Annual Report for Fiscal Year 2000

Scientific and clinical interest in PTSD grew exponentially during the 1990s. Although initially considered primarily a problem of veterans of the Vietnam War, PTSD is now recognized as a major public and behavioral health problem affecting more than ten million Americans at some point in their lives. Its victims represent military personnel and civilian citizens, men and women, and adults and children, in locations throughout the US and around the world.

The primary focus of the Center’s activities from its inception to the present day has been and remains America’s veterans. But over the years it has become clear that by addressing and improving conditions during active military service, the Center can have a tremendously beneficial impact on the lives of veterans in their later years. This has led the Center to broaden its focus to include research, education, and consultation to the active-duty military of today – who are the veterans of tomorrow.

In late 1990 and early 1991, the American military was building up for hostilities in the Persian Gulf. At the time, planning was difficult because of the lack of accurate information about the lethal capabilities of the notorious Iraqi Guards. US military leaders feared the worst, so the best course of action seemed to be to prepare for a worst-case scenario. The military medical establishment was told to prepare for the possibility of tens of thousands of patients needing hospital beds within 72 hours of the outbreak of hostilities.

Such a massive influx of patients would clearly overwhelm the number of available beds in military hospitals in Europe and the US, especially since military medical resources had been steadily downsized since the end of World War II. The military planners turned to the Department of Veterans Affairs and its network of hospitals for help. Some 80 VA hospitals, mainly those located in the eastern US near Air Force bases, were readied to receive fresh casualties.

But in addition to increasing the supply of hospital beds, planners were considering ways to reduce demand. By 1991, researchers had had ample time to study the phenomenon of post-traumatic stress on veterans of the Vietnam War, and had shown conclusively that a significant number of war-zone casualties were the result of traumatic stress. In addition, it was clear that traumatic stress was more likely to occur among personnel with physical injuries, thereby complicating and possibly prolonging the period of recovery. Would it be possible to reduce the demand for hospital beds by more effective treatment of post-traumatic stress?

The Department of Defense turned to the recently-established National Center for PTSD for assistance. Center staff were called upon to help design and implement two immediate large-scale training conferences, presented at Fort Benjamin Harrison and at the Northport Regional Medical Educational Center, to representatives from 80 VA hospitals and 80 Vet Centers, as well as to active-duty National Guard and military reserve personnel.

The Educational Division of the Center also quickly developed and distributed its Operation Desert Storm (ODS) Clinical Packet on the clinical approach to assessment and treatment of acute war-zone stress. The packet included information on critical incident stress debriefing, acute psychosocial intervention, intervention with families, ethnocultural issues, and psychopharmacotherapy. It also included psychometrically-based measures of combat-related PTSD and ODS monitoring and assessment materials.

In addition to their educational role, Center staff provided consultation services to DoD and VA personnel, advising military and medical personnel on overall policy, combat stress reactions, clinical approaches, intervention strategies, pharmacological approaches, and more. The Center came to be viewed as a leader and valuable resource at a time of national emergency. Moreover, the collaborations that began during this period of crisis formed the basis for working relationships that continued long after the Iraqi threat had ended.

But it was in the research realm that the most far-reaching work began. Virtually all of the soldiers who returned to the New England states from Southwest Asia were processed through Ft. Devens, a military base near Boston, MA. Dr. Jessica Wolfe, head of the Women’s Health Sciences Division, worked with the Ft. Devens chaplain, the Rev. Bill Marks, to survey over 3,000 Gulf War returnees within a day of their return from Southwest Asia. The questionnaire included items about war-zone exposure, PTSD, the adequacy of the respondent’s coping strategies, and social and occupational functioning.

This study provided a unique opportunity for the study of exposure to war-zone trauma within days or weeks of its occurrence, rather than years afterward. It also provided a discrete population that formed the basis for longitudinal research, and a small initial grant from the National Institute of Mental Health allowed ongoing research to be started. Four waves of follow-up research have now been conducted with this population.

