cognitive change and therefore maintain the disorder.52

Foa and Kozak51 suggest that there are two conditions for change in these problematic fear-related 

memories once they have been created: (1) the fear 

structure must be activated, and (2) there must be an 

incorporation of new information into the memory. 

Memory activation alone is insufficient for change. 

In fact, trauma memories are frequently activated by 

nightmares, conversations, or trauma reminders without benefit to the survivor. These experiences often 

increase fear for the person, or prompt maladaptive 

escape or avoidance behaviors. Dual representation 

theory argues that activation of memories can lead 

not only to recovery but also to chronic emotional processing (permanent preoccupation with consequences 

of trauma and intrusive memories), or to premature 

inhibition of processing that results from avoidance 

and is associated with continued phobic avoidance, 

somatization, and vulnerability to reactivation later 

in life.53 When PTSD symptoms become chronic, this 

is thought to reflect a failure to engage in successful 

emotional processing of the traumatic experience, because avoidance limits activation of the memory and 

access to new, corrective information.54 

Following this thinking, it is the job of the treating provider to encourage conditions for change and 

reduce emotional avoidance. Deliberate therapeutic 

activation of traumatic memories is most directly 

attempted in exposure therapies that require the individual to repetitively talk about the trauma in detail 

and approach previously avoided trauma-related 

stimuli. During effective treatment, therefore, avoidance is limited and new information of many kinds 

is purposefully incorporated into the memory. The 

individual learns that it is not dangerous to remember the trauma and experience strong emotions, that 

events can be remembered deliberately with a feeling 

of personal control and manageable physical reactions, that the trauma memory may not be completely 

accurate and must be updated, and that some beliefs 

or judgments about the experience can be challenged 

and changed. 

Although most theories of PTSD emphasize the relationship of fear to the development of PTSD, combat 

and other deployment-related traumas often activate 

other intense emotions—including sadness, anger, and 

guilt—that can be connected to the development of 

PTSD and other posttrauma problems. In Operation 

Iraqi Freedom (OIF), for example, substantial percentages of US Army and US Marine Corps personnel reported potentially traumatic experiences that 

included not only events likely to be associated with 

fear (“being attacked or ambushed”), but also those 

related to loss (“knowing someone seriously injured 

or killed”), moral conflict (“being responsible for the 

death of a noncombatant”), horror (“handling or uncovering human remains”), or helplessness (“seeing ill 

or injured women or children whom you were unable 

to help”).44 These types of experiences are associated 

with a range of intense emotions that can continue to 

trouble trauma survivors. Some of these emotions are 

fueled by negative interpretations or appraisals (of 

personal behavior during the trauma, or the effects of 

the trauma); thus it may be important to supplement 

exposure interventions with those explicitly designed 

to modify appraisals. The cognitive theory of PTSD 

emphasizes “idiosyncratic negative appraisals of the 

traumatic event and/or its sequelae that have the 
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common effect of creating a sense of serious current 

threat”52(p320) and thus serve to maintain acute stress 

reactions. 

Generally, cognitive-behavioral psychological theories and treatment of PTSD instruct that the trauma 

memory needs to be actively confronted, elaborated, 

and integrated into the context of the individual’s 

preceding and subsequent experience; problematic 

appraisals that maintain sense of threat and other negative emotions need to be modified; and dysfunctional 

coping strategies that prevent emotional processing of 

the trauma, and thus recovery, need to be reduced. 

TREATMENT OF DEPLOYMENT-RELATED POSTTRAUMATIC STRESS DISORDER

Treatment of PTSD depends upon a careful assessment of the individual. Treatment plan formulation 

should be based on judgments of factors that may have 

caused problems for that particular person, those that 

maintain them, co-occurring problems of the person, 

and priorities for intervention. Regardless of specific 

interventions, treatment of individuals with PTSD can 

be conceptualized as a temporal process that starts 

with client engagement, alliance building, and education about the nature of trauma, posttraumatic stress 

reactions, and the recovery process. This is followed 

by coping skills training or trauma-focused interventions or both—aspects of treatment that require greater 

involvement and commitment by the client. Finally, as 

treatment intensity is decreased, attention is focused 

on relapse prevention and maintenance of treatment 

gains. 

Active Engagement and Alliance Building 

In order for treatment of PTSD to commence, individuals with PTSD must present for care. However, 

many are reluctant to seek mental health treatment. 

Those experiencing higher levels of symptoms may be 

even less likely to seek help and report more barriers to 

help-seeking.55 For example, four US combat infantry 

units were administered an anonymous survey 3 to 4 

months after their return from combat duty in Iraq or 

Afghanistan.44 Only 38% to 45% of the soldiers whose 

responses met criteria for a mental health disorder 

indicated an interest in receiving help, and only 23% 

to 40% reported having received professional help in 

the past year. Those screening positive for disorder 

were twice as likely to report concern about being 

stigmatized, as well as other barriers to seeking mental 

health services. In this study, barriers to seeking help 

included concern about being seen as weak, feelings 

of embarrassment, and concern about reactions from 

leadership. For some, another barrier to seeking treatment for PTSD within a Veterans Healthcare Administration (VHA) or Department of Defense (DoD) setting 

is fear that documentation of PTSD-related problems 

in the medical record might have an adverse effect on 

advancement in a military career or later employment 

in some civilian occupations (eg, police).

Screening programs can increase rates of identification of PTSD and rates of referral.56 These screenings 

should occur at multiple points in time, given that 

soldiers have been found to report more mental health 

concerns 3 to 6 months following return than in the first 

month.57,58 In some screening environments, however, 

there may be significant disincentives to give positive 

responses. Factors that may lead to underreporting of 

early postdeployment distress in military personnel 

include positive mood at the time of return, misattributions about existing symptomatology, and reluctance 

to endorse distress because of perceived stigma.43 Although many who screen positive will not seek care, 

many individuals may nonetheless ask for help—35% 

of Iraq war veterans accessed mental health services 

in the year after returning home.59

Relatively little is known about the determinants 

of help-seeking in those with PTSD. Treatment seeking in Canadian veterans with lifetime PTSD was 

predicted by cumulative lifetime trauma exposure, 

traumatic event type, PTSD symptom interference, 

and comorbid major depressive disorder.21 Those with 

comorbid depressive disorder were 3.75 times more 

likely to have sought treatment than veterans without 

concurrent depression. Multiple deployments are associated with greater levels of PTSD symptoms,38 so 

that soldiers with more than one deployment should 

be monitored. In research with veterans, the failure of 

veterans with PTSD to seek VHA mental healthcare 

was found to be affected by personal obligations that 

prevented clinic attendance, inconvenient clinic hours, 

and current receipt of mental health treatment from a 

non-VHA provider.60 Another study suggested that 

veterans’ pursuit of mental health services appears to 

be driven more by their guilt, and the weakening of 

their religious faith, than by the severity of their PTSD 

symptoms or their deficits in social functioning.61

Outreach interventions can be investigated empirically. In a study of veterans who were service-connected for PTSD but not receiving PTSD treatment, half 

received an outreach intervention, and the other half 

were assigned to a control group.60 The intervention 

group received a mailing that included a brochure 

describing VHA PTSD treatment and a letter telling 

them how to access care. These individuals were also 
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Treatment of Deployment-Related Posttraumatic Stress Disorder

telephoned and encouraged to enroll in treatment. 

Results indicated that those receiving the intervention were significantly more likely to schedule an 

intake appointment, attend the intake, and enroll in 

treatment. 

Initial presentation for help does not necessarily 

result in active involvement in the treatment process. 

The importance of this issue is highlighted by clinical experience with OIF veterans 1 and 2 years after 

their return to the United States. In VHA settings, 

many veterans come to one or two treatment sessions 

but do not begin active participation in counseling 

services. In fact, once an individual presents for help, 

clinicians must take steps to maintain attendance and 

achieve active engagement in the treatment process. 

It is important to assess for obstacles to participation 

and make efforts to ensure that treatment makes sense 

to these individuals and is perceived as relevant to 

their needs. 

Ongoing Assessment and Monitoring of Treatment 

Effectiveness 

Initial engagement in treatment can be expected 

to be affected by the assessment process. Assessment 

provides practitioners with an opportunity to inquire 

about perceived needs and to describe treatment in 

terms that make clear its relevance to those needs. This 

suggests that assessment must include not only attention to symptoms and problems, but also perceived 

areas of importance to the help-seeker (eg, partner and 

family conflict, sexual functioning, work functioning 

and satisfaction, and parenting experiences). The assessment interaction communicates interest in, and 

understanding of, the individual, as well as expertise 

on the part of the provider. 

Assessment of military-related PTSD requires a 

multimethod approach in which multiple measures 

are used to assess different domains of functioning, 

both to improve diagnostic confidence and to identify 

multiple targets for intervention.62 A few key issues can 

be identified. First, it is important for the provider to 

gather information about the individual’s experiences 

during deployment. Use of self-report questionnaires, 

such as the Deployment Risk and Resilience Inventory, 

can make this process more complete and efficient for 

provider and patient.63 Second, findings of high rates 

of lifetime physical and sexual victimization among 

veterans in treatment for chronic PTSD support the 

need for routine assessment of history of trauma exposure.64 Adverse childhood experiences are strongly 

associated with mental health symptoms65 and predict 

the presence of PTSD and depression among active 

duty soldiers seeking mental health services.

66 Third, 

it is important that clinicians engage in ongoing assessment and monitoring of treatment impact. Although 

this is not currently routine practice in many treatment 

settings, it is important to help provider and survivor 

evaluate the effectiveness of their work together, and 

make changes when necessary. The clinical practice 

guideline for PTSD, jointly developed by the VHA 

and the DoD, recommends routine use of validated 

self-administered checklists (and interviews as appropriate) at intake and to monitor follow-up status 

(at least every 3 months).67

Ongoing Interactive Education 

Patient education comprises a basic component of 

most forms of psychotherapy for PTSD, and should be 

introduced early and continued throughout all stages 

of the treatment process. To this end, traumatic stress 

education classes are often included as part of a first 

phase of comprehensive treatment programs. Traumatic stress education includes a number of components: (a) information about how traumatic experiences 

can affect individuals; (b) information about common 

reactions to trauma; (c) “normalization” of reactions; 

(d) emotional support and reassurance; (e) presentation 

of a rationale for, and description of, what happens in 

treatment and what the individual will be asked to 

do; and (f) a description of how recovery can happen. 

Education for the family is also important. Although 

education alone is unlikely to result in remission of 

PTSD, it is important to building commitment to 

treatment participation and helping the survivor more 

clearly understand the traumatic experience and how 

to actively participate in treatment.68

Coping Skills Training 

There is a great difference between knowing what 

to do versus knowing how to do it. Skills training 

methods are designed to help individuals learn and 

practice what to do to cope more effectively with the 

various kinds of situations that challenge them. Skills 

training methods are commonly used to help those 

suffering with PTSD to increase their ability to reduce 

anxiety, communicate with loved ones, manage anger, 

and respond assertively (not aggressively) to conflict 

situations. Through a cycle of instruction, demonstration, rehearsal/practice, feedback/coaching, and more 

practice, survivors learn skills in treatment sessions 

and practice them in the natural environment. They 

keep written records of their attempts to apply the 

skills, which help them learn and provide practitioner 

and survivor with real-world experiences to review. 

Clinical experience indicates that survivors are typi-
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cally attracted to the idea of learning skills (“tools”) 

for coping. The methods of skills training help to 

actively involve the survivor in treatment, provide a 

greater sense of control (and responsibility for active 

participation in treatment), and strengthen the transfer 

of what is learned in treatment to the natural environment of the client. For example, stress inoculation 

training (SIT)69 focuses on teaching the survivor skills 

for managing anxiety symptoms, and includes education, muscular relaxation training, breathing retraining 

(slow abdominal breathing), assertiveness training, 

covert (imaginal) modeling, role playing, thought stopping, and positive thinking and self-talk. SIT has been 

found to significantly reduce PTSD symptoms in some 

treatment research,70 and is “strongly recommended” 

in the VA/DoD clinical practice guideline.

Deliberate, Planned Confrontation of Trauma 

Memories and Reminders 

The core element of PTSD treatment is active discussion and exploration of traumatic experiences and their 

implications. The treatments that focus explicitly on 

traumatic memories and meanings—prolonged exposure (PE),71 cognitive therapy (CT), and eye movement 

desensitization and reprocessing (EMDR)72—have 

received the most empirical support to date, and comprise three of the four “strongly recommended” treatments in the VA/DoD clinical practice guideline. 

Methods of therapeutic exposure, such as PE, involve the most direct confrontation of memories and 

reminders. Imaginal exposure involves a repeated 

retelling of the trauma story with emotional activation. In vivo exposure adds real-world exposure to 

stimuli associated with the trauma via confrontation of 

avoided trauma-related stimuli in the natural environment. These procedures involve multiple repetitions 

achieved by listening to a cassette recording of the 

trauma narrative, writing about the experience, or 

approaching real-world trauma reminders systematically in between-session tasks. A combination of 

imaginal and in vivo exposure is thought to be more 

effective than either procedure alone. According to 

Foa and Jaycox,73 PE treatment assists the individual 

to incorporate new information into the memory by 

reducing cognitive avoidance of trauma-related feelings, demonstrating that remembering the experience 

is not dangerous and that anxiety will diminish via habituation, fostering discrimination between the trauma 

and similar nontraumatic situations, strengthening 

ability to tolerate memories and thereby challenging 

perceptions of personal incompetence, and reviewing 

details of the experience that provide evidence against 

disabling beliefs about danger and incompetence.

