3
Background—PTSD and Impairment

This chapter briefly outlines the characteristics, etiology, and course of posttraumatic stress disorder (PTSD). It provides information on comorbidities, risk factors, and special considerations for veterans.1 A companion report, Posttraumatic Stress Disorder: Diagnosis and Assessment (IOM, 2006), also addresses these topics and deals with some of them in greater detail. The discussion here is focused on issues that are relevant to the committee’s charge, specifically the impairment caused by PTSD and its comorbid disorders. Material in the chapter is intended to serve as a foundation for some of the findings, conclusions, and recommendations in later chapters that address the disability associated with PTSD.

PTSD CHARACTERISTICS, ETIOLOGY, AND COURSE

PTSD is one of an interrelated and overlapping set of possible mental health responses to combat exposures and trauma. The illness of PTSD— illness meaning the interaction of a disease with an individual in a particular social context—creates four different types of burdens in those who are affected: suffering, altered functional capacity, impairment, and disability. These four types of PTSD burdens can in turn each play out in four different domains: the cognitive, emotional, social, and occupational. PTSD is classically a waxing and waning illness. While recovery from the acute

1

Chapter 2 of this report presents an extended discussion of the history of stress-related mental disorders, centered on U.S. military populations.



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PTSD Compensation and Military Service 3 Background—PTSD and Impairment This chapter briefly outlines the characteristics, etiology, and course of posttraumatic stress disorder (PTSD). It provides information on comorbidities, risk factors, and special considerations for veterans.1 A companion report, Posttraumatic Stress Disorder: Diagnosis and Assessment (IOM, 2006), also addresses these topics and deals with some of them in greater detail. The discussion here is focused on issues that are relevant to the committee’s charge, specifically the impairment caused by PTSD and its comorbid disorders. Material in the chapter is intended to serve as a foundation for some of the findings, conclusions, and recommendations in later chapters that address the disability associated with PTSD. PTSD CHARACTERISTICS, ETIOLOGY, AND COURSE PTSD is one of an interrelated and overlapping set of possible mental health responses to combat exposures and trauma. The illness of PTSD— illness meaning the interaction of a disease with an individual in a particular social context—creates four different types of burdens in those who are affected: suffering, altered functional capacity, impairment, and disability. These four types of PTSD burdens can in turn each play out in four different domains: the cognitive, emotional, social, and occupational. PTSD is classically a waxing and waning illness. While recovery from the acute 1 Chapter 2 of this report presents an extended discussion of the history of stress-related mental disorders, centered on U.S. military populations.

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PTSD Compensation and Military Service form may occur in the months following onset, most studies suggest that PTSD is more likely to manifest in the chronic form with effects that are enduring. Military-related PTSD may be more complex and more persistent than other subtypes of the disease. PTSD can be diagnosed as early as one month after exposure to a traumatic event.2 The text revision of the fourth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV-TR) specifies six criteria (Criterion A through Criterion F) that must be satisfied for a diagnosis; these are summarized in Table 3-1 (APA, 2000). PTSD is designated as either acute or chronic, depending on its duration. Acute PTSD is diagnosed between one to three months after a traumatic exposure and has symptoms that last fewer than three months. PTSD that is present beyond three months after the traumatic event is termed chronic. When PTSD does not appear until six months or more after the exposure to the traumatic event, it is termed delayed onset. The symptoms of PTSD and the accompanying impaired function may be continuous or sporadic (Schnurr et al., 2003) and are often exacerbated by the presence of adversity or new life stressors. In a 20-year follow-up of Israeli combat casualties, among those who had PTSD one year after a combat stress reaction, 22.6 percent did not have PTSD at the end of the second year. However, among the group with PTSD at the end of the first year but not at the end of the second year, by the end of the third year 36.8 percent once again had PTSD (Solomon and Mikulinver, 2006). Stressors associated with age-related changes in familial structure as well as with job and health status can contribute to the exacerbation of symptoms and to a subsequent variation in the degree of impairment. Some data indicate that aging and its accompanying loss of cognitive executive function3 may increase the severity and frequency of PTSD symptoms in later life. COMORBIDITY AND FUNCTIONAL IMPAIRMENT OR DISABILITY As Posttraumatic Stress Disorder—Diagnosis and Assessment (IOM, 2006) notes, determining comorbidity is an essential component of assessing a patient with PTSD. In that report, comorbidity was defined as the presence of at least one disorder in addition to the presenting diagnosis; that is, in addition to the PTSD. The rates of comorbidity are high among 2 Acute stress disorder may be diagnosed in circumstances where “[t]he disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event” (DSM IV-TR; APA, 2000). 3 Executive function refers to processes involving the prefrontal cortex related to decision making, memory, and learning (Koso and Hansen, 2005; Shors, 2006).