From these modest but promising beginnings, the Center’s involvement with active-duty personnel has deepened and intensified. Although the Gulf War ended relatively quickly and with far less bloodshed than had been initially feared, the importance of the Center’s educational and consultative activities and the need for continuing research was clearly recognized.

Not long after the hostilities ended in the Gulf, reports began to surface about unexplained medical complaints among Gulf War veterans, which came to be known as "Gulf War Syndrome." The White House challenged DoD, the VA, and the Department of Health and Human Services to work together to study Gulf War Syndrome and determine how to address this problem. The blue-ribbon panels that were established at this time gave personnel from all departments the opportunity to continue to work together – and pointed up the critical need for more research, better screening instruments, and better individual patient information.

Center staff who participated on these panels had an unparalleled opportunity to have their voices heard as research and clinical policy were being established. A key early example was Dr. Robert Rosenheck of the Center’s Evaluation Division, who co-chaired a working group under a mandate from Congress. This group provided the first published account of the war-zone and readjustment experiences of the Persian Gulf troops, and Dr. Rosenheck was called upon to testify before a Senate Veterans Affairs Committee. In addition, Dr. Matthew Friedman served for five years on the blue-ribbon VA/DoD/HHS Persian Gulf Expert Scientific Committee that helped to set clinical and research policy for Gulf War veterans and active-duty personnel.

Research efforts in the first few years after the Gulf War concentrated on follow-up with the veterans of that conflict. But at the same time, research activities began to branch out along several paths.

Dr. Brett Litz of the Behavioral Sciences Division had been working with the Readjustment Counseling Service; using Dr. Wolfe’s questionnaire methodology, he was studying veterans who were seeking assistance from 70 Vet Centers across the country. As the research progressed, he began to encounter personnel who were returning from peacekeeping duty in Somalia, and he became interested in studying the unique stresses of this type of duty. By 1995 he had begun research with peacekeeping forces in various places around the world, and he has now studied personnel in Bosnia and Kosovo, in addition to Somalia.

Another exciting avenue of research was begun in 1997 by Dr. Andrew Morgan of the Clinical Neurosciences Division in West Haven, CT. He began working with the Special Warfare Training Center at Ft. Bragg, NC and with the Navy Dive School, both of which conduct simulations of life-threatening situations as part of their training program. Dr. Morgan realized that – even though they know the situations are simulated – trainees exhibit stress reactions very similar in intensity to those they would experience in a real situation. This offered an unprecedented opportunity for controlled research.

Also in the mid-1990s, researchers from the Women’s Health Sciences Division began studying female Marine Corps recruits at Parris Island to assess their adaptation to first-term enlistment. This study paid particular attention to the individuals’ prior history of traumatic stress, both to establish baseline data for the individuals and to determine whether it is possible to predict success rates in advance. Dr. Julia Whealin of the Pacific Islands Division, in collaboration with military investigators at Tripler Army Medical Center in Hawaii, is currently researching the psychological impact of deployment stress on active-duty personnel.

The relationship with DoD, forged during the Gulf War, has also strengthened over the past decade and given rise to several cooperative research studies. The latest, which began in FY 2000, is a formal collaboration led by Drs. Paula Schnurr and Matthew Friedman of the Executive Division and Lt. Colonel Charles C. Engel of the Walter Reed Army Institute for Research. The project, focused on PTSD in women, will have Walter Reed Army Hospital in Washington, DC, along with eleven VA hospitals, as sites.

A thread running through all this activity has been the effort to study traumatic stress and treat PTSD closer and closer to the time of the trauma. Prior to 1991, research and educational publications were based almost entirely on work with military – and to an increasing extent, civilian – populations years after the trauma occurred. Dr. Wolfe’s pioneering work at Ft. Devens in 1991 took place just days after troops returned from the Gulf War. Dr. Morgan’s work with the special training facilities a decade later examines reactions just moments after the traumatic stress takes place. Dr. Litz’s studies in Kosovo and Dr. Whealin’s research at Tripler Army Medical Center in Hawaii are even collecting data prior to the individuals’ deployment for military operations.

The Center’s work with active-duty personnel has a number of positive implications for both the military of today and the veterans of tomorrow.