Exposure to trauma memories is an element of a 

number of treatments other than PE that are supported 

in the research literature. For example, individuals being treated with cognitive processing therapy (CPT)74

are asked to write out the details of their traumatic 

experience and to read the account on a regular basis. 

EMDR includes an exposure component that involves 

bringing to mind an image of a traumatic event while 

visually tracking a therapist’s finger as it moves back 

and forth in front of the patient’s visual field (or tracking a light moving back and forth, or listening to tones 

alternating from one ear to the other).

Challenging Negative Trauma-Related Thoughts 

CT is a systematic approach that includes education 

about the role of beliefs in causing distress; identification of distressing beliefs held by the individual; 

discussion and a review of evidence for and against 

the beliefs; testing of beliefs; generation of alternative 

beliefs; and rehearsal of new, more adaptive beliefs. 

Thoughts that create significant distress (eg, traumarelated guilt, exaggerated thoughts about danger) 

are replaced with more realistic and self-supportive 

thoughts. For example, if an individual has the thought 

“I will never be safe again, the world is a very dangerous place,” CT might focus on helping the individual 

to consider evidence for and against the belief and 

move toward a more realistic appraisal (eg, “I am safe 

in most situations and the chances of harm coming to 

me are quite small in the civilian world”). It is often 

important that trauma-related guilt be made a formal 

target of PTSD treatment, and some interventions 

with a strong CT component, such as CPT74 and CT 

for guilt,75 target guilt explicitly. Instruments designed 

to assess guilt (eg, Trauma-Related Guilt Inventory76) 

and other trauma-related beliefs (eg, Post-Traumatic 

Cognitions Inventory77) are available. 

Negative thoughts can be challenged through 

direct review of the belief and consideration of 

alternatives, and through encouraging real-world 

experiences that can help to disconfirm them. For 

example, having a successful experience in disclosing personal information to another person can help 

challenge the belief that “other people cannot be 

trusted.” Successful implementation of PE can also 

result in modification of distressing trauma-related 

cognitions by disconfirming beliefs (“anxiety stays 

forever” or “I will go crazy”) and helping the survivor differentiate the trauma from similar but safe 

events (disconfirming “the world is extremely dangerous”). PTSD symptoms themselves may begin to 

be associated with mastery rather than incompetence 

(disconfirming “I am incompetent”).
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Treatment of Deployment-Related Posttraumatic Stress Disorder

Pharmacotherapy 

Medication is an important treatment option that 

should be considered for almost all patients with significant symptoms of PTSD. The use of a medication 

in these patients may be directed at PTSD symptoms 

generally, specific symptoms, common co-occurring 

symptoms, or comorbid conditions (eg, depression). 

Initiating a medication trial may occur at different 

phases in treatment, depending on patient-specific 

factors. As mentioned earlier, those patients with high 

levels of symptoms may be the most reluctant to seek 

psychotherapy care. A medication initiated within the 

primary care setting may reduce symptoms to a level 

such that this reluctance can be overcome. However, 

many military patients may be concerned about the 

potential side effects of a medication or the stigma of 

taking a “psych drug” and will need to build trust with 

their mental health provider before starting a medication can become an option. 

Despite the wide use of a variety of medications 

for the treatment of PTSD, there is a relative lack of 

definitive evidence for their efficacy.78 The most thoroughly investigated agents are the selective serotonin 

reuptake inhibitors (SSRIs). SSRIs have demonstrated 

superiority over placebo in large randomized controlled trials (RCTs) as well as in a number of smaller 

investigations, and they are now considered the firstline pharmacological treatment option for PTSD.79

Sertraline and paroxetine have been subjected to 

large industry-sponsored trials for the acute treatment of symptoms and have received US Food and 

Drug Administration approval for treating PTSD.80–82

Fluoxetine, escitalopram, and citalopram have shown 

efficacy in smaller randomized or open trials.83,84 In 

these trials, SSRIs improved all three clusters of symptoms in PTSD, as well as quality of life and functional 

impairments. They appear effective in preventing the 

relapse of symptoms once a patient has responded to 

treatment.81,85,86 But the data on SSRIs in the treatment 

on PTSD in certain populations, including combat 

veterans, are still limited.78

SSRIs have proven effectiveness for many other anxiety and depressive disorders that are highly comorbid 

with PTSD. PTSD and major depression overlap to a 

considerable degree; both share sleep disturbances, 

social withdrawal and isolation, decreased pleasure 

and enjoyment, and impaired concentration. Major 

depression is the most common comorbid disorder in 

patients with PTSD, with close to 50% of PTSD subjects having a history of major depression.25 Although 

SSRIs improve both PTSD and depression, SSRIs are 

efficacious for both PTSD patients with and without 

depression.82 Panic disorder and generalized anxiety 

are also responsive to SSRI treatment and also often 

co-occur with PTSD.87

As with most other disorders treated with antidepressants, a full therapeutic response to SSRIs in PTSD 

takes 4 to 6 weeks. Although better tolerated than older 

antidepressants, SSRIs are not without side effects 

that can include nausea and gastrointestinal distress, 

insomnia, akathesia, and sexual dysfunction. Many 

of these side effects are time-limited but still result in 

relatively high rates of medication discontinuation.88

Education and support by all members of the treatment 

team are vital to prevent early discontinuation.

Other antidepressants have less empirical support 

for the treatment of PTSD than do SSRIs, but available 

evidence suggests similar efficacy. Therefore, non-SSRI 

antidepressants should be considered as second-line 

medication treatment options for PTSD. Antidepressants with RCT data supporting their use in PTSD 

include venlafaxine,89 mirtazapine,90 and nefazodone.91

Clinically, the choice of an antidepressant is often based 

on comorbid symptoms and conditions. Venlafaxine, 

as well as duloxatine, are efficacious in some chronic 

pain conditions92 and may be useful in PTSD patients 

with diabetic neuropathy, fibromyalgia, or certain 

other pain disorders. Mirtazapine is generally sedating 

and may be useful in targeting insomnia in PTSD, but 

weight gain can be a problem. Although the efficacy 

of bupropion in PTSD is uncertain,93 it is an option for 

patients with PTSD who are also attempting to stop 

smoking.94 There is limited RCT data to support the 

efficacy of tricyclic antidepressants and monoamine 

oxidase inhibitors. Furthermore, their clinical use is 

limited by their higher rate of side effects, from common dry mouth and constipation to more serious 

cardiac conduction delays and a lower safety index in 

overdose. Noradrenergic reuptake inhibiting tricyclic 

antidepressants, such as nortriptyline, are efficacious 

for chronic pain conditions92 and may also be used 

in PTSD patients with these conditions. Trazodone is 

widely used at lower dose as a hypnotic in PTSD due 

to lack of addiction potential. 

If antidepressant treatment fails to produce a sufficient treatment response, other psychopharmacological treatment options are available, but with even less 

empirical support. After antidepressants, the atypical 

antipsychotics have the most RCT data supporting 

their efficacy in the treatment of PTSD. Data support 

their use either as an augmentation therapy to SSRI 

treatment95–98 or as a single agent therapy,99 although 

not all studies have been positive100 and the studies 

conducted to date have been limited in size. In addition to targeting core PTSD symptoms, atypical antipsychotics are often used to treat comorbid psychotic 

symptoms96 or as mood stabilizers to treat symptoms 
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Combat and Operational Behavioral Health

related to bipolar disorder or symptoms associated 

with borderline personality disorder. Another class 

of mood stabilizers, the third-generation anticonvulsants, had shown promising findings in early clinical 

case reports and open-label investigations, but small 

RCT investigations of valproate,101 topiramate102 and 

tiagabine103 have all failed to demonstrate statistically 

significant efficacy in PTSD. Therefore, their use should 

be limited to treating refractory cases or comorbid 

mood disorders. 

Agents targeting noradrenergic neurotransmission 

have been proposed as possible treatments for PTSD, 

based in part on the role noradrenergic neurons play in 

the biological response to stress.104 Due in part to their 

ability to decrease central and peripheral noradrenergic activity, the α-2 adrenergic receptor agonists clonidine and guanfacine had been suggested as treatments 

for PTSD. But RCT investigations of guanfacine have 

failed to demonstrate efficacy in patients with chronic 

PTSD.101,105 Centrally active β-adrenergic receptor 

antagonists, such as propranolol, may influence how 

stressful memories are stored106 and have been efficacious in some,107 but not all,108 preliminary studies in 

preventing the development of PTSD in traumatized 

individuals. There are also limited data indicating 

that the α-1 adrenergic agonist prazosin has efficacy 

in treating nightmares and sleep disturbances in PTSD 

patients.109,110 Both propranolol and prazosin are currently under investigation in larger RCT trials. 

Benzodiazepines are effective in treating timelimited anxiety, but have significant dependence and 

abuse potential and are associated with adverse effects, 

including short-term memory impairment. Small RCTs 

have failed to demonstrate efficacy for benzodiazepines in the treatment of PTSD111,112 or in preventing 

the development of PTSD in trauma survivors.113 If 

benzodiazepines are prescribed, they should be used 

in a time-limited manner and with great caution in 

patients with PTSD due to the high rates of substance 

use disorders.114

A possible problem with prescription of medications (as with nonpharmacological interventions) 

is nonadherence to appropriate use. Indeed, many 

trauma survivors discontinue their medications 

without discussion with their provider. It can often be 

important to explore the meaning of medication for the 

person. When survivors interpret their need for medication as a sign of personal weakness or inability to 

cope, a judgment of failure in psychotherapy, evidence 

of the clinician’s lack of personal interest, or avoidance 

of dealing with the “real” problem, they may be less 

likely to adhere to appropriate use.

In summary, medications, particularly antidepressants, may reduce the overall severity of PTSD symptoms and serve as useful tools in the treatment of PTSD. 

Psychotropic medications may also be used to treat 

associated features or comorbid conditions or both. 

But the practitioner and the patient must be aware that, 

with the exception of antidepressants, their use is off 

label. Drug treatments for PTSD should not be used as 

a routine first-line treatment in preference to a traumafocused psychological therapy. Individuals with PTSD 

should be offered a course of trauma-focused cognitivebehavioral therapy or EMDR, regardless of time since 

trauma.115 If the PTSD sufferer reports little or no 

improvement after one of these psychological treatments, an alternative trauma-focused treatment, and 

then augmentation with pharmacological treatment, 

can be considered. It is important to consider the least 

restrictive or intrusive treatment model and choose efficacious treatments.116 Medications may be warranted, 

particularly when symptoms are significant and daily 

functioning is severely impaired, the person has severe 

insomnia, an additional psychiatric condition (eg, depression) is present, or if significant symptoms are still 

present following psychological treatment. Polypharmacy can occur in patients with PTSD in the absence 

of empirical support117 and should be avoided. 

Maintenance and Relapse Prevention 

Relatively little is known about rates and processes 

of relapse after treatment for PTSD. Studies in the 

civilian sector suggest that improvements resulting 

from use of evidence-based treatments can be maintained for significant periods of time.118 Some evidence 

suggests that patients discharging from residential 

PTSD treatment and referred for outpatient aftercare 

are more likely to make an outpatient visit within 1 

month of discharge if they receive biweekly telephone 

calls after discharge.119 Research also suggests that 

long-term treatment of PTSD with SSRIs maintains 

treatment response and quality-of-life improvements, 

and that discontinuation of SSRI treatment after 12 

weeks results in a greater relapse risk, compared with 

extended treatment.120 

ASSOCIATED PROBLEMS IN POSTTRAUMATIC STRESS DISORDER TREATMENT

As noted above, approximately 80% of those diagnosed with PTSD experience concurrent additional 

mental health disorders.25 They also experience a range 

of problems in living that are often addressed in treatment. PTSD symptoms are associated with reduced 

quality of life before treatment. Evidence suggests that 
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Treatment of Deployment-Related Posttraumatic Stress Disorder

positive change in PTSD is significantly associated 

with positive change in quality of life.121 Most PTSD 

outcomes research has focused on reduction of PTSD 

symptoms; the impact of treatment on the wider range 

of quality of life and functional outcomes is less well 

investigated. Successful treatment should be accompanied not only by a reduction in PTSD symptoms but 

also by an improvement in quality of life.122 To address 

the many problems for which those with PTSD seek 

help, it will often be important to supplement PTSD 

symptom-focused interventions with adjunctive 

treatment components targeted at other clinically significant problems identified in the assessment process, 

especially if these problems do not remit once PTSDfocused interventions have been provided. 