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PTSD Compensation and Military Service TABLE 3-1 DSM-IV-TR Diagnostic Criteria for PTSD Criterion Description A The person has been exposed to a traumatic event in which both of the following have been present: The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. The person’s response involved intense fear, helplessness, or horror. B The traumatic event is persistently reexperienced in one (or more) of the following ways: Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Recurrent distressing dreams of the event. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. C Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following: efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to avoid activities, places, or people that arouse recollections of the trauma; inability to recall an important aspect of the trauma; markedly diminished interest or participation in significant activities; feeling of detachment or estrangement from others; restricted range of affect (e.g., unable to have loving feelings); and sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span). D Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following: difficulty falling or staying asleep; irritability or outbursts of anger; difficulty concentrating; hypervigilance; and exaggerated startle response. E Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month. F The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. SOURCE: Reprinted with permission from APA (2000).

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PTSD Compensation and Military Service PTSD patients (Kessler et al., 1995, for example). In general, the more illnesses an individual has, the more functional impairment and disability one might expect, so diagnosing a given illness with associated comorbidities would lead one to predict greater problems with functioning than a diagnosis of that illness alone. A study of medically hospitalized veterans found that comorbid psychiatric disorders were associated with “substantial and significant” impairment in multiple dimensions of functioning (Booth et al., 1998). Belzer and Schneier (2004) report that there is substantial comorbidity among generalized anxiety disorder, social anxiety disorder, and depressive disorders and that this comorbidity is associated with clinically significant impairment in social and occupational functioning. Psychiatric Comorbidity with PTSD The effect that psychiatric comorbidity with PTSD has on functional outcomes following catastrophic trauma was illustrated by a study of 182 survivors of the 1995 bombing of the Oklahoma City Murrah Federal Building (North et al., 1999). These survivors had been directly exposed to the bombing. Of those with no postdisaster psychiatric diagnosis, only 16 percent reported problems in functioning after the bombing, compared with 27 percent of those diagnosed with a non-PTSD psychiatric disorder, 52 percent of those diagnosed with PTSD only, and 87 percent of those diagnosed with both PTSD and another psychiatric disorder. Although a number of reports have described functional impairment in association with PTSD and other psychiatric disorders in combat veterans (Bleich and Solomon, 2004; Frayne et al., 2004; Zatzick et al., 1997), there has been little research on the incremental effects of other psychopathologies comorbid with combat PTSD. In one relevant study, Evans and colleagues reported that posttraumatic symptoms and depressive symptoms independently predicted difficulties in family functioning, as self-reported by Australian military veterans in PTSD treatment (Evans et al., 2003). However, in another study, Bleich and Solomon (2004) could discern no incremental effects of psychiatric comorbidity with PTSD on the level of disability among a sample of Israeli military veterans seeking disability compensation. Some studies of primary-care patients and domestic-violence victims have similarly failed to find incremental functional impairment in those with PTSD who had comorbid depression, compared to those without comorbid depression (Rapaport et al., 2005; Stein and Kennedy, 2001). On the other hand, a study of suicidality in Vietnam veterans showed that veterans with a diagnosis of PTSD plus depression or dysthymia were more likely to report suicidal thinking and behaviors, including suicide attempts, than were veterans with only one of the diagnoses (Kramer et al., 1994). The mixed findings across studies suggest that there may be differences in how great