First, it has now become accepted practice to screen for symptoms of deployment stress and PTSD as soon as possible after the individual has been removed from the stressful environment, so that effective treatments can begin quickly. Veterans of Vietnam and earlier wars often suffered debilitating symptoms for years, or decades, before they were diagnosed and treated. In the future, the psychological injuries of military service will be treated as promptly and thoroughly as physical wounds.

Second, in contrast to victims of violent crimes or natural disasters, military personnel know in advance when they are likely to encounter traumatic situations. In the future, through research and education, it will be possible to emphasize preventive strategies and to provide better preparation to soldiers heading to a war zone or to a hazardous peacekeeping mission. Training for "psychological fitness" may someday become as common as basic training for physical fitness is today.

The National Center for PTSD’s research efforts with active-duty personnel have resulted in dozens of published articles, scholarly papers, speeches, and presentations to professional associations. The following published articles summarize the results of the major research projects undertaken with the veterans of tomorrow. Abstracts for these and related articles are available at www.ncptsd.org

Southwick, S.M., Morgan, C.A., Nagy, L.M., Bremner, J.D., Nicolaou, A.L., Johnson, D.R., Rosenheck, R.A., & Charney, D.S. (1993). Trauma-related symptoms in veterans of Operation Desert Storm: A preliminary report. American Journal of Psychiatry, 150, 1524-1528.

Wagner, A.W., Wolfe, J., Rotnitsky, A., Proctor, S.P., & Erickson, D.J. (2000). An investigation of the impact of posttraumatic stress disorder on physical health. Journal of Traumatic Stress, 13, 41-55.

Wolfe, J., Sharkansky, E.J., Read, J.P., Dawson, R., Martin, J.A., & Ouimette, P.C. (1998). Sexual harassment and assault as predictors of PTSD symptomatology among U.S. female Persian Gulf War military personnel. Journal of Interpersonal Violence, 13, 40-57.

Fontana, A., Litz, B.T., & Rosenheck, R.A. (2000). Impact of combat and sexual harassment on the severity of posttraumatic stress disorder among men and women peacekeepers in Somalia. Journal of Nervous and Mental Disease, 188, 163-169.

Litz, B.T., King, L.A., King, D.W., Orsillo, S.M., & Friedman, M.J. (1997). Warriors as peacekeepers: Features of the Somalia experience and PTSD. Journal of Consulting and Clinical Psychology, 65, 1001-1010.

Litz, B.T., Orsillo, S.M., Friedman, M.J., Ehlich, P.J., & Batres, A.R. (1997). Posttraumatic stress disorder associated with peacekeeping duty in Somalia for U.S. military personnel. American Journal of Psychiatry, 154, 178-184.

Morgan, C.A., Wang, S., Mason, J.W., Southwick, S.M., Fox, P., Hazlett, G., Charney, D.S., & Greenfield, G. (2000). Hormone profiles in humans experiencing military survival training. Biological Psychiatry, 47, 891-901.

Morgan, C.A., Wang, S., Southwick, S.M., Rasmusson, A.M., Hazlett, G., Hauger, R.L., & Charney, D.S. (2000). Plasma neuropeptide-Y concentrations in humans exposed to military survival training. Biological Psychiatry, 47, 902-909.

Finally, it may be possible eventually to develop screening protocols that assess the degree to which specific individuals are likely to develop PTSD during their military service. An individual profile would certainly provide valuable baseline data for use by clinicians if the person is eventually hospitalized; the profile data could also be used to determine psychological fitness for military service, or could be a factor in duty assignments. As promising behavioral and drug therapies are identified, it might even be possible to treat at-risk individuals in advance.

Looking to the future, it is clear that the efforts of the staff of the National Center for PTSD, working with the Department of Defense and other committed professionals, are creating better lives for the active-duty military personnel of today, and for the veterans of tomorrow.