Substance Abuse and Addictive Behaviors 

Co-occurrence of PTSD and substance abuse (SA) 

problems is well documented in populations of civilians and veterans.123,124 For example, Kulka et al13

reported that 73% of Vietnam veterans with PTSD met 

criteria for lifetime alcohol abuse or dependence. It is 

likely that untreated alcohol and drug problems will 

impede treatment of PTSD; continuing PTSD symptoms may make sobriety more difficult to achieve. 

Some research suggests that veterans with PTSD 

who also abuse substances will benefit more from SA 

treatment if they also address PTSD. Patients who received PTSD treatment in the first 3 months following 

discharge from SA treatment were more likely to be 

in remission from substance use disorders at followup than those who did not receive PTSD treatment.123

The interconnectedness of these disorders has generated increased development of integrated PTSD/SA 

treatments.125 However, the widespread organization 

of PTSD and SA care in separate clinics, and the lack 

of cross-training of professionals in these areas, are 

among the impediments to delivery of integrated 

care. 

Evidence also suggests that PTSD is associated 

with increased risk of smoking26 and that unremitted 

PTSD is a risk factor for late-onset smoking among 

individuals who were nonsmokers prior to developing PTSD.126 In an RCT, McFall et al127 demonstrated 

that smoking cessation intervention incorporated into 

routine mental health care for PTSD is more effective 

than treatment delivered separately by a specialized 

smoking-cessation clinic.

Other addictive behaviors may also be associated 

with PTSD. In civilians seeking treatment for pathological gambling, frequency of PTSD symptoms has 

been found to predict greater lifetime gambling severity.128 A study of Australian PTSD treatment-seeking 

veterans found that the veterans were likely to be 

problem gamblers, but that PTSD was unrelated to 

the behavior.129 However, because all subjects had 

PTSD, the study was not optimally designed to detect 

a relationship.

Depression and Suicidality 

PTSD is strongly comorbid with depression.18,23,25,38,130,131 For example, Vietnam veterans with 

PTSD have higher levels of depression than veterans without PTSD.13 In retrospective studies, most 

individuals with both disorders report that PTSD 

developed first.25 A 2-year prospective study of the 

temporal relationship between PTSD and depression 

symptomatology in Gulf War veterans indicated a 

bidirectional relationship in which initial PTSD symptoms predicted increases in depression symptoms and 

initial depression symptoms predicted PTSD, although 

initial PTSD symptoms were more strongly predictive of later depression.132 Breslau et al found greatly 

increased risk for major depression in persons with 

PTSD,23 but not in exposed persons without PTSD, 

suggesting that exposure to traumatic events does not 

increase the risk for major depression independent of 

its effects on PTSD. 

Presence of PTSD is associated with increased risk 

of suicide. Sareen et al used data from the nationally 

representative National Comorbidity Survey to investigate the relationships between anxiety disorders and 

suicidal ideation and attempts.133 PTSD was significantly associated with suicidal ideation and suicide 

attempts; none of the other anxiety disorders showed 

such an association. Generally, PTSD in US Army 

veterans is associated with mortality from external 

causes, including homicide, suicide, drug overdoses, 

and unintended injury.134 Clinicians treating PTSD 

should therefore routinely screen for suicidality and 

remain alert to the need to monitor suicidal ideation 

and provide preventive interventions.

Anxiety 

PTSD, itself classified as an anxiety disorder, is 

highly comorbid with other anxiety disorders, including panic disorder, generalized anxiety disorder, social 

anxiety disorder, obsessive-compulsive disorder, and 

phobias. Among veterans receiving medical care in primary care clinics, those with PTSD have greater rates of 

social anxiety disorder (22%) than those without PTSD 

(1.1%).135 Development of obsessive-compulsive disorder can be precipitated by trauma in combat.136 Little 

research has examined the impact of PTSD treatment 

on co-occurring anxiety problems, but a treatment for 
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Combat and Operational Behavioral Health

individuals with PTSD who also experience panic attacks has been developed.137

Anger and Violence 

Anger and irritability comprise one of the symptoms of PTSD. Intense anger is commonly part of 

the presentation of those with PTSD138 and is more 

significant among those whose traumas were experienced during military service.139 Vietnam veterans 

with PTSD have higher levels of anger than veterans 

without PTSD,13 and high levels of anger have been 

reported among Iraq and Afghanistan War veterans.140

Compared to veterans without PTSD, those with it take 

less time to feel anger, have greater mean heart rate 

and diastolic blood pressure responses during relived 

anger, and report greater anger and anxiety during 

a laboratory task in which they are asked to relive a 

self-chosen anger memory.141

The volatile anger reactions of their patients can 

present treatment providers with challenges in establishing therapeutic relationships and in delivering 

treatment itself. In a study of Australian veterans, anger at intake was the most potent predictor of failure to 

show symptom change.

142 Anger might interfere with 

the confrontation with, and processing of, traumatic 

memories that can be important in recovery from the 

disorder.71 A high level of anger at the beginning of 

PE treatment interferes with response to treatment.143

Anger reduction should often be made an explicit goal 

of treatment; individuals can be taught skills (eg, time 

out/cool down, anger self-monitoring, identifying anger situations, relaxation/breathing, anger discrimination, self-talk, assertion training) to reduce their anger 

or modify its expression. 

Anger problems may also require the provider to 

assist the veteran in reducing risk of violence. Research 

has indicated that veterans receiving inpatient treatment for PTSD are more violent than male psychiatric 

inpatients without PTSD and community Vietnam 

veterans with PTSD not undergoing inpatient treatment.144 Domestic violence may be an accompanying 

problem,145,146 and experiencing PTSD symptoms 

increases risk for perpetrating intimate partner 

violence.147 Moreover, veterans with PTSD often have 

ready access to weapons and engage in potentially 

dangerous firearm-related behaviors.148 Thus, clinicians should routinely address gun storage and safety 

issues as part of the treatment process.

Complicated or Traumatic Bereavement 

Many of those deployed to a war zone will be exposed to significant personal losses, and these deaths 

will often be encountered in traumatic circumstances. 

Traumatic bereavement can lead to anhedonia and 

depression; grief about fallen friends can make social 

interaction and activity seem pointless. Loss of close 

comrades and friends in battle is associated with 

postwar distress and social dysfunction.149,150 Pivar 

and Field found that grief-specific symptoms can be 

distinguished from other war trauma-related symptoms in combat veterans with PTSD. In their sample, 

veterans’ mean scores on grief measures 30 years after 

their losses were higher than those found in studies of 

midlife individuals whose spouses had died within the 

previous 6 months.151 The authors argued that unresolved grief will endure over time for many individuals if not addressed by clinical intervention. Indeed, 

treating symptoms of unresolved grief may be as 

important as treating fear-based symptoms associated 

with PTSD. Unfortunately, treatment for traumatic or 

complicated grief has received relatively little formal 

evaluation. However, most treatments include education about grief, restructuring of cognitive distortions 

about events, restoration of positive memories of the 

deceased, acknowledgment of caring feelings toward 

those lost, retelling the story of the death, and help in 

tolerating painful feelings.152 Elements of treatment 

for PTSD can be adapted for treatment of complicated 

grief.153

Physical Health Problems 

PTSD is associated with poorer perceived health 

status, greater somatic complaints, greater number 

of chronic health problems, and increased levels of 

healthcare utilization.13,18,154–156 Overall, studies suggest 

that PTSD mediates the relationship between war zone 

exposure and physical health for both men and women.155 The majority of veterans seeking PTSD treatment 

do not engage in preventive health behaviors (eg, 

exercise and medical screening) at levels consistent 

with healthcare guidelines.157 These issues should be 

assessed and, if necessary, addressed in treatment.

Attention to management of health problems in 

veterans with PTSD is especially important in light 

of the “graying” of the veteran population. Veterans 

with PTSD report greater increases in psychological 

and physical symptoms during retirement than other 

veterans.158 Some research suggests that the challenges 

of aging may be associated with exacerbation of PTSD 

symptoms.159,160 Davison and colleagues, for example, 

described a phenomenon observed in aging combat 

veterans that they labeled late-onset stress symptomatology, or “LOSS.” For many veterans who experienced 

highly stressful combat events in early adulthood, and 

then managed to function successfully throughout 
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Treatment of Deployment-Related Posttraumatic Stress Disorder

their lives without chronic stress-related disorders, 

the changes of aging are associated with increased 

combat-related thoughts, memories, and symptoms.159

The strong relationships between PTSD and health 

outcomes also extend to OIF returnees.161 For this latter 

population, early severity of physical injury is strongly 

associated with development of later PTSD or depression.162 Such findings support the need for increasing 

integration of mental health screening and services in 

primary care and other medical settings. 

Traumatic Brain Injury 

The high rate of co-occurring traumatic brain injury 

(TBI) and PTSD in those returning from deployment to 

Iraq and Afghanistan poses clinical challenges that are 

ill understood at present. Evidence suggests that PTSD 

can develop following both mild and severe TBI, even 

in individuals who have lost consciousness during the 

event or display posttraumatic amnesia.163 In one study 

of military personnel deployed to Iraq, mild TBI (ie, 

concussion) was found to be strongly correlated with 

PTSD and physical health problems 3 to 4 months 

after return to the United States. The relationship 

between mild TBI and health was largely mediated 

by PTSD and depression.164 Thus, PTSD treatment 

for those with TBI may need to include modifications 

that address difficulties that may be associated with 

injury, including difficulty in retrieving the traumatic 

memory, comprehending and remembering treatment 

recommendations, and reporting on symptoms and 

experience. Bryant et al demonstrated that civilians diagnosed with mild TBI and acute stress disorder could 

be effectively treated with a brief cognitive-behavioral 

therapy protocol designed to prevent development of 

PTSD.165

AREAS OF IMPAIRED FUNCTIONING

Family 

The anger, emotional numbing, and social withdrawal often associated with PTSD can isolate veterans 

from their families. PTSD veterans and their partners 

report more problems in their relationships and more 

difficulties with intimacy (and have taken more steps 

toward separation and divorce) than veterans without 

PTSD and their partners. The degree of relationship 

distress is correlated with the severity of veterans’ 

PTSD symptoms, particularly symptoms of emotional 

numbing.34 Emotional numbing symptoms are also 

correlated with perceived relationship quality with 

children.166 Higher levels of PTSD symptoms (avoidance and emotional numbing symptoms in particular) 

may lower parent–child relationship satisfaction.167

Men reporting combat as their worst trauma are more 

likely to be divorced and physically abusive to their 

spouses than men reporting other traumas as their 

worst experience.168 

Partners of those with PTSD are significantly 

affected by the symptoms of their loved one and 

experience burdens associated with care giving.169

Compared to partners of Dutch peacekeepers without 

PTSD symptoms, partners of peacekeepers with PTSD

symptoms reported more sleep and somatic problems, 

more negative social support, and poorer marital relationships.170 PTSD symptomatology places veterans at 

increased risk for perpetrating relationship aggression 

against their partners.171 Such findings suggest that 

more attention should be paid to supporting partners. 

Treatment goals should include reduction of problems 

for the partner and family. 

A treatment focus on improvement of family functioning would suggest that steps should be taken 

to more systematically involve spouses or partners 

in care.172,173 Significant others can be included in 

the assessment process, in the setting of treatment 

goals, and in treatment itself. Although couples’ 

interventions require systematic development, early 

work suggests that they can reduce survivors’ selfreported levels of anxiety and depression.174 However, 

combining family therapy with exposure is not more 

effective than exposure alone in reducing symptoms 

of PTSD.175

Social Connections 

Military-related PTSD is often associated with 

withdrawal from participation in social activities, 

limited friendships, and reduced emotional intimacy.34,176,177 As noted above, some research suggests 

that veterans with PTSD have greater rates of social 

anxiety disorder. Poor social support predicts development of PTSD and a more chronic course of the 

disorder. Veterans with PTSD who are more involved 

in the community are more likely to show remission 

in PTSD symptoms than those with less community 

involvement7 and adjustment to peacekeeping stressors is significantly related to self-disclosure, especially to supportive significant others.178 Overcoming problems in social functioning and promoting 

social participation may require active, sustained 

intervention. When indicated, improvements in 

social functioning should be established as a formal 

treatment goal.
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Combat and Operational Behavioral Health

Workplace 

Evidence indicates that PTSD impairs work performance and reduces work productivity.179 Savoca and 

Rosenheck found that, on average, veterans with a 

lifetime diagnosis of PTSD were less likely to be currently working than veterans who did not meet diagnostic criteria.180 Among those who were employed, 

veterans with PTSD earned less per hour. Veterans 

with more severe symptoms were more likely to work 

part-time or not at all. Men reporting combat as their 

worst trauma are more likely to be unemployed, or 

fired, compared to men reporting other traumas as 

their worst experience.168 It has been suggested that 

even modest reductions in PTSD symptoms may lead 

to employment gains, even if the overall symptom 

levels remain severe.181

No interventions to date have targeted the workplace functioning of individuals with PTSD. It would, 

however, seem useful for clinicians to assist employed 

patients to apply stress and anger management 

skills on the job. Patients could also be taught to use 

problem-solving skills in difficult situations. These 

strategies would help reduce the impact of traumatic 

stress reactions on this important domain of patient 

functioning.