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PTSD Compensation and Military Service an effect psychiatric comorbidity with PTSD has on functional outcomes, depending on the population and the type of trauma. PTSD is clearly associated with impairment, and adding other disorders to PTSD does not always produce incremental impairment. It is possible that this may be due to the fact that there is a stronger link between PTSD and impairment than there is between other disorders and impairment, as noted by North and colleagues (1999) (52 percent for PTSD versus 27 percent for other disorders), but the research on this question is indeterminate. Nonpsychiatric Medical Comorbidity with PTSD Although much research has focused on the effect of comorbidity among various psychiatric disorders, only recently has research begun to pay attention to the synergy between psychiatric disorders, particularly PTSD, and medical conditions and to how that interaction can affect health status or disability. In a large study based on data from the National Co-morbidity Survey, men and women with PTSD were more than twice as likely to experience a nonpsychiatric condition as those without PTSD, even after controlling for age, socioeconomic status, and major depression (Kimerling, 2004). Indeed, literature reviews have documented that people who have been exposed to trauma experience more adverse health outcomes in a number of domains: self-reported health, morbidity, mortality, and health care utilization (Schnurr and Green, 2004a). The same authors have proposed an integrative model that relates trauma to physical health through psychological, biological, behavioral, and attentional mechanisms, and that supports PTSD as the key mechanism for this link (Schnurr and Green, 2004b). While the relationship between PTSD and health outcomes is well established, it is less clear how PTSD with medical comorbidity might lead to increased impairment of functioning. It might be expected that, as with comorbid psychiatric disorders, having more disorders would predict worse functional impairment, but the findings on the incremental functional risk associated with PTSD plus other disorders is mixed (see above). Some authors have examined the interrelationships among PTSD, other psychiatric disorders, and physical health. For example, Norris and colleagues (2003) found that among respondents from Mexico, those who had PTSD symptoms that lasted more than a year showed elevated depression scores and also more physical problems, as compared with those whose PTSD lasted less than one year. Research also shows that relative both to nonpsychiatric control subjects and to subjects with psychiatric disorders other than PTSD, individuals with PTSD showed elevated rates of role-functioning impairment due to physical morbidity (Zayfert et al., 2002). Thus while there are few studies that examine how psychiatric comor-

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PTSD Compensation and Military Service bidity and physical plus psychiatric comorbidity affect impairment and disability, a picture does emerge that ties PTSD strongly to other psychiatric disorders, to impairment, and to poor medical outcomes. These outcomes and their effects on functional disability are more than likely all interrelated. PTSD may have a larger effect on impairment and on health than other psychiatric disorders, perhaps in part because of the biological and physiological burden it places on those with chronic disorders (Friedman and McEwen, 2004). RISK FACTORS, PROTECTIVE FACTORS, MEDIATORS, AND MODERATORS A great deal has been written about risk factors for the development and persistence of PTSD, both for war trauma and for more general trauma (Brewin et al., 2000; Heinrichs et al. 2005; Yehuda, 1999; King et al., 1998; IOM, 2006). These authors and others have proposed categories of risk factors that appear to predict the development of PTSD following traumatic events. In war or combat populations, these categories include premilitary/historical factors such as demographics, genetics, and family factors; combat stressors specifically and war-zone stressors more generally; homecoming environment; and other life stressors and postmilitary circumstances (Green et al., 1985; Yehuda, 1999). Studies have shown variables in all of these categories to predict PTSD. According to a meta-analysis by Brewin and colleagues (2000), the most consistent predictors of PTSD are childhood abuse, personal psychiatric history, and family psychiatric history. Greater trauma severity, low socioeconomic status, low education, low intelligence or cognitive capacity, prior trauma, other adverse childhood circumstances, life stressors, and lack of social support are all significant predictors of developing PTSD, although they vary in the extent of predictiveness. In some studies, female gender, younger age, and minority status are also significant predictors of developing PTSD (Brewin et al., 2000). A meta-analysis of the role of gender in PTSD concluded that gender is consistently a predictive factor (Tolin and Foa, 2006); this topic is discussed in greater detail in the Chapter 6 section entitled Gender and Military Sexual Assault. Restricting attention to military populations specifically, PTSD predictors include the severity and type of combat or other war experience, other aspects of the military environment, the homecoming environment, and various other demographic and personal factors. Table 3-2, adapted from the Diagnosis and Assessment report (IOM, 2006), provides citations to this literature. These factors may sometimes operate independently of each other, but they can also have complex interrelationships that can only be captured with relatively sophisticated models (King et al., 1998). As Yehuda