The National Center for PTSD has come to be regarded both in the US and around the world as the pre-eminent clearinghouse for information and activity related to PTSD, and is widely acclaimed for its research, education, and consultation expertise. This Annual Report describes the National Center’s key accomplishments in FY 2000 in its three areas of endeavor:

• Research: Through its research publications, methodological breakthroughs, development of new assessment strategies, consortium projects, and promotion of innovative and collaborative research, the Center is a world leader in research on trauma and its aftermath. By integrating research programs with education and consultation activities, the Center is in the forefront of development of effective preventive strategies, cost-effective assessment and treatment protocols, and specialized training and consultation to practitioners working with PTSD.
• Education: The Center’s educational initiatives aim to assimilate information and coordinate communication among top scientists in the field of PTSD, and to bring that information to clinicians and policymakers both inside and outside the VA. Information is rapidly disseminated through multiple channels and can be accessed by a diverse group of users through publications, presentations, consultation, training, teleconferences, satellite broadcasts, and the Center’s database and website.
• Consultation: Center expertise has been sought with increasing frequency by the top leadership, policy makers, and program directors in the VA and in other government agencies and branches. The Center has also been called upon for consultation by a growing number of academic and non-governmental organizations that are dealing with PTSD as a major public health problem within the civilian community. And, since PTSD occurs in locations around the world, the Center has become a resource for the United Nations (UN) as well as many national governments, some of which have requested help to establish similar centers of excellence in their own countries.

A series of tables at the back of this document provides details on the organization of the Center and its seven individual divisions and covers research grants, publications, and educational activities. Detailed reports of activities at the divisions can be obtained by contacting the individual locations directly or by visiting the Center’s website at www.ncptsd.org.

A complete listing of Center researchers’ 110 professional publications, 95 in-press articles, and 227 educational and scientific presentations is included in Tables 1, 2, and 4.

In a major effort completed during the year, Drs. Terence Keane and Matthew Friedman, along with Dr. Edna Foa at the University of Pennsylvania, produced the first Practice Guidelines for PTSD treatment. This project, conducted under the auspices of the International Society for Traumatic Stress Studies (ISTSS), involved the coordination of quantitative literature reviews as a basis for the guidelines. This work was published in book form during FY 2000, and will be a significant step forward in the use of evidence-based treatment in the VA and beyond.

During FY 2000, the Center engaged in a number of studies to evaluate different forms of cognitive-behavioral therapies, which currently have the strongest support of any available psychotherapeutic approach. In July, data collection was completed for VA Cooperative Study #420, a test of cognitive-behavioral group psychotherapy for PTSD in male Vietnam veterans. The project, led by the Executive Division in collaboration with other divisions, involved 10 sites and 360 patients and is the largest study of psychotherapeutic treatment for PTSD that has been conducted to date. Results will be made public during FY 2001.The Executive Division, in collaboration with DoD and the Women’s Health Sciences and Behavioral Science Divisions, also submitted a proposal to the Cooperative Studies program for a new multi-site study of cognitive-behavioral treatment for PTSD. The study will enroll 384 female veterans and active-duty personnel across 10 VA and two DoD sites. The proposal will be reviewed in October 2000 and, if funded, would likely begin in late FY 2001 or early FY 2002.

Work continued on several other projects that investigated cognitive-behavioral psychotherapy, with specific projects focusing on:

In addition to these efforts to study psychotherapeutic interventions, the Center continued its program of research on pharmacologic treatments for PTSD. The Clinical Neurosciences Division led efforts on several treatment trials with pharmacological agents, including clonidine and guanfacine, that appear promising for patients with symptoms of hyperarousal and re-experiencing. A pharmacological trial of naltrexone and sertraline in veterans with PTSD and co-morbid alcohol dependence is just beginning, and trial of the drug risperidone continued.

Medication trials also were performed in the Clinical Laboratory at the Education Division. Among these trials is a collaboration between the Clinical Laboratory and the Clinical Neurosciences Division on a study of the anticonvulsant topiramate for treating impulsive aggression and startle responses in male veterans with PTSD.