TREATMENT OUTCOME RESEARCH

Reviews of the impact of PTSD interventions have 

generally concluded that PTSD treatment can be efficacious.182 In their meta-analysis of PTSD outcome studies, Bradley and colleagues183 reported that 40% to 70%

of trauma survivors included in controlled research 

trials showed substantial reduction in symptoms or 

were no longer diagnosablewith PTSD posttreatment. 

To what extent these gains are sustained beyond6 to 12 

months following completion of treatment is relatively 

unknown. Although there is little empirical support 

for group-administered treatments at present,184,185 

research suggests that several kinds of individually 

administered psychological interventions, including 

exposure-based interventions (eg, PE), EMDR, CPT, 

and SIT, are effective in reducing PTSD symptomatology. 

CPT and PE were compared in treating a sample 

of chronically distressed rape victims with PTSD.186

Compared to a group of victims receiving only minimal attention and assessment, both treatments were 

effective in reducing PTSD and depression symptoms. 

CPT was superior to PE in reducing some kinds of guilt 

cognition. Some research has suggested that adding 

CT to PE appears not to improve PTSD outcomes,187,188

but findings are mixed.186,189 It should be noted that 

although CT and exposure have been separated for 

research purposes, they are usually combined in 

clinical practice. For example, PE treatment includes 

extensive processing of trauma memories that assists 

in modification of trauma-related cognition. CPT combines repeated writing about the trauma memory with 

a systematic approach to challenging negative beliefs 

or meanings associated with the trauma.

The few studies that have compared CT and imaginal (not in vivo) exposure have found no significant 

differences between the two approaches at the end of 

treatment.190 However, a long-term, 5-year follow-up of 

patients who had taken part in a randomized clinical 

trial comparing imaginal exposure and CT showed a 

clear superiority of CT,191 although there had been no 

difference at 12 months posttreatment. Those receiving 

CT showed significantly fewer PTSD symptoms and 

were less likely to meet criteria for PTSD. Indeed, no 

patients who received CT were diagnosed with full 

PTSD, compared to 29% of those who received imaginal exposure. These results cannot be generalized 

to exposure treatments, however, because imaginal 

exposure should be combined with in vivo exposure 

for best effects.

There is little research comparing cognitivebehavioral or other psychological interventions to 

medications or examining the combination of these 

approaches for treating PTSD. Individuals with PTSD 

were randomly assigned by van der Kolk et al to eight 

sessions of EMDR, 8 weeks of fluoxetine, or placebo. 

Immediately following treatment, there were no differences among the three groups. At 6-month follow-up, 

the EMDR group was more likely to show reductions 

in PTSD symptom severity and remission and depression symptoms than the other two groups.192 For individuals showing only a partial response to sertraline, 

PE treatment has been found to further reduce PTSD 

severity following 10 weeks of medication treatment.193

More research is needed before recommendations 

regarding the relative and combined effectiveness of 

medications and psychosocial interventions can be 

made with confidence.

Research With Veterans and Active Duty Military 

Personnel 

Several studies have examined various traumafocused interventions with veterans who have combatrelated PTSD. Individually administered imaginal 

(without in vivo) exposure has been associated with 

modest but significantly improved PTSD symptom 
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Treatment of Deployment-Related Posttraumatic Stress Disorder

outcomes compared to other treatment as usual.194–196

Glynn et al found that a combination of imaginal exposure plus cognitive restructuring was more effective 

than a wait-list control condition.175 These studies also 

suggested that in veterans with chronic PTSD, avoidance and emotional numbing symptoms may respond 

less well to treatment than symptoms of reexperiencing 

and hyperarousal. 

Schnurr et al compared two treatments for male 

veterans with chronic PTSD: (1) trauma-focused group 

psychotherapy, and (2) a present-centered comparison treatment that avoided detailed discussion of the 

military trauma.197 Weekly group treatment was provided for 30 weeks (followed by 5 monthly “booster” 

sessions). Follow-up assessments were conducted at 

the end of treatment (7 months) and at the end of the 

booster sessions (12 months). A subset of participants 

was also followed up at 18 and 24 months. Both treatments resulted in modest but significant improvements in PTSD symptoms and other outcomes, but 

no differences between the two interventions were 

observed.

In a trial of CPT, significant improvements were 

reported in PTSD and comorbid symptoms in those receiving CPT compared with a wait-list control group.198

Forty percent of the intention-to-treat sample receiving 

CPT did not meet criteria for a PTSD diagnosis at posttreatment, and 50% had a reliable change in their PTSD 

symptoms.198 The positive effects of CPT extended 

beyond PTSD symptoms to include improvements in 

frequently co-occurring symptoms of depression and 

general anxiety, affective functioning, guilt, and social 

adjustment. This trial provides some of the most encouraging results to date related to treatment of male 

veterans with chronic PTSD. 

Positive results have also been obtained with female 

veterans with chronic PTSD. Schnurr et al compared 

two types of individually administered cognitivebehavioral therapy—PE and present-centered therapy 

(a supportive intervention)—for female veterans 

with PTSD in an RCT. PE treatment was associated 

with greater reduction of PTSD symptoms, decreased 

likelihood of meeting PTSD diagnostic criteria, and 

greater total remission (15.2% vs 6.9%) posttreatment 

and at follow-up.199 This study is especially significant 

in that it demonstrated increased impact of PE when 

compared with a well-designed alternative treatment, 

and when delivered by practitioners in the VHA and 

DoD health care systems.

Studies have also investigated the effectiveness 

of EMDR as a treatment for veterans with PTSD. A 

number of studies have produced positive findings 

with veterans,200,201 but there is some reason for concern 

that changes may not be maintained over time. For 

example, Devilly and colleagues found that Australian veterans treated with EMDR were initially more 

likely to display reliable posttreatment improvement 

in trauma symptomatology than those in a control 

group, but that at 6-month follow-up, reductions in 

symptomatology were not maintained and there were 

no differences between groups.202 A 5-year follow-up 

evaluation of 13 US combat veterans of the Vietnam 

War with chronic PTSD who participated in a study 

of EMDR found that the moderate therapeutic benefits that were obtained immediately were lost at 

5-year follow-up. Furthermore, there was an overall 

worsening of PTSD symptomatology over the 5-year 

follow-up period in both EMDR-treated subjects and 

nontreated control subjects.203

Some research with veterans has targeted the sleep 

disturbance associated with PTSD. In a placebo-controlled, blinded study of veterans of multiple conflicts, 

prazosin was found to be significantly more effective 

than placebo in reducing trauma nightmares, improving sleep quality, and improving the general clinical 

condition of the treated patients.204 Prazosin has also 

been effective with OIF returnees.205 In an uncontrolled 

investigation, Forbes et al offered preliminary evidence 

for the impact of imagery rehearsal therapy in veterans with PTSD.206 The treatment reduced nightmare 

frequency and intensity and overall PTSD, depression, and anxiety symptomatology. Changes were 

maintained at 12-month follow-up. Some research has 

suggested that imagery rehearsal therapy can reduce 

nightmares and improve sleep quality in civilians 

with PTSD.207

In a comprehensive review of PTSD treatment effectiveness, the Institute of Medicine Committee on 

Treatment of Posttraumatic Stress Disorder applied 

conservative methodological criteria and found that 

the research evidence is sufficient to conclude that 

exposure therapies are efficacious in the treatment of 

PTSD.208 The Institute of Medicine found that the evidence for other psychopharmacological treatments and 

psychosocial interventions is inadequate to reach clear 

conclusions. It was also judged that the evidence supporting PE was less consistent for veteran populations, 

especially male veterans with chronic PTSD. Generally, 

treatment outcomes in veteran samples have been less 

robust than those obtained with civilian groups.183

The reasons for this are not well understood, but may 

include a number of factors. Those who seek treatment 

at VHA hospitals may have more severe pathology 

than some civilian samples. Veteran samples have 

typically been characterized by PTSD that has existed 

for many years. Veterans seeking care for chronic 

PTSD may represent a treatment-refractory subgroup 

of the more general PTSD veteran population. Veter-
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Combat and Operational Behavioral Health

ans whose problems were more malleable may have 

already recovered and thus be underrepresented in 

the treatment system. The PTSD disorder commonly 

observed in veterans may also differ in various ways 

from PTSD among other groups. Or, the compensation system for PTSD may cause some veterans to be 

reluctant to report symptom improvement.

Posttraumatic Stress Disorder Program Evaluation 

Some uncontrolled studies have evaluated individual treatment programs for veterans.209,210 Johnson 

et al analyzed the outcome of a 4-month intensive 

inpatient program for combat-related PTSD among

Vietnam veterans.209,210 Comprehensive measures of 

PTSDand psychiatric symptoms, as well as social functioning, were assessed at admission, discharge, and 6, 

12, and 18 months after discharge from the intervention 

program. The study showed an increase in symptoms 

from admission tofollow-up, but a decrease in violent 

actions, thoughts, and legal problems. Family and 

interpersonal relationships and overall morale were

improved at discharge but then returned to pretreatment levels at 18 months. 

Johnson et al conducted a long-term follow-up of 

the program at 18 months and 6 years later because 

previous studies had shown that program impact on 

course of illness had been negligible.211 The sample 

of 51 veterans showed an extremely high mortality 

rate of 17% over 6 years. Nearly three-fourths of the 

sample had experienced an inpatient hospitalization. 

Self-ratings showed significant improvement in all 

areas of functioning except employment, and a positive view of the effects of the program. The majority 

had experienced some improvement in their ability to 

cope with their chronic illness and decreased their use 

of violence and substance abuse. Nevertheless, most 

continued to experience high levels of symptomatology with worsening of hyperarousal symptoms and 

social isolation. 

Bolton et al studied veterans with PTSD who participated in a series of groups focusing on understanding 

PTSD (education), stress management, and anger management.212 Although the impact on PTSD symptoms 

was small, there were moderate impacts on depression 

and overall life satisfaction, and strong declines in 

reports of recent violent behavior and improvements 

in self-reported physical health. Ready et al185 evaluated a VHA specialized PTSD outpatient program 

that delivered a three-phase treatment that included 

group-based exposure therapy. At posttreatment and 

at 6-month follow-up, veteran patients showed significant reductions in PTSD symptoms.185

Findings of evaluations of individual PTSD programs are difficult to generalize to the larger population of treatment programs. However, larger scale 

evaluations of PTSD treatment are available. Creamer 

et al reported on the effectiveness of hospital-based 

programs for Australian veterans with PTSD.213 These 

group-based programs deliver a set of cognitivebehavioral interventions, including psychoeducation 

about PTSD and its treatment; symptom management for anxiety and depression; anger management; 

interpersonal, problem-solving, and communication 

skills training; attention to substance abuse, physical 

health and lifestyle issues; and relapse prevention. 

Trauma focus work (or direct therapeutic exposure) 

is delivered in group or individual formats or both. 

Individual counseling is provided throughout the 

12 weeks, in addition to regular medication reviews. 

Education and support are provided for veterans’ 

partners, often in the form of a weekly group. Overall, individuals in these programs showed significant 

improvements in core PTSD symptoms, anxiety, depression, alcohol abuse, social dysfunction, and anger. 

Changes occurred most frequently between admission 

and 3 months posttreatment, and were maintained at 

9 months. Patients and partners reported perceived 

improvement and strong satisfaction with treatment. 

Nevertheless, treatment gains were variable and, for 

most veterans, considerable pathology remained following the program. Creamer et al reported 2-year 

follow-up outcomes for 1,508 Australian veterans 

receiving care in the same treatment system. Selfreport measures of PTSD,214 anxiety, depression, anger, 

alcohol use, and general functioning showed significant improvements at 6 months (with smaller gains 

continuing through to the 24-month assessment) for 

PTSD (effect size = 0.8), anxiety (0.5), and depression 

(0.5). These results suggest that specialized treatment 

programs for combat-related PTSD can be effective and 

that improvements are maintained over time.

As noted earlier, existing treatments are often not as 

effective for veterans as they are for civilian populations with PTSD. Studies of individual programs attest 

to the difficulty of treating PTSD in veterans whose 

problems have lasted many years. Veterans themselves 

report greater satisfaction with participation in specialized PTSD programs than nonspecialized psychiatry 

programs215 and high absolute levels of satisfaction.216

National program evaluation in VHA PTSD residential 

rehabilitation programs shows significant decreases 

in PTSD symptoms, alcohol and drug abuse, and violence,216 but the magnitude of changes in PTSD is modest. Increasingly, PTSD is treated in outpatient settings. 

Therefore, future research should compare the impact 

of various forms of intensive outpatient treatment on 

the full range of outcomes related to traumatization. 
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Treatment of Deployment-Related Posttraumatic Stress Disorder

TOWARD IMPROVEMENT OF POSTTRAUMATIC STRESS DISORDER SERVICES

to monitor changes in key indicators throughout 

treatment, to evaluate the impact of intervention, 

and to inform ongoing redesign of treatment. At 

the level of the treatment program, outcomes-based 

program evaluation can assist teams with redesign 

of services to ensure program improvement over 

time. Ongoing administration of validated questionnaires as measures of change has not been standard 

practice in PTSD treatment or in mental health 

treatment generally. With the use of computerized 

self-administration of measures, this situation can be 

expected to change, thereby leading to more rapid 

improvement of treatment. 