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PTSD Compensation and Military Service TABLE 3-2 Risk Factors for PTSD in Military Populations Risk Factor References Combat exposure Combat and its severity Black et al., 2004; Goldberg et al., 1990; Hoge et al., 2004; Kang et al., 2003; Kulka et al., 1990; O’Toole et al., 1998; Roy-Byrne et al., 2004; Wolfe et al., 1999. Being wounded or injured Koren et al., 2005; North et al., 1999; Schreiber and Galai-Gat, 1993. Witnessing death Breslau et al., 1999; Ford, 1999. Witnessing grotesque death Green et al., 1990. Serving on graves-registration duty Sutker et al., 1994. Being tortured or being taken captive de Jong et al., 2001; Mollica et al., 1998; Speed et al., 1989; Sutker et al., 1993. Unpredictable and uncontrollable stressful exposure Foa et al., 1992; Southwick et al., 1993. Military environment Sexual trauma, including assault Fontana et al., 1997b; Kang et al., 2005. Combat preparedness Asmundson et al., 2002. Deployment to war zone without combat Ikin et al., 2004. Homecoming environment Lack of social support Fontana and Rosenheck, 1994; Fontana et al., 1997a; Green et al., 1990; Johnson et al., 1997; Koenen et al., 2003; Stretch, 1985; Stretch et al., 1985. Personal factors Cumulative life stress before or after the traumatic event Breslau et al., 1999; Brewin et al., 2000; King et al., 1998; Maes et al., 2001; North et al., 1999. Being a member of a racial or ethnic minority Beals et al., 2002; Friedman et al., 2004; Kulka et al., 1990; Loo et al., 2005; Ruef et al., 2000. More resource loss, lower income or education, older age Norris et al., 2002. Being female Kang et al., 2003; Wolfe et al., 1999. SOURCE: Adapted from IOM (2006) and expanded.

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PTSD Compensation and Military Service and Hyman (2005) have pointed out, most of the research on this question has been done retrospectively. There is relatively little prospective research on how these factors operate. Few studies have looked at how this array of factors might predict the development of impairment or disability, especially in military samples, and the committee was unable to locate any articles that used these risk factors to predict impairment or disability in those who had a diagnosis of PTSD, although many studies report associations between disability and PTSD. Some authors have defined disability as poor physical health status and have investigated the role of risk factors in the development of physical health problems. Mollica and colleagues (1999) studied Bosnian refugees in Croatia and found that 25 percent reported a physical disability. They found that a number of factors were predictive of physical disability, including having comorbid depression and PTSD symptoms, older age, cumulative trauma, and chronic medical illness. Leserman and colleagues (1998) studied female patients from a gastroenterology clinic, assessing risk factors that were associated with poor health status, including pain, bed disability days, and functional disability. The four stressors that predicted poor health status were abuse history, lifetime trauma, turmoil in childhood family, and recent stressful life events. Interestingly, this study did not find that social support buffered the effects of these stressors on health. In a prospective study, van der Ploeg and Kleber (2003) studied 123 ambulance drivers and predicted both symptom outcomes and fatigue and burnout, controlling for symptoms present at the time that the measurements were first taken. A tenth of their sample reported fatigue and burnout symptoms that put them at high risk for sick leave and work disability. The primary predictor of these functional outcomes was lack of social support from the supervisor and from colleagues. In addition to lack of social support, poor communication with colleagues was an important predictor in this sample of individuals stressed in the course of their job assignments. Another study looked at social and occupational functioning as they related to a history of parental problem drinking (Greenfield et al., 1993), taking other variables into account as well. Marital instability, in the form of hitting and throwing things at one’s spouse, was associated with a history of child abuse, and both childhood physical and sexual abuse predicted occupational problems. Early economic deprivation predicted both educational achievement and occupational functioning. In a sample of Vietnam combat veterans, Green and colleagues (1990) predicted combinations of outcomes, including drug abuse and alcohol abuse. They found that premilitary factors (particularly having a pre-war diagnosis) predicted both types of substance abuse, while military (combat) factors predicted alcohol abuse but not drug abuse. Postmilitary factors predicted both, with the strongest association being between drug abuse