The Evaluation Division issued the fifth report of the National Mental Health Program Performance Monitoring System, which evaluates PTSD as well as mainstream mental health care provided at each VA medical center and in each of VA’s 22 Veterans Integrated Service Networks (VISNs). In addition, the Division issued the fourth report on the effects of specialized intensive PTSD programs (inpatient, residential, and day hospital) on veterans’ PTSD symptoms, alcohol abuse, drug abuse, violence, and work. These data are widely used in making programmatic changes as part of VA’s commitment to continuous improvement in the cost-effectiveness of service delivery.

The Clinical Neurosciences Division is the leader on research into the neurobiological changes associated with PTSD, but other divisions complement this program as well. The Behavioral Science Division, for example, is the leader on research to understand the psychophysiological changes associated with PTSD; the Education Division houses a Sleep Laboratory. Collaboration across divisions is encouraged to support multi-disciplinary protocols.

One current area of investigation involves the use of neuroimaging to examine the structure and functioning of the brain in people who have been exposed to trauma. During the past year, studies at the Clinical Neurosciences Division synthesized new pharmacological tracers to identify chemical systems in the brain that may be altered in PTSD. These efforts included the synthesis of a probe of the brain’s nicotine receptor, relevant in part because of the high prevalence of smoking in PTSD patients.

The Division also used imaging technologies to study whether disturbances in limbic-cortical glutamatergic communication might contribute to the development of dissociative symptoms, a hallmark of PTSD. Several studies examined how changes in the hippocampus and other brain areas relate to memory performance in male veterans. One study of the hippocampus is being carried out in a collaborative project between the Behavioral Science Division and the Sleep Laboratory.

Neurotransmitters and neurohormones constitute another area of investigation. Findings from a recent study at the Clinical Neurosciences Division support the notion that norepinephrine may contribute to over-consolidation of memory and recurrent intrusive memories. The Division continued to investigate multidimensional hormonal profiles in combat veterans, prisoners of war, civilian women, and adolescents.

Data from a large sample of Vietnam combat veterans studied the production of urinary cortisol, a hormone produced by the hypothalamic-pituitary-adrenal (HPA) axis in response to stress. This study revealed no differences in urinary cortisol between PTSD and non-PTSD groups, which was contrary to findings in previous studies; efforts are underway to explore these contrasting findings. Division researchers are also looking at the effect of dexamethasone, a substance that suppresses the release of cortisol, on memory function in PTSD. Studies are also planned to understand how the function of the HPA axis changes across the menstrual cycle in women with PTSD.

A number of psychobiological projects are underway throughout the Center, including research on:

The Behavioral Science Division is the leader of the Center’s efforts to understand trauma and PTSD from a psychobehavioral perspective, although other sites also contribute to the behavioral science research program. The Division is also the leader in developing and refining methods of assessing trauma, PTSD, and other stress-related disorders.

During FY 2000, the Center expanded its efforts to study the physical health consequences of trauma and PTSD. Investigators examined the impact of PTSD on cardiovascular activity by using ambulatory monitors to record heart rate and blood pressure over 24-hour periods in the home and work environments of study participants. A meta-analysis found that individuals with PTSD show elevated resting heart rate and blood pressure relative to comparable individuals without PTSD. Findings from these studies may provide important information about health risks associated with chronic PTSD.

Another project involved the analysis of archival Navy records to investigate the physical and mental health of repatriated Vietnam-era prisoners of war. The Center reported the first results linking PTSD to increased incidence of physician-diagnosed medical disorders in older veterans, and also reported on physical health and PTSD in World War II veterans who were exposed to mustard gas.

Other important areas of investigation were domestic violence and the impact of PTSD on family functioning. One project, funded by the National Institute of Justice, conducted a sequence of inquiries into marital dysfunction and domestic violence within Vietnam veteran families. Another project assessed interpersonal functioning in Vietnam veterans with PTSD and found that interpersonal problems within the marital relationships of these men appear to be influenced by the PTSD symptoms of both the veterans and their wives.

Two projects focused specifically on young adults, one on the development of violence within relationships, and the other investigating how gender-role attitudes of both female and male young adults account for attributions about interpersonal violence within heterosexual relationships. A recent study of women who were battered by their partners found that psychological abuse is stronger than physical abuse as a predictor of PTSD symptoms.