In many settings, including the VHA, PTSD treatment is commonly delivered through programs that 

combine delivery of focal PTSD treatment with other 

intervention components designed to address concurrent disorders and difficulties.223 Treatment of PTSD 

in such programs commonly involves participating 

in both individual and group activities that includes 

individual assessment, PTSD education classes, 

problem-targeted groups (eg, anger management 

groups, communication skills groups), trauma-focused 

interventions (eg, PE), case management, and pharmacotherapy. Treatment programs are often delivered in 

phases, with a beginning, middle, and end of active 

treatment, followed by lower-intensity maintenance 

support as needed. Little is known about the best way 

to organize these structures of care. More research into 

the types of services that are being provided and the 

real-world effectiveness of such services is required. 

Establishment of systematic outcome monitoring of 

treatment programs can facilitate research and enable 

comparison of treatment structure. 

In fact, there are many treatments for PTSD and 

co-occurring problems,224 and new treatments are 

being developed at an increasing rate. The increasing complexity of the field means that, especially in 

large-scale treatment systems like the DoD and VHA, 

it will be important to develop more effective ways to 

“manage knowledge” within the field of PTSD.225 It 

will also be important to help providers upgrade their 

information, acquire new skills, and learn new interventions, as well as to assist providers and program 

managers in sharing experiences and learning from 

one another’s efforts. 

Despite the existence of a VHA-DoD clinical practice guideline for PTSD that spells out recommended 

practices derived from clinical consensus and research 

findings (available online at www.QMO.amedd.

army.mil or www.oqp.med.va.gov/cpg/cpg.htm), 

there is wide variation in treatment of deploymentrelated PTSD within VHA217 and DoD healthcare 

systems and in the civilian community. Programs 

vary along many dimensions, including the nature 

of interventions, intensity of treatment, balance of 

group or individual therapy, and relative reliance on 

psychosocial interventions versus medication. This 

variation reflects the fact that there are many ways of 

structuring care for PTSD and many treatment options 

that may in principle be concordant with treatment 

guidelines. However, variation in treatment practices 

illustrates the challenge of ensuring that key elements 

of practice guidelines are implemented in routine care. 

Central to service improvement is the dissemination of 

evidence-based treatments.218 Consistent with reviews 

of the general PTSD treatment outcome literature, the 

VA/DoD clinical practice guideline endorses four 

interventions most strongly: (1) exposure therapy, 

(2) CT, (3) SIT, and (4) EMDR. In the past, empirically supported treatments for PTSD have not been 

widely available in most treatment settings, including 

military mental health settings and the VHA.219 Some 

treatments, such as PE, have occasionally been seen 

as difficult or risky to administer, despite the fact that 

the evidence does not support the validity of these 

perceptions.187,220 In the civilian community, Becker 

et al found that two major barriers to clinician use of 

exposure therapy in treatment of PTSD are (1) lack of 

sufficient training, and (2) concern about the safety of 

exposure therapy.221 Findings from research evaluating 

whether more patients drop out from PE than other 

treatments for PTSD and whether PE causes symptom 

worsening have not supported such concerns.222 Dissemination initiatives are now underway to ensure 

that PE and CPT are accessible to veterans and active 

duty personnel with PTSD.

In addition to implementation of evidencebased interventions, another important way to 

use evidence to enhance treatment delivery is to 

establish routine monitoring of outcomes in PTSD 

services. For the individual clinician, it is important 

SUMMARY

Management of deployment-related PTSD has been 

changing rapidly. Screening for PTSD is widespread, 

returning personnel are informed about the disorder, 

and the VHA and DoD have collaborated to establish 

clinical practice guidelines for responding to the specific needs of those with PTSD. As treatment systems 
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evolve, it is critical that more and better quality evaluation of treatment effectiveness be undertaken. More 

treatment outcome research is needed, and program 

evaluative outcomes monitoring, if extended routinely 

to active duty and veteran treatment systems, can 

inform all aspects of care and enable more rapid and 

effective improvement of services. Because PTSD is 

associated with a wide array of co-occurring disorders 

and associated problems in living, assessment and 

program evaluation must be expanded beyond PTSD 

symptomatology. And because PTSD and other posttraumatic problems affect the whole family, their needs, 

too, should receive consideration when evaluating and 

providing services. More systematic monitoring of the 

effectiveness of PTSD services, along with increasing 

systemic and public knowledge of PTSD, will inform 

discussions on disability, fitness for military service, 

and, most importantly, what constitutes satisfactory 

support following deployment. As approaches to treatment of deployment-related PTSD continue to develop, 

the authors anticipate that use of evidence-based 

practices will increase, routine evaluation of outcomes 

will become standard practice, and care decisions will 

become increasingly guided by empirical data. 

REFERENCES

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Health Disorders. 4th-TR ed. Washington, 

DC: APA; 2005.

2. King D, Leskin G, King L, Weathers FW. Confirmatory factor analysis of the clinician-administered PTSD scale: evidence for the dimensionality of posttraumatic stress disorder. Psychol Assess. 1998;10:90–96.

3. McWilliams LA, Cox BJ, Asmundson GJ. Symptom structure of posttraumatic stress disorder in a nationally representative sample. J Anxiety Disord. 2005;19(6):626–641.

4. Buckley T, Blanchard E, Hickling E. A prospective examination of delayed onset PTSD secondary to motor vehicle 

accidents. J Abnorm Psychol. 1996;105:617–625.

5. Gray MJ, Bolton EE, Litz BT. A longitudinal analysis of PTSD symptom course: delayed-onset PTSD in Somalia peacekeepers. J Consult Clin Psychol. 2004;72(5):909–913.

6. Zeiss RA, Dickman HR. PTSD 40 years later: incidence and person-situation correlates in former POWs. J Clin Psychol. 

1989;45(1):80–87.

7. Koenen KC, Stellman JM, Stellman SD, Sommer JF Jr. Risk factors for course of posttraumatic stress disorder among 

Vietnam veterans: a 14-year follow-up of American Legionnaires. J Consult Clin Psychol. 2003;71(6):980–986.

8. Bramsen I, Dirkzwager A, van der Ploeg H. Predeployment personality traits and exposure to trauma as predictors 

of posttraumatic stress symptoms: a prospective study of former peacekeepers. Am J Psychiatry. 2000;157:1115–1119.

9. Dohrenwend B, Turner J, Turse N, Adams B, Koenen K, Marshall R. The psychological risks of Vietnam for US veterans: 

a revisit with new data and methods. Science. 2006;313:979–982.

10. Litz BT, Orsillo SM, Friedman M, Ehlich P, Batres A. Posttraumatic stress disorder associated with peacekeeping duty 

in Somalia for US military personnel. Am J Psychiatry. 1997;154(2):178–184.

11. Mehlum L, Weisaeth L. Predictors of posttraumatic stress reactions in Norwegian UN peacekeepers 7 years after 

service. J Trauma Stress. 2002;15(1):17–26.

12. Ramchand R, Karney B, Osilla K, Burns R, Caldarone L. Prevalence of PTSD, depression, and TBI among returning 

service members. In: Tanielian T, Jaycox LH, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their 

Consequences, and Services to Assist Recovery. Santa Monica, Calif: RAND; 2008: 35–85. 

13. Kulka RA, Schlenger WE, Fairbank JA, et al. Trauma and the Vietnam War Generation: Report of the Findings From the 

National Vietnam Veterans Readjustment Study. New York, NY: Bruner/Mazel; 1990.
313

Treatment of Deployment-Related Posttraumatic Stress Disorder

14. Roy-Byrne P, Arguelles L, Vitek ME, et al. Persistence and change of PTSD symptomatology—a longitudinal co-twin 

control analysis of the Vietnam Era Twin Registry. Soc Psychiatry Psychiatr Epidemiol. 2004;39(9):681–685.

15. Schlenger WE, Fairbank JA, Jordan BK. Combat-related posttraumatic stress disorder: prevalence, risk factors and 

comorbidity. In: Saigh PA, Bremner JD, eds. Posttraumatic Stress Disorder: A Comprehensive Text. Boston, Mass: Allyn 

and Bacon; 1999: 69–91. 

16. Stein MB, Walker JR, Hazen AL, Forde DR. Full and partial posttraumatic stress disorder: findings from a community 

survey. Am J Psychiatry. 1997;154(8):1114–1119.

17. Weiss DS, Marmar CR, Schlenger WE, Fairbank JA, Jordan BK, Hough RL. The prevalence of lifetime and partial 

posttraumatic stress disorder in Vietnam theater veterans. J Trauma Stress. 1992;5(3):365–376.

18. Yarvis J, Bordnick P, Spivey C, Pedlar D. Subthreshold PTSD: a comparison of alcohol, depression, and health problems 

in Canadian peacekeepers with different levels of traumatic stress. Stress Trauma Crisis. 2005;8:195–213.

19. Zlotnick C, Franklin CL, Zimmerman M. Does ”subthreshold” posttraumatic stress disorder have any clinical relevance? 

Compr Psychiatry. 2002;43(6):413–419.

20. Asmundson G, Stein M, McCreary D. PTSD symptoms influence health status of deployed peacekeepers and nondeployed personnel. J Nerv Ment Dis. 2002;180:807–815.

21. Fikretoglu D, Brunet A, Guay S, Pedlar D. Mental health treatment seeking by military members with posttraumatic 

stress disorder: findings on rates, characteristics, and predictors from a nationally representative Canadian military 

sample. Can J Psychiatry. 2007;52(2):49–55.

22. Ruscio AM, Ruscio J, Keane TM. The latent structure of posttraumatic stress disorder: a taxometric investigation of 

reactions to extreme stress. J Abnorm Psychol. 2002;111(2):290–301.

23. Breslau N, Davis GC, Peterson EL, Schultz LR. A second look at comorbidity in victims of trauma: the posttraumatic 

stress disorder–major depression connection. Biol Psychiatry. 2000;48:902–909.

24. Helzer JE, Robins LN, McEvoy L. Posttraumatic stress disorder in the general population. Findings of the epidemiologic catchment area survey. N Engl J Med. 1987;317(26):1630–1634.

25. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity 

Survey. Arch Gen Psychiatry. 1995;52(12):1048–1060.

26. Beckham J, Kirby A, Feldman M. Prevalence and correlates of heavy smoking in Vietnam veterans with chronic posttraumatic stress disorder. Addict Behav. 1997;22:637–647.

27. Beckham JC, Moore SD, Feldman ME, Herzberg MA, Kirby AC, Fairbank JA. Health status, somatization and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder. Am J Psychiatry. 

1998;155:1565–1569.

28. Brown P, Wolfe J. Substance abuse and posttraumatic stress disorder comorbidity. Drug Alcohol Dependency. 1994;35:51–

59.

29. Clum G, Calhoun K, Kimerling R. Associations among symptoms of depression and posttraumatic stress disorder 

and self-reported health in sexually assaulted women. J Nerv Ment Dis. 2000;188:671–678.

30. Ferrada-Noli M, Asberg M, Ormstad K, Lundin T, Sundbom E. Suicidal behavior after severe trauma, part 1: PTSD 

diagnoses, psychiatric comorbidity, and assessments of suicidal behavior. J Trauma Stress. 1998;11:103–122.

31. Kang HK, Natelson BH, Mahan CM, Lee KY, Murphy FM. Posttraumatic stress disorder and chronic fatigue syndromelike illness among Gulf War veterans: a population-based survey of 30,000 veterans. Am J Epidemiol. 2003;157(2):141–

148.
314

Combat and Operational Behavioral Health

32. Marshall RD, Olfson M, Hellman F, Blanco C, Guardino M, Struening EL. Comorbidity, impairment, and suicidality 

in subthreshold PTSD. Am J Psychiatry. 2001;158(9):1467–1473.

33. Neal LA, Hill N, Hughes J, Middleton A, Busuttil W. Convergent validity of measures of PTSD in an elderly population of former prisoners of war. Int J Geriatr Psychiatry. 1995;10:617–622.

34. Riggs DS, Byrne CA, Weathers FW, Litz BT. The quality of the intimate relationships of male Vietnam veterans: problems associated with posttraumatic stress disorder. J Trauma Stress. 1998;11(1):87–101.

35. Sharp TJ, Harvey AG. Chronic pain and posttraumatic stress disorder: mutual maintenance? Clin Psychol Rev. 

2001;21(6):857–877.

36. Wagner AW, Wolfe J, Rotnitsky A, Proctor SP, Erickson DJ. An investigation of the impact of posttraumatic stress 

disorder on physical health. J Trauma Stress. 2000;13(1):41–55.

37. Westerink J, Giarratano L. The impact of posttraumatic stress disorder on partners and children of Australian Vietnam 

veterans. Aust N Z J Psychiatry. 1999;33(6):841–847.

38. Yarvis J, Schiess L. Subthreshold PTSD as a predictor of depression, alcohol use, and health problems in veterans. J 

Workplace Behav Hlth. 2008;23:4. 

39. Koenen KC, Stellman SD, Sommer JF Jr, Stellman JM. Persisting posttraumatic stress disorder symptoms and their 

relationship to functioning in Vietnam veterans: a 14-year follow-up. J Trauma Stress. 2008;21(1):49–57.