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PTSD Compensation and Military Service and current lack of social support. Fischer (1991) examined a national random sample of Vietnam veterans surveyed by Lou Harris and Associates and compared those who reported postdischarge problems with drugs or drinking with those who did not report such problems. The factors that correlated with having more problems were greater extent of combat (as measured with the Combat Exposure Scale), lower age at assignment, having completed a tour of duty or received a medical discharge, a greater length of time between discharge and first job, and a shorter length of time in the first postdischarge job. Fontana and Rosenheck (2005) used data from the National Vietnam Veterans Readjustment Study (NVVRS) to develop and evaluate etiological models of postwar antisocial behavior (ASB), predicting it from premilitary risk factors, military traumas and disciplinary actions, homecoming reception, postmilitary PTSD and substance abuse, and postmilitary ASB. PTSD and substance abuse were included in one analysis and excluded from another. The models suggested that black ethnicity, family instability and similar premilitary experiences, and conduct disorder and similar behaviors were the factors that were most predictive of postwar ASB. Disciplinary action taken against the soldier while in the military also predicted this variable. Traumatic military exposure and a rejecting and nonsupportive homecoming relationship were related to ASB only through their relationship with PTSD and substance abuse, both of which predicted ASB. Homelessness is a factor that suggests major functional impairment. Rosenheck and Fontana (1994) examined premilitary, military, homecoming (readjustment), and postmilitary factors that might predict homelessness among male veterans of the Vietnam War generation, using the NVVRS sample. All of the factors they examined except minority status and parental mental illness predicted homelessness, which they defined as spending at least one one-month period with no place to live. When all variables were analyzed together, the variables with the strongest associations with homelessness were lack of postmilitary social support and being unmarried, both of which are measures of social isolation. Interestingly, PTSD was not a predictor of homelessness. Premilitary factors that predicted homelessness directly or indirectly were birth year, physical and sexual abuse, other traumatic experiences, and placement in foster care. Other psychiatric disorders and substance abuse also had direct effects, while conduct disorder and war-zone traumas had only indirect effects. The authors offered a complex path model to explain these various relationships. There are some more general aspects of military conflicts and the circumstances that surround them that also influence the nature of the stressors experienced and the risk and protective factors for PTSD—or at least the perception of these factors. Long separation from the only homes they had known led to the diagnosis of “nostalgia” in U.S. Civil War combat-

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PTSD Compensation and Military Service ants, a condition with the symptoms of PTSD (Hyams et al, 1996). The nature of trench warfare, with frequent artillery bombardments, resulted in the term “shell shock” being applied to World War I veterans who experienced symptoms that were only later attributed to psychological factors. Some World War II veterans were said to suffer from “battle fatigue” or “combat exhaustion” due to the intensity and duration of fighting that characterized that conflict. However, WWII veterans also “returned to a generally supportive, appreciative society whose federal government provided many immediate unemployment, housing, and educational benefits, thus facilitating rapid reintegration into civilian life” (McCranie and Hyer, 2000; citing Adams, 1994, and Fleming, 1985). In contrast, the Korean and Vietnam wars saw relatively lower combat intensity4 but their veterans came home to less robust economies and indifferent or hostile public receptions. The Gulf War and Operation Iraqi Freedom/Operation Enduring Freedom conflicts have seen several changes from earlier hostilities, including technological advances in body armor and medical interventions for injuries, opponents who tend to use explosive devices rather than bullets, far greater gender integration of the force, and large numbers of reservists seeing active duty. These will undoubtedly influence PTSD rates in the cohorts in the coming years. It is thus difficult to summarize the literature on risk and protective factors for PTSD-related impairment and the mediators and moderators of this impairment. Part of this difficulty stems from the fact that functional impairment and disability can be defined in many different ways, including physical illness, fatigue, burnout, problems in social and occupational functioning, substance abuse, ASB, and even homelessness. While different studies have examined various constellations of risk factors, some consistent themes have emerged. Some of the consistent risk factors for impairment—in line with studies of the predictors of developing the diagnosis of PTSD—include childhood sexual or physical abuse, and instability or turmoil in childhood families (for example, foster care, early economic deprivation, or parental alcohol consumption). Psychiatric disorders present before military service also appear to play an important role, along with other types of trauma and exposure to stressful events. Lack of social support upon homecoming or later was a consistent predictor of poor outcome. These variables may be important to examine in the course of determining the impairment or disability status of a veteran with PTSD. 4 As measured by the ratio of casualties to the number serving (DoD, 2004).