At the Behavioral Science Division, a new focus of particular relevance to the VA system is testing the utility of the Global Assessment of Functioning scale (GAF), a mandated measure by which the effectiveness of VA care is now determined. The Division was involved in studies seeking to identify the best methods for training clinicians to assign reliable and valid GAF ratings to PTSD clinical and compensation cases. The Division also continued its project to develop an efficient instrument for PTSD screening in primary care patients.

A project at the Education Division is concerned with the measurement of gun possession and safety practices among veterans with chronic combat-related PTSD. As part of this project, the investigators are developing a way to measure a veteran’s readiness to change gun safety practices, in an attempt to identify the best way to help the veteran change.

Gulf War Veterans: The Behavioral Science and Women’s Health Sciences Divisions completed several studies using state-of-the-art statistical methods to identify factors contributing to PTSD and comorbid depression among a large cohort of Gulf War veterans. Other projects at the two divisions used neuroimaging to investigate whether there are structural and functional changes in the brains of Gulf War veterans with PTSD. Several projects targeted memory and concentration problems, a particular concern for Gulf War veterans.

The Women’s Health Sciences Division published another series of findings on the longitudinal Ft. Devens study, based on a large sample of active-duty personnel that was initially assessed within five days of returning from the Gulf. The Clinical Neurosciences Division completed data collection in a project that investigated possible stress-related alterations in memory function and hippocampal volume. Another project studied benzodiazepine receptors in Gulf War veterans with PTSD; the results will have useful implications for treatment.

Asian-American Vietnam Veterans: The Pacific Islands Division completed development of the Race-Related Stressor Scale, a questionnaire instrument that measures exposure to race-related experiences in the military among Asian-Americans who served in the Vietnam War. Findings show that race-related stressors may partially explain the development of PTSD in these veterans. The Executive Division continued analyses of the Hawaii Vietnam Veterans Project, which is focused on assessing the effects of Native Hawaiian and Japanese ancestry on the development of PTSD in male Vietnam veterans.

Women: Research at the Women’s Health Sciences Division addressed how gender is linked via various mechanisms to post-traumatic stress and associated syndromes. Along with national changes in the delivery of VA health care, the research has increasingly focused on assessing domains of health service delivery, including access, quality, satisfaction, and outcome.

During FY 2000, a Health Services Research & Development (HSR&D) project focused on employees’ gender awareness in VA health care, studying core concepts such as beliefs about the proper roles of men and women, gender sensitivity in the delivery of care, and knowledge of health care programs and services available to women veterans. The project produced a gender awareness assessment inventory for organizational monitoring throughout the VA health care system. An application to develop and evaluate a computerized interactive learning model as an intervention to enhance gender awareness has been submitted for funding.

Adolescents and Children: Almost since its inception in 1989, the Center has received some funding from outside the VA to study PTSD in children. In FY 2000, the Center was directed by Senate Report 106-410 to include family issues as a topic in its research program generally, so that adolescents and children will remain an important focus of Center research.

The Clinical Neurosciences Division conducted several projects on inner-city adolescents who have PTSD and recently published a study on the functional implications of a PTSD diagnosis in inner-city adolescent girls. Other projects involved research on startle responses in adolescent girls with PTSD, and a study of salivary cortisol responses to low-dose dexamethasone in adolescents with PTSD compared to traumatized controls and healthy control adolescents. A project is planned to evaluate a new intervention for children who are removed from their parents’ care due to abuse or neglect, and to evaluate outcomes due to this intervention. Another planned project will use neuroimaging to study alterations of brain development in traumatized children.

Aging Veterans: The physical health of older veterans is a topic of concern, and several projects investigated aspects of PTSD in World War II and Korean conflict veterans. The Education Division surveyed approximately 1,000 male members of the American Ex-Prisoner of War Association of California to determine the prevalence of PTSD and its relationship to POW trauma, POW knowledge of PTSD, and quality of intimate dyadic relationships among POWs and their significant partners. Other studies include investigations of PTSD in older adult veterans in long-term care settings, adjustment to aging in treatment-seeking Vietnam veterans with PTSD, and the history of traumatic experiences in depressed older adult primary care patients in the general community.