40. Engdahl B, Dikel TN, Eberly R, Blank A. Posttraumatic stress disorder in a community group of former prisoners of 

war: a normative response to severe trauma. Am J Psychiatry. 1997;154(11):1576–1581.

41. Green BL, Lindy JD, Grace MC, Leonard AC. Chronic posttraumatic stress disorder and diagnostic comorbidity in a 

disaster sample. J Nerv Ment Dis. 1992;180(12):760–766.

42. King DW, King LA, Foy DW, Gudanowski DM. Prewar factors in combat-related posttraumatic stress disorder: 

structural equation modeling with a national sample of female and male Vietnam veterans. J Consult Clin Psychol. 

1996;64(3):520–531.

43. Wolfe J, Erickson DJ, Sharkansky EJ, King DW, King LA. Course and predictors of posttraumatic stress disorder among 

Gulf War veterans: a prospective analysis. J Consult Clin Psychol. 1999;67(4):520–528.

44. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental 

health problems, and barriers to care. N Engl J Med. 2004;351(1):13–22.

45. Himmelfarb N, Yaeger D, Mintz J. Posttraumatic stress disorder in female veterans with military and civilian sexual 

trauma. J Trauma Stress. 2006;19(6):837–846.

46. Yaeger D, Himmelfarb N, Cammack A, Mintz J. DSM-IV diagnosed posttraumatic stress disorder in women veterans 

with and without military sexual trauma. J Gen Intern Med. 2006;21(Suppl 3):S65–S69.

47. Fontana A, Rosenheck R. Duty-related and sexual stress in the etiology of PTSD among women veterans who seek 

treatment. Psychiatric Serv. 1998;49:658–662.

48. King LA, King DW, Fairbank JA, Keane TM, Adams GA. Resilience-recovery factors in posttraumatic stress disorder 

among female and male Vietnam veterans: hardiness, postwar social support, and additional stressful life events. J 

Pers Soc Psychol. 1998;74(2):420–434.

49. Boscarino J. Posttraumatic stress and associated disorders among Vietnam veterans: the significance of combat exposure and social support. J Trauma Stress. 1995;8:317–336.

50. Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed 

adults. J Consult Clin Psychol. 2000;68:748–766.
315

Treatment of Deployment-Related Posttraumatic Stress Disorder

51. Foa E, Kozak M. Emotional processing of fear: exposure to corrective information. Psychol Bull. 1986;99:20–35.

52. Ehlers A, Clark D. A cognitive model of posttraumatic stress disorder. Behav Res Ther. 2000;38:319–345.

53. Brewin C, Dalgleish T, Joseph S. A dual representation theory of posttraumatic stress disorder. Psychol Rev. 1996;103:670–

686.

54. Foa E, Cahill S. Psychological therapies: emotional processing. In: Smelser N, Bates P, eds. International Encyclopedia 

of the Social and Behavioral Sciences. Oxford, UK: Elsevier, 2001; 12363–12369.

55. Maguen S, Litz BT. Predictors of barriers to mental health treatment for Kosovo and Bosnia peacekeepers: a preliminary 

report. Mil Med. 2006;171(5):454–458.

56. Kimerling R, Trafton JA, Nguyen B. Validation of a brief screen for posttraumatic stress disorder with substance use 

disorder patients. Addict Behav. 2006;31(11):2074–2079.

57. Bliese P, Wright K, Adler A. Timing of postcombat mental health assessments. Psychol Serv. 2007;4:141–148.

58. Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve 

component soldiers returning from the Iraq war. JAMA. 2007;298(18):2141–2148.

59. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from 

military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006;295(9):1023–1032.

60. McFall M, Malte C, Fontana A, Rosenheck RA. Effects of an outreach intervention on use of mental health services by 

veterans with posttraumatic stress disorder. Psychiatr Serv. 2000;51(3):369–374.

61. Fontana A, Rosenheck R. Trauma, change in strength of religious faith, and mental health service use among veterans 

treated for PTSD. J Nerv Ment Dis. 2004;192:579–584.

62. Keane T, Street A, Stafford J. The assessment of military-related PTSD. In: Wilson J, Keane T, eds. Assessing Psychological 

Trauma and PTSD. New York, NY: Guilford Press; 2004: 262–285.

63. King LA, King DW, Vogt DS, Knight J, Samper RE. Deployment Risk and Resilience Inventory: a collection of measures 

for studying deployment-related experiences of military personnel and veterans. Mil Psychol. 2006;18:89–120.

64. Lapp KG, Bosworth HB, Strauss JL, et al. Lifetime sexual and physical victimization among male veterans with combatrelated posttraumatic stress disorder. Mil Med. 2005;170(9):787–790.

65. Cabrera O, Hoge C, Bliese P. Childhood adversity and combat as predictors of depression and post-traumatic stress 

in deployed troops. Am J Prev Med. 2007;33:77–82.

66. Gahm GA, Lucenko BA. Screening soldiers in outpatient care for mental health concerns. Mil Med. 2008;173(1):17–

24.

67. Department of Veterans Affairs/Department of Defense (VA/DoD). Clinical Practice Guideline for the Management of 

Posttraumatic Stress. Washington, DC: VA/DoD Clinical Practice Guideline Working Group, Veterans Health Administration, Department of Veterans Affairs and Health Affairs, Department of Defense. 2004.

68. Gray MJ, Elhai JD, Frueh BC. Enhancing patient satisfaction and increasing treatment compliance: patient education 

as a fundamental component of PTSD treatment. Psychiatr Q. 2004;75(4):321–332.

69. Meichenbaum D. Stress Inoculation Training. New York, NY: Pergamon; 1985.

70. Foa E, Dancu C, Hembree E. A comparison of exposure therapy, stress inoculation training, and their combination for 

reducing posttraumatic stress disorder in female assault victims. J Consult Clin Psychol. 1999;67:194–200.
316

Combat and Operational Behavioral Health

71. Foa E, Rothbaum B. Treating the Trauma of Rape: Cognitive-Behavioral Therapy for PTSD. New York, NY: Guilford Press; 

1998.

72. Shapiro F. Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures. New York, NY: 

Guilford Press; 2001.

73. Foa E, Jaycox L. Cognitive-behavioral theory and treatment of posttraumatic stress disorder. In: Spiegel D, ed. Efficacy 

and Cost-Effectiveness of Psychotherapy. Washington, DC: American Psychiatric Press; 1999: 23–61.

74. Resick PA, Schnicke MK. Cognitive processing therapy for sexual assault victims. J Consult Clin Psychol. 1992;60(5):748–

756.

75. Kubany ES. Cognitive therapy for trauma-related guilt. In: Follette V, Ruzek JI, Abueg F, eds. Cognitive-Behavioral 

Therapies for Trauma. New York, NY: Guilford Press; 1998: 124–161.

76. Kubany ES, Abueg FR, Kilauano WL, Manke FP, Kaplan AS. Development and validation of the sources of traumarelated guilt survey-war-zone version. J Trauma Stress. 1997;10(2):235–258.

77. Foa E, Ehlers A, Clark D. The Post-Traumatic Cognitions Inventory (PTCI): development and validation. Psychol Assess. 1999;11:303–314.

78. The Committee on Treatment of Posttraumatic Stress Disorder. Treatment of Posttraumatic Stress Disorder: An Assessment 

of the Evidence. Washington, DC: Institute of Medicine; 2007.

79. Ballenger JC, Davidson JR, Lecrubier Y, et al. Consensus statement update on posttraumatic stress disorder from the 

international consensus group on depression and anxiety. J Clin Psychiatry. 2004;65(Suppl 1):55–62.

80. Brady K, Pearlstein T, Asnis G, et al. Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a 

randomized controlled trial. JAMA. 2000;283:1837–1844.

81. Davidson J, Pearlstein T, Londborg P, et al. Efficacy of sertraline in preventing relapse of posttraumatic stress disorder: 

results of a 28-week double-blind, placebo-controlled study. Am J Psychol. 2001;158:1974–1981.

82. Stein DJ, Davidson J, Seedat S, Beebe K. Paroxetine in the treatment of posttraumatic stress disorder: pooled analysis 

of placebo-controlled studies. Expert Opin Pharmacother. 2003;4(10):1829–1838.

83. Robert S, Hamner MB, Ulmer HG, Lorberbaum JP, Durkalski VL. Open-label trial of escitalopram in the treatment of 

posttraumatic stress disorder. J Clin Psychiatry. 2006;67(10):1522–1526.

84. Seedat S, Stein DJ, Emsley RA. Open trial of citalopram in adults with posttraumatic stress disorder. Int J Neuropsychopharmacol. 2000;3(2):135–140.

85. Martenyi F, Brown EB, Zhang H, Koke SC, Prakash A. Fluoxetine versus placebo in prevention of relapse in posttraumatic stress disorder. Br J Psychiatry. 2002;181:315–320.

86. Martenyi F, Brown EB, Zhang H, Prakash A, Koke SC. Fluoxetine versus placebo in posttraumatic stress disorder. J 

Clin Psychiatry. 2002;63(3):199–206.

87. Stein MB, McQuaid JR, Pedrelli P, Lenox R, McCahill ME. Posttraumatic stress disorder in the primary care medical 

setting. Gen Hosp Psychiatry. 2000;22(4):261–269.

88. Mullins CD, Shaya FT, Meng F, Wang J, Harrison D. Persistence, switching, and discontinuation rates among patients 

receiving sertraline, paroxetine, and citalopram. Pharmacother. 2005;25(5):660–667.

89. Davidson J, Rothbaum B, Tucker P, Asnis G, Benattia I, Musgnung J. Venlafaxine extended release in posttraumatic 

stress disorder: a sertraline- and placebo-controlled study. J Clin Psychopharmacol. 2006;26:259–267.
317

Treatment of Deployment-Related Posttraumatic Stress Disorder

90. Davidson J, Weisler R, Butterfield M, et al. Mirtazapine vs placebo in posttraumatic stress disorder: a pilot trial. Biol 

Psychiatry. 2003;53:188–191.

91. Davis LL, Jewell ME, Ambrose S, et al. A placebo-controlled study of nefazodone for the treatment of chronic posttraumatic stress disorder: a preliminary study. J Clin Psychopharmacol. 2004;24(3):291–297.

92. Briley M. Clinical experience with dual action antidepressants in different chronic pain syndromes. Hum Psychopharmacol. 2004;19(Suppl 1):S21–S25.

93. Becker M, Hertzberg M, Moore S, Dennis M, Bukenya D, Beckham J. A placebo-controlled trial of bupropion SR in the 

treatment of chronic posttraumatic stress disorder. J Clin Psychopharmacol. 2007;27:193–197.

94. Hertzberg MA, Moore SD, Feldman ME, Beckham JC. A preliminary study of bupropion sustained-release for smoking cessation in patients with chronic posttraumatic stress disorder. J Clin Psychopharmacol. 2001;21(1):94–98.

95. Bartzokis G, Lu PH, Turner J, Mintz J, Saunders CS. Adjunctive risperidone in the treatment of chronic combat-related 

posttraumatic stress disorder. Biol Psychiatry. 2005;57:474–479.

96. Hamner MB, Faldowski RA, Ulmer HG, Frueh BC, Huber MG, Arana GW. Adjunctive risperidone treatment in posttraumatic stress disorder: a preliminary controlled trial of effects on comorbid psychotic symptoms. Int Clin Psychopharmacol. 2003;18(1):1–8.

97. Monnelly EP, Ciraulo DA, Knapp C, Keane T. Low-dose risperidone as adjunctive therapy for irritable aggression in 

posttraumatic stress disorder. J Clin Psychopharmacol. 2003;23(2):193–196.

98. Padala PR, Madison J, Monnahan M, et al. Risperidone monotherapy for posttraumatic stress disorder related to sexual 

assault and domestic abuse in women. Int Clin Psychopharmacol. 2006;21(5):275–280.

99. Stein MB, Kline NA, Matloff JL. Adjunctive olanzapine for SSRI-resistant combat-related PTSD: a double-blind, 

placebo-controlled study. Am J Psychiatry. 2002;159(10):1777–1779.

100. Rothbaum BO, Killeen TK, Davidson JR, Brady KT, Connor KM, Heekin MH. Placebo-controlled trial of risperidone 

augmentation for selective serotonin reuptake inhibitor-resistant civilian posttraumatic stress disorder. J Clin Psychiatry. 

2008;69(4):520–525.

101. Davis LL, Ward C, Rasmusson A, Newell JM, Frazier E, Southwick SM. A placebo-controlled trial of guanfacine for 

the treatment of posttraumatic stress disorder in veterans. Psychopharmacol Bull. 2008;41:8–18.

102. Lindley SE, Carlson EB, Hill K. A randomized, double-blind, placebo-controlled trial of augmentation topiramate for 

chronic combat-related posttraumatic stress disorder. J Clin Psychopharmacol. 2007;27(6):677–681.

103. Davidson J, Brady K, Mellman T, Stein M, Pollack M. The efficacy and tolerability of tiagabine in adult patients with 

posttraumatic stress disorder. J Clin Psychopharmacol. 2007;27:85–88.