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PTSD Compensation and Military Service REFERENCES Adams MCC. 1994. The Best War Ever: America and World War II. Baltimore, MD: Johns Hopkins University Press. APA (American Psychiatric Association). 2000. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR, Fourth Edition (Text Revisions). Washington, DC: American Psychiatric Association. Asmundson GJ, Stein MB, McCreary DR. 2002. Posttraumatic stress disorder symptoms influence health status of deployed peacekeepers and nondeployed military personnel. Journal of Nervous and Mental Disease 190(12):807–815. Beals J, Manson SM, Shore JH, Friedman M, Ashcraft M, Fairbank JA, Schlenger WE. 2002. The prevalence of posttraumatic stress disorder among American Indian Vietnam veterans: disparities and context. Journal of Traumatic Stress 15:89–97. Belzer K, Schneier FR. 2004. Comorbidity of anxiety and depressive disorders: issues in conceptualization, assessment, and treatment. Journal of Psychiatric Practice 10(5):296–306. Black DW, Carney CP, Peloso PM, Woolson RF, Schwartz DA, Voelker MD, Barrett DH, Doebbeling BN. 2004. Gulf War veterans with anxiety: prevalence, comorbidity, and risk factors. Epidemiology 15(2):135–142. Bleich A, Solomon Z. 2004. Evaluation of psychiatric disability in PTSD of military origin. Israel Journal of Psychiatry and Related Sciences 41:268–276. Booth BM, Blow FC, Cook CA. 1998. Functional impairment and co-occurring psychiatric disorders in medically hospitalized men. Archives of Internal Medicine 158:1551–1559. Breslau N, Chilcoat HD, Kessler RC, Davis GC. 1999. Previous exposure to trauma and PTSD effects of subsequent trauma: results from the Detroit Area Survey of Trauma. American Journal of Psychiatry 156(6):902–907. Brewin CR, Andrews B, Valentine JD. 2000. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology 68(5):748–766. de Jong JT, Komproe IH, Van Ommeren M, El Masri M, Araya M, Khaled N, van De Put W, Somasundaram D. 2001. Lifetime events and posttraumatic stress disorder in 4 postconflict settings. Journal of the American Medical Association 286(5):555–562. DoD (Department of Defense). 2004. Principal Wars in Which the United States Participated: U.S. Military Personnel Serving and Casualties. [Online]. Available: http://siadapp.dior.whs.mil/personnel/CASUALTY/WCPRINCIPAL.pdf (accessed March 7, 2007). Evans L, McHugh T, Hopwood M, Watt C. 2003. Chronic posttraumatic stress disorder and family functioning of Vietnam veterans and their partners. The Australian and New Zealand Journal of Psychiatry 37:765–772. Fischer VJ. 1991. Combat exposure and the etiology of postdischarge substance abuse problems among Vietnam veterans. Journal of Traumatic Stress 4:251–277. Fleming RH. 1985. Post-Vietnam syndrome: neurosis or sociosis? Psychiatry 48(2):122–139. Foa EB, Zinbarg R, Rothbaum BO. 1992. Uncontrollability and unpredictability in post-traumatic stress disorder: an animal model. Psychological Bulletin 112(2):218–238. Fontana A, Rosenheck R. 1994. Posttraumatic stress disorder among Vietnam Theater Veterans: a causal model of etiology in a community sample. Journal of Nervous and Mental Disease 182(12):677–684. Fontana A, Rosenheck R, Horvath T. 1997a. Social support and psychopathology in the war zone. Journal of Nervous and Mental Disease 185(11):675–681. Fontana A, Schwartz LS, Rosenheck R. 1997b. Posttraumatic stress disorder among female Vietnam veterans: a causal model of etiology. American Journal of Public Health 87(2):169–175.

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