During FY 2000, the Clinical Neurosciences Division, in collaboration with DoD colleagues (including the JFK Special Warfare Training Center and School at Ft. Bragg, NC), completed several projects that evaluated the impact of both acute and extended stress. This important work has investigated several key neurobiological changes associated with acute, extreme stress, and has identified characteristics that predict successful performance during a stressful task as well as quicker recovery from the stress. The fact that individuals in these studies exhibited traits prior to the training that predicted subsequent performance, as well as biological and psychological responses to stress, reinforces the notion that some individuals are more at risk than others for a stress-related illness such as PTSD.

Work continued during FY 2000 on a number of other research projects aimed at the veterans of tomorrow:

• The Behavioral Science Division found that frustrations and demands associated with peacekeeping duties among personnel deployed to Bosnia are among the strongest predictors of long-term stress symptoms. The Division is collaborating with Army researchers to determine if psychological debriefing for soldiers returning from Kosovo is effective in preventing mental health problems.

The Center regularly publishes two quarterly journals that summarize and disseminate PTSD information. The National Center for PTSD Clinical Quarterly serves busy VA practitioners by publishing topical articles related to assessment and treatment of trauma-related problems. Clinical Quarterly issues in FY 2000 included articles by nationally-recognized experts from both within and outside the VA in the areas of trauma and physical health, dialectical behavior therapy, the effect of writing about traumatic experiences, emotion-focused therapy, assessment of PTSD in couples, and counter-transference and the management of anger. The featured columns, "Women and Trauma: A Clinical Forum" and "New Directions," addressed interpersonal stressors and health, self-care models, social support, psychotraumatology in the twenty-first century, and practice guidelines for PTSD.

The second quarterly publication, the PTSD Research Quarterly, is a guide to the scientific literature on traumatic stress and PTSD. During FY 2000 the Research Quarterly included articles on risk factors, acute stress disorder, pharmacotherapy, and trauma and memory.

The Center’s PTSD Resource Center, located at the Executive Division, houses the world’s largest single collection of traumatic stress literature, with over 1,200 books and more than 12,000 reprints of journal articles and book chapters. Its book catalog was made available for online searching on the Dartmouth College Information System. The PILOTS database, the National Center’s online index to Published International Literature on Traumatic Stress, has grown to over 18,000 entries. It is heavily used; nearly 27,000 connections were made to the database during FY 2000.

"Science-into-Practice" is a major new educational initiative that is intended to help reduce the gap between research and practice in PTSD care, and to assist clinicians and administrators in sorting through the abundance of information on traumatic stress and PTSD. An interdivision team will review the traumatic stress literature periodically, select recent publications with important clinical care implications, and translate these publications into brief digestible summaries with clinical commentary regarding application. The final summaries will be electronically distributed to PTSD treatment providers both in and outside the VA and placed on the Center’s website.

In the assessment arena, the Center collaborated with the Veterans Benefits Administration and the VISN to develop best-practice guidelines for the compensation and pension examinations through which veterans receive disability compensation for PTSD. Center staff also continued their collaboration with the Sierra-Pacific Mental Illness Research, Education, and Clinical Center (MIRECC) to produce an educational CD-ROM to be used by VA clinicians treating PTSD patients on the Clinician-Administered PTSD Scale (CAPS). Developed at the Center in the early 1990s and still regarded as state-of-the-art, CAPS is a structured interview instrument for diagnosing PTSD.

Another initiative launched during FY 2000, in collaboration with the Sierra-Pacific MIRECC and Dr. Lisa Najavits of Harvard Medical School, dealt with cognitive-behavioral group therapy for concurrent PTSD and substance abuse. Dr. Najavits’s "Seeking Safety" treatment protocol, originally designed to help women who suffer from combined PTSD and substance abuse problems, is being modified for application with male and female veterans. Pilot clinical services have been established in both residential and outpatient PTSD services in the VA Palo Alto Health Care System, and training and support activities are being designed to promote implementation of the approach in additional facilities.