104. Southwick SM, Bremner JD, Rasmusson A, Morgan CA 3rd, Arnsten A, Charney DS. Role of norepinephrine in the 

pathophysiology and treatment of posttraumatic stress disorder. Biol Psychiatry. 1999;46(9):1192–1204.

105. Neylan TC, Lenoci M, Samuelson KW, et al. No improvement of posttraumatic stress disorder symptoms with guanfacine treatment. Am J Psychiatry. 2006;163(12):2186–2188.

106. Reist C, Duffy JG, Fujimoto K, Cahill L. β-Adrenergic blockade and emotional memory in PTSD. Int J Neuropsychopharmacol. 2001;4(4):377–383.

107. Pitman RK, Sanders KM, Zusman RM, et al. Pilot study of secondary prevention of posttraumatic stress disorder with 

propranolol. Biol Psychiatry. 2002;51(2):189–192.

108. Stein MB, Kerridge C, Dimsdale JE, Hoyt DB. Pharmacotherapy to prevent PTSD: results from a randomized controlled 

proof-of-concept trial in physically injured patients. J Trauma Stress. 2007;20(6):923–932.
318

Combat and Operational Behavioral Health

109. Raskind MA, Peskind ER, Hoff DJ, et al. A parallel group placebo controlled study of prazosin for trauma nightmares 

and sleep disturbance in combat veterans with posttraumatic stress disorder. Biol Psychiatry. 2007;61(8):928–934.

110. Raskind MA, Peskind ER, Kanter ED, et al. Reduction of nightmares and other PTSD symptoms in combat veterans 

by prazosin: a placebo-controlled study. Am J Psychiatry. 2003;160(2):371–373.

111. Braun P, Greenberg D, Dasberg H, Lerer B. Core symptoms of posttraumatic stress disorder unimproved by alprazolam 

treatment. J Clin Psychiatry. 1990;51:236–238.

112. Cates M, Bishop M, Davis L, Lowe J, Woolley T. Clonazepam for treatment of sleep disturbances associated with 

combat-related posttraumatic stress disorder. Ann Pharmacother. 2004;38:1395–1399.

113. Gelpin E, Bonne O, Peri T, Brandes D, Shalev AY. Treatment of recent trauma survivors with benzodiazepines: a prospective study. J Clin Psychiatry. 1996;57(9):390–394.

114. Hermos JA, Young MM, Lawler EV, Rosenbloom D, Fiore LD. Long-term, high-dose benzodiazepine prescriptions 

in veteran patients with PTSD: influence of preexisting alcoholism and drug-abuse diagnoses. J Trauma Stress. 

2007;20(5):909–914.

115. Bisson J. Pharmacological treatment of posttraumatic stress disorder. Adv Psychiatr Treatment. 2007;13:119–126.

116. NICE: National Institute for Health and Clinical Excellence Report. Birmingham, UK: National Institute for Health 

and Clinical Excellence, 2005. Available at: http://www.nice.org.uk/nicemedia/pdf/CG026NICEguideline.pdf. Accessed February 18, 2009.

117. Mellman TA, Clark RE, Peacock WJ. Prescribing patterns for patients with posttraumatic stress disorder. Psychiatr 

Serv. 2003;54(12):1618–1621.

118. Resick PA, Williams L, Orazem R, Gutner C. Can we cure PTSD? Five-year follow-up of a clinical trial comparing 

cognitive processing therapy and prolonged exposure. Paper presented at: The Association for Behavioral and Cognitive Therapies; 2005; Washington, DC. 

119. Rosen CS, DiLandro C, Corwin KN, Drescher KD, Cooney JH, Gusman F. Telephone monitoring and support for 

veterans with chronic posttraumatic stress disorder: a pilot study. Community Ment Health J. 2006;42(5):501–508.

120. Davis LL, Frazier EC, Williford RB, Newell JM. Long-term pharmacotherapy for posttraumatic stress disorder. CNS 

Drugs. 2006;20(6):465–476.

121. Schnurr PP, Hayes AF, Lunney CA, McFall M, Uddo M. Longitudinal analysis of the relationship between symptoms 

and quality of life in veterans treated for posttraumatic stress disorder. J Consult Clin Psychol. 2006;74(4):707–713.

122. Gladis MM, Gosch EA, Dishuk NM, Crits-Christoph P. Quality of life: expanding the scope of clinical significance. J 

Consult Clin Psychol. 1999;67(3):320–331.

123. Ouimette P, Moos RH, Finney JW. PTSD treatment and 5-year remission among patients with substance use and posttraumatic stress disorders. J Consult Clin Psychol. 2003;71(2):410–414.

124. Ruzek JI. Concurrent posttraumatic stress disorder and substance use disorder among veterans: evidence and treatment issues. In: Ouimette P, Brown P, eds. Trauma and Substance Abuse: Causes, Consequences, and Treatment of Comorbid 

Disorders. Washington, DC: American Psychological Association; 2002: 191–207. 

125. Najavits LM. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. New York, NY: Guilford Press; 2002.

126. Koenen KC, Hitsman B, Lyons MJ, et al. Posttraumatic stress disorder and late-onset smoking in the Vietnam era twin 

registry. J Consult Clin Psychol. 2006;74(1):186–190.

127. McFall M, Saxon AJ, Thompson CE, et al. Improving the rates of quitting smoking for veterans with posttraumatic 

stress disorder. Am J Psychiatry. 2005;162(7):1311–1319.
319

Treatment of Deployment-Related Posttraumatic Stress Disorder

128. Ledgerwood DM, Petry NM. Posttraumatic stress disorder symptoms in treatment-seeking pathological gamblers. J 

Trauma Stress. 2006;19(3):411–416.

129. Biddle D, Hawthorne G, Forbes D, Coman G. Problem gambling in Australian PTSD treatment-seeking veterans. J 

Trauma Stress. 2005;18:759–767.

130. Blanchard E, Buckley T, Hickling E, Taylor A. Posttraumatic stress disorder and comorbid depression: is the correlation an illusion? J Anxiety Dis. 1998;12:21–37.

131. Shalev AY, Freedman S, Peri T, et al. Prospective study of posttraumatic stress disorder and depression following 

trauma. Am J Psychiatry. 1998;155(5):630–637.

132. Erickson D, Wolfe J, King DW, King LA, Sharkansky EJ. Posttraumatic stress disorder and depression symptomatology 

in a sample of Gulf War veterans: a prospective analysis. J Consult Clin Psychol. 2001;69:41–49.

133. Sareen J, Houlahan T, Cox BJ, Asmundson GJ. Anxiety disorders associated with suicidal ideation and suicide attempts 

in the National Comorbidity Survey. J Nerv Ment Dis. 2005;193(7):450–454.

134. Boscarino J. External-cause mortality after psychologic trauma: the effects of stress exposure and predisposition. Compr 

Psychiatry. 2006;47:503–514.

135. Kashdan TB, Frueh BC, Knapp RG, Hebert R, Magruder KM. Social anxiety disorder in Veterans Affairs primary care 

clinics. Behav Res Ther. 2006;44(2):233–247.

136. Sasson Y, Dekel S, Nacasch N, et al. Posttraumatic obsessive-compulsive disorder: a case series. Psychiatry Res. 

2005;135(2):145–152.

137. Falsetti S, Davis J. Multiple channel exposure therapy: combining cognitive-behavioral therapies for the treatment of 

posttraumatic stress disorder with panic attacks. Behav Modif. 2005;29:70–94.

138. Novaco RW, Chemtob CM. Anger and combat-related posttraumatic stress disorder. J Trauma Stress. 2002;15(2):123–

132.

139. Orth U, Wieland E. Anger, hostility, and posttraumatic stress disorder in trauma-exposed adults: a meta-analysis. J 

Consult Clin Psychol. 2006;74(4):698–706.

140. Jakupcak M, Conybeare D, Phelps L, et al. Anger, hostility, and aggression among Iraq and Afghanistan war veterans 

reporting PTSD and subthreshold PTSD. J Trauma Stress. 2007;20(6):945–954.

141. Beckham J, Vrana S, Barefoot J, Feldman M, Fairbank J, Moore S. Magnitude and duration of cardiovascular response to 

anger in Vietnam veterans with and without posttraumatic stress disorder. J Consult Clin Psychol. 2002;70:228–234.

142. Forbes D, Creamer M, Hawthorne G. Comorbidity as a predictor of symptom change after treatment in combat-related 

posttraumatic stress disorder. J Nerv Ment Dis. 2003;191:93–99.

143. Foa E, Riggs D, Massie E, Yarczower M. The impact of fear activation and anger on the efficacy of exposure treatment 

for posttraumatic stress disorder. Behav Ther. 1995;26:487–499.

144. McFall M, Fontana A, Raskind M, Rosenheck R. Analysis of violent behavior in Vietnam combat veteran psychiatric 

inpatients with posttraumatic stress disorder. J Trauma Stress. 1999;12(3):501–517.

145. Sherman MD, Sautter F, Jackson MH, Lyons JA, Han X. Domestic violence in veterans with posttraumatic stress disorder who seek couples therapy. J Marital Fam Ther. 2006;32(4):479–490.

146. Taft CT, Pless AP, Stalans LJ, Koenen KC, King LA, King DW. Risk factors for partner violence among a national sample 

of combat veterans. J Consult Clin Psychol. 2005;73(1):151–159.
320

Combat and Operational Behavioral Health

147. Orcutt HK, King LA, King DW. Male-perpetrated violence among Vietnam veteran couples: relationships with veteran’s early life characteristics, trauma history, and PTSD symptomatology. J Trauma Stress. 2003;16(4):381–390.

148. Freeman T, Roca V, Kimbrell T. A survey of gun collection and use among three groups of veteran patients admitted 

to Veterans Affairs hospital treatment programs. South Med J. 2003;96:240–243.

149. Holman EA, Silver RC. Getting “stuck” in the past: temporal orientation and coping with trauma. J Pers Soc Psychol. 

1998;74(5):1146–1163.

150. Neria Y. Coping with tangible and intangible traumatic losses in prisoners of war. Isr J Psychiatry Relat Sci. 2001;38(3–

4):216–225.

151. Pivar IL, Field NP. Unresolved grief in combat veterans with PTSD. J Anxiety Disord. 2004;18(6):745–755.

152. Shear K, Frank E. Treatment of complicated grief: integrating cognitive-behavioral methods with other treatment approaches. In: Follette V, Ruzek JI, eds. Cognitive-Behavioral Therapies for Trauma. 2nd ed. New York, NY: Guilford Press; 

2006: 290–320.

153. Ehlers A. Understanding and treating complicated grief: what can we learn from posttraumatic stress disorder? Clin 

Psychol Sci Pract. 2006;13:135–140.

154. Richardson JD, Elhai JD, Pedlar DJ. Association of PTSD and depression with medical and specialist care utilization 

in modern peacekeeping veterans in Canada with health-related disabilities. J Clin Psychiatry. 2006;67(8):1240–1245.

155. Schnurr PP, Green BL. Understanding relationships among trauma, posttraumatic stress disorder, and health outcomes. 

Adv Mind-Body Med. 2004;20:18–29.

156. Stapleton JA, Asmundson GJ, Woods M, Taylor S, Stein MB. Health care utilization by United Nations peacekeeping veterans with co-occurring, self-reported, posttraumatic stress disorder and depression symptoms versus those 

without. Mil Med. 2006;171(6):562–566.

157. Buckley TC, Mozley SL, Bedard MA, Dewulf AC, Greif J. Preventive health behaviors, health-risk behaviors, physical 

morbidity, and health-related role functioning impairment in veterans with posttraumatic stress disorder. Mil Med. 

2004;169:536–540.

158. Schnurr PP, Lunney CA, Sengupta A, Spiro A III. A longitudinal study of retirement in older male veterans. J Consult 

Clin Psychol. 2005;73(3):561–566.

159. Davison E, Pless A, Gugliucci M, et al. Late-life emergence of early life trauma: the phenomenon of late-onset stress 

symptomatology among aging combat veterans. Res Aging. 2006(28):84–114.

160. Solomon Z, Mikulincer M. Trajectories of PTSD: a 20-year longitudinal study. Am J Psychiatry. 2006;163(4):659–666.

161. Hoge CW, Terhakopian A, Castro CA, Messer SC, Engel CC. Association of posttraumatic stress disorder with somatic 

symptoms, health care visits, and absenteeism among Iraq war veterans. Am J Psychiatry. 2007;164(1):150–153.

162. Grieger TA, Cozza SJ, Ursano RJ, et al. Posttraumatic stress disorder and depression in battle-injured soldiers. Am J 

Psychiatry. 2006;163(10):1777–1783.

163. McMillan TM, Williams WH, Bryant R. Posttraumatic stress disorder and traumatic brain injury: a review of causal 

mechanisms, assessment, and treatment. Neuropsychol Rehab. 2003;13:149–164.

164. Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild traumatic brain injury in US soldiers returning 

from Iraq. N Engl J Med. 2008;358(5):453–463.

165. Bryant R, Moulds M, Guthrie R. Treating acute stress disorder following mild traumatic brain injury. Am J Psychiatry. 

2003;160:585–587.
321

Treatment of Deployment-Related Posttraumatic Stress Disorder

166. Ruscio AM, Weathers FW, King LA, King DW. Male war-zone veterans’ perceived relationships with their children: 

the importance of emotional numbing. J Trauma Stress. 2002;15(5):351–357.

167. Samper RE, Taft CT, King DW, King LA. Posttraumatic stress disorder symptoms and parenting satisfaction among 

a national sample of male Vietnam veterans. J Trauma Stress. 2004;17(4):311–315.

168. Prigerson HG, Maciejewski PK, Rosenheck RA. Combat trauma: trauma with highest risk of delayed onset and 

unresolved posttraumatic stress disorder symptoms, unemployment, and abuse among men. J Nerv Ment Dis. 

2001;189(2):99–108.

169. Calhoun P, Beckham J, Bosworth H. Caregiver burden and psychological distress in partners of veterans with chronic 

posttraumatic stress disorder. J Trauma Stress. 2002;15:205–212.

170. Dirkzwager A, Bramsen I, Adèr H. Secondary traumatization in partners and parents of Dutch peacekeeping soldiers. 

J Fam Psychol. 2005;19:217–226.

171. Byrne C, Riggs D. The cycle of trauma: relationship aggression in male Vietnam veterans with symptoms of posttraumatic stress disorder. Violence Vict. 1996;11:213–225.

172. Devilly GJ. The psychological effects of a lifestyle management course on war veterans and their spouses. J Clin Psychol. 

2002;58:1119–1134.

173. Sautter F, Lyons JA, Manguno-Mire G, et al. Predictors of partner engagement in PTSD treatment. J Psychopathol Behav 

Assess. 2006;28:123–130.

174. Monson CM, Schnurr PP, Stevens SP, Guthrie KA. Cognitive-behavioral couple’s treatment for posttraumatic stress 

disorder: initial findings. J Trauma Stress. 2004;17(4):341–344.

175. Glynn SM, Eth S, Randolph ET, et al. A test of behavioral family therapy to augment exposure for combat-related 

posttraumatic stress disorder. J Consult Clin Psychol. 1999;67(2):243–251.

176. Frueh BC, Turner SM, Beidel DC, Cahill S. Assessment of social functioning in combat veterans with PTSD. Aggression 

Violent Behav. 2001;6:79–90.

177. Jordan BK, Marmar CR, Fairbank JA, et al. Problems in families of male Vietnam veterans with posttraumatic stress 

disorder. J Consult Clin Psychol. 1992;60(6):916–926.

178. Bolton E, Glenn D, Orsillo S, Roemer L, Litz B. The relationship between self-disclosure and symptoms of posttraumatic 

stress disorder in peacekeepers deployed to Somalia. J Trauma Stress. 2003;10:203–210.

179. Kessler RC, Frank RG. The impact of psychiatric disorders on work loss days. Psychol Med. 1997;27(4):861–873.

180. Savoca E, Rosenheck R. The civilian labor market experiences of Vietnam-era veterans: the influence of psychiatric 

disorders. J Ment Health Policy Econ. 2000;3(4):199–207.

181. Smith MW, Schnurr PP, Rosenheck RA. Employment outcomes and PTSD symptom severity. Ment Health Serv Res. 

2005;7(2):89–101.

182. Foa E, Keane T, Friedman M, Cohen J. Effective Treatments for PTSD. Practice Guidelines From the International Society for 

Traumatic Stress Studies. 2nd ed. New York, NY: Guilford Press; 2008.

183. Bradley R, Greene J, Russ E, Dutra L, Western D. A multidimensional meta-analysis of psychotherapy for PTSD. Am 

J Psychiatry. 2005;162:214–227.

184. Foy D, Glynn S, Schnurr P, et al. Group therapy. In: Foa E, Keane T, Friedman M, Cohen J, eds. Effective Treatments for 

PTSD: Practice Guidelines From the International Society for Traumatic Stress Studies. New York, NY: Guilford Press; 2000: 

155–175.
322

Combat and Operational Behavioral Health

185. Ready DJ, Thomas KR, Worley V, et al. A field test of group based exposure therapy with 102 veterans with war-related 

posttraumatic stress disorder. J Trauma Stress. 2008;21(2):150–157.

186. Resick PA, Nishith P, Weaver TL, Astin MC, Feuer CA. A comparison of cognitive-processing therapy with prolonged 

exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. J 

Consult Clin Psychol. 2002;70(4):867–879.

187. Foa EB, Zoellner LA, Feeny NC, Hembree EA, Alvarez-Conrad J. Does imaginal exposure exacerbate PTSD symptoms? 

J Consult Clin Psychol. 2002;70:1022–1028.

188. Paunovic N, Ost LG. Cognitive-behavior therapy vs exposure therapy in the treatment of PTSD in refugees. Behav Res 

Ther. 2001;39(10):1183–1197.

189. Bryant R, Moulds M, Guthrie R. Imaginal exposure alone and imaginal exposure with cognitive restructuring in treatment of posttraumatic stress disorder. J Consult Clin Psychol. 2003;71:706–712.

190. Tarrier N, Pilgrim H, Sommerfield C, et al. A randomized trial of cognitive therapy and imaginal exposure in the 

treatment of chronic posttraumatic stress disorder. J Consult Clin Psychol. 1999;67(1):13–18.

191. Tarrier N, Sommerfield C. Treatment of chronic PTSD by cognitive therapy and exposure: 5-year follow-up. Behav 

Ther. 2004;35:231–246.

192. van der Kolk BA, Spinazzola J, Blaustein ME, et al. A randomized clinical trial of eye movement desensitization and 

reprocessing (EMDR), fluoxetine, and pill placebo in the treatment of posttraumatic stress disorder: treatment effects 

and long-term maintenance. J Clin Psychiatry. 2007;68(1):37–46.

193. Rothbaum BO, Cahill SP, Foa EB, et al. Augmentation of sertraline with prolonged exposure in the treatment of posttraumatic stress disorder. J Trauma Stress. 2006;19(5):625–638.

194. Boudewyns P, Hyer L, Woods M, Harrison W, McCranie E. PTSD among Vietnam veterans: an early look at treatment 

outcome using direct therapeutic exposure. J Trauma Stress. 1990;3:359–368.

195. Cooper N, Clum G. Imaginal flooding as a supplementary treatment for PTSD in combat veterans: a controlled study. 

Behav Ther. 1989;20:381–391.

196. Keane T, Fairbank JA, Caddell J, Zimering R. Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam 

combat veterans. Behav Ther. 1989;20:245–260.

197. Schnurr PP, Friedman MJ, Foy DW, et al. Randomized trial of trauma-focused group therapy for posttraumatic stress 

disorder: results from a Department of Veterans Affairs cooperative study. Arch Gen Psychiatry. 2003;60(5):481–489.

198. Monson CM, Schnurr PP, Resick PA, Friedman MJ, Young-Xu Y, Stevens SP. Cognitive processing therapy for veterans 

with military-related posttraumatic stress disorder. J Consult Clin Psychol. 2006;74(5):898–907.

199. Schnurr PP, Friedman MJ, Engel CC, et al. Cognitive behavioral therapy for posttraumatic stress disorder in women: 

a randomized controlled trial. JAMA. 2007;297(8):820–830.

200. Boudewyns P, Hyer L. Eye movement desensitization and reprocessing (EMDR) as a treatment for posttraumatic stress 

disorder. Clin Psychol Psychother. 1996;3:185–195.

201. Carlson JG, Chemtob CM, Rusnack K, Hedlund NL, Muraoka MY. Eye movement desensitization and reprocessing 

(EDMR) treatment for combat-related posttraumatic stress disorder. J Trauma Stress. 1998;11:3–24.

202. Devilly G, Spence S, Rapee R. Statistical and reliable change with eye movement desensitization and reprocessing: 

treating trauma within a veteran population. Behav Ther. 1998;29:435–455.

203. Macklin ML, Metzger LJ, Lasko NB, Berry NJ, Orr SP, Pitman RK. Five-year follow-up study of eye movement desensitization and reprocessing therapy for combat-related posttraumatic stress disorder. Compr Psychiatry. 2000;41(1):24–27.
323

Treatment of Deployment-Related Posttraumatic Stress Disorder

204. Raskind MA, Peskind ER, Kanter ED, et al. Prazosin for Treating Noncombat Trauma Post-Traumatic Stress Disorder. 

Bethesda, Md: National Institute of Mental Health; 2007. Clinical Trial #NCT00183430.

205. Daly C, Doyle M, Raskind M, Raskind E, Daniels C. Clinical case series: the use of prazosin for combat-related recurrent nightmares among Operation Iraqi Freedom combat veterans. Mil Med. 2005;170:513–515.

206. Forbes D, Phelps A, McHugh A, Debenham P, Hopwood M, Creamer M. Imagery rehearsal in the treatment of posttraumatic nightmares in Australian veterans with chronic combat-related PTSD: 12-month follow-up data. J Trauma 

Stress. 2003;16:509–513.

207. Krakow B, Hollifield M, Schrader R, et al. A controlled study of imagery rehearsal for chronic nightmares in sexual 

assault survivors with PTSD: a preliminary report. J Trauma Stress. 2000;13(4):589–609.

208. Institute of Medicine Committee on Treatment of Posttraumatic Stress Disorder. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press; 2008.

209. Frueh BC, Turner SM, Beidel DC, Mirabella RF, Jones WJ. Trauma management therapy: a preliminary evaluation of 

a multicomponent behavioral treatment for chronic combat-related PTSD. Behav Res Ther. 1996;34(7):533–543.

210. Johnson DR, Rosenheck R, Fontana A, Lubin H, Charney D, Southwick S. Outcome of intensive inpatient treatment 

for combat-related posttraumatic stress disorder. Am J Psychiatry. 1996;153(6):771–777.

211. Johnson DR, Fontana A, Lubin H, Corn B, Rosenheck R. Long-term course of treatment-seeking Vietnam veterans with 

posttraumatic stress disorder: mortality, clinical condition, and life satisfaction. J Nerv Ment Dis. 2004;192(1):35–41.

212. Bolton EE, Lambert JF, Wolf EJ, Raja S, Varra AA, Fisher LM. Evaluating a cognitive-behavioral group treatment program for veterans with posttraumatic stress disorder. Psychol Serv. 2004;1:140–146.

213. Creamer M, Morris P, Biddle D, Elliott P. Treatment outcome in Australian veterans with combat-related posttraumatic 

stress disorder: a cause for cautious optimism? J Trauma Stress. 1999;12:545–558.

214. Creamer M, Elliott P, Forbes D, Biddle D, Hawthorne G. Treatment for combat-related posttraumatic stress disorder: 

two-year follow-up. J Trauma Stress. 2006;19:675–685.

215. Fontana A, Rosenheck R. An Evaluation of the Inpatient Treatment of Posttraumatic Stress Disorder in Specialized PTSD 

Programs. West Haven, Conn: Northeast Program Evaluation Center, Department of Veterans Affairs; 1996.

216. Fontana A, Rosenheck R, Spencer H, Gray S. The Long Journey Home XVI: Treatment of Posttraumatic Stress Disorder in 

the Department of Veterans Affairs: Fiscal Year 2006 Service Delivery and Performance. West Haven, Conn: Department of 

Veterans Affairs, Northeast Program Evaluation Center; 2007.

217. Dieperink M, Erbes C, Leskela J, et al. Comparison of treatment for posttraumatic stress disorder among three Department of Veterans Affairs medical centers. Mil Med. 2005;170:305–308.

218. Tanielian TL, Jaycox LH. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to 

Assist Recovery. Santa Monica, Calif: RAND; 2008.

219. Rosen CS, Chow HC, Finney JF, et al. VA practice patterns and practice guidelines for treating posttraumatic stress 

disorder. J Trauma Stress. 2004;17(3):213–222.

220. Hembree EA, Foa EB, Dorfan NM, Street GP, Kowalski J, Tu X. Do patients drop out prematurely from exposure 

therapy for PTSD? J Trauma Stress. 2003;16(6):555–562.

221. Becker CB, Zayfert C, Anderson E. A survey of psychologists’ attitudes towards and utilization of exposure therapy 

for PTSD. Behav Res Ther. 2004;42:277–292.

222. Riggs DS, Cahill SP, Foa EB. Prolonged exposure treatment of PTSD. In: Follette V, Ruzek JI, eds. Cognitive-Behavioral 

Therapies for Trauma. 2nd ed. New York, NY: Guilford Press; 2006: 65–95.
324

Combat and Operational Behavioral Health

223. Turner SM, Beidel DC, Frueh BC. Multicomponent behavioral treatment for chronic combat-related posttraumatic 

stress disorder: trauma management therapy. Behav Modif. 2005;29(1):39–69.

224. Follette V, Ruzek JI. Cognitive-Behavioral Therapies for Trauma. 2nd ed. New York, NY: Guilford Press; 2006.

225. Ruzek JI, Friedman MJ, Murray S. Towards a PTSD knowledge management system in veterans health care. Psychiatr 

Ann. 2005;35:911–920.