In response to significant demand for online information – especially introductory information about PTSD – the Center’s web-based educational services underwent significant modifications and upgrades during FY 2000. With consultation from the Koop Institute at Dartmouth Medical School, the Center’s website (www.ncptsd.org) was expanded to contain substantially more content and redesigned to give it a more easily navigable structure, a simpler URL, and a new logo.

Preliminary data suggest that these changes have produced significantly more traffic, with visitors remaining online longer. Overall, bulk traffic is up by 55%, and the number of pages visited is up by 84%. Average requests for pages per day increased from approximately 3,000 to 5,700. There was 50% growth in visitors seeking information about research, a 100% increase in those seeking information specifically for veterans, and a whopping 500% increase in people seeking introductory information. People are spending more time on the site and visiting more pages; and primary referral to the website has shifted from VA-based websites to major search engines and professional organizations.

In collaboration with the Sierra-Pacific MIRECC, Education Division staff began development of PTSD materials to be placed on both the SP-MIRECC and Center websites. The SP-MIRECC site includes video-streaming services, so that clinicians and veterans and their families can watch videotaped educational materials on their computers. The first trauma-related videos were streamed this year. Also this year, Executive and Education Division staff participated in the Veterans Health Administration Office of Special Projects Executive Loan program, delivering a set of PTSD-related patient education materials to be offered to veterans through the national VA website.

During FY 2000, Center investigators presented a total of 87 workshops, training sessions, and papers in a wide range of educational settings. Key topics included the neurobiology of PTSD, disaster mental health, acute stress and prevention of PTSD, and cognitive-behavioral treatment of PTSD and related problems. A complete list of programs and presentations is included in Table 4.

The Center’s week-long Clinical Training Program continues to be the primary PTSD-related training forum in the country for VA health care staff. The curriculum includes a comprehensive range of trauma-related topics, including assessment of PTSD, anger management, PTSD/substance abuse comorbidity, the psychobiology and psychopharmacology of PTSD, and trauma theory. During FY 2000, 129 participants completed the program, including 48 psychologists and interns, eight psychiatrists, 30 social workers and interns, seven marriage and family counselors, three drug counselors, 17 nurses, and a chaplain.

Many of the presentations during the year were custom-designed to meet the needs of specific audiences. For example, the Center provided a week-long training program for 12 prison psychologists from around the country designed to improve their ability to provide mental health services to veteran inmates who have survived various forms of trauma. The aim of the program is to increase awareness of the needs of incarcerated veterans with PTSD, and to improve planning for the release of such veterans. Custom training programs were also provided in the international arena, including training sessions for visitors from Australia, Canada, Kosovo, Uzbekistan, and the U.K.

The Education and Evaluation Divisions continued to provide cost-effective education for the nation’s specialized PTSD treatment program staffs through regular telephone conference calls. In FY 2000, calls focused on Vet Center tele-health services for veterans with PTSD, Gulf War veterans seeking VA primary care services, trauma-related beliefs and PTSD treatment, assessment and treatment of males who were sexually abused as children, and an intervention to reduce gun availability in veterans with chronic PTSD.

Six psychology interns successfully completed the year-long Pacific Islands Division course that incorporates clinical activities, individual and group supervision, seminars, and case presentations, with an emphasis on ethnoculturally sensitive approaches to care. In addition, all Divisions continued to offer internships and post-graduate fellowships in a variety of disciplines. When possible, members from all Divisions provide training to trainees at different Divisions via videoteleconference technology.

The Center relies on feedback from clinicians and patients, treatment research, clinical experience, and practice guidelines to inform the selection and design of educational activities. During FY 2000, Education Division staff, in collaboration with the Sierra-Pacific MIRECC, conducted several focus groups with VA PTSD clinicians to assess their training needs; they also conducted a focus group with patients to learn about their needs for educational programs.

In collaboration with the Evaluation Core of the Sierra-Pacific MIRECC, a written practice survey was conducted to establish the PTSD-related treatment practices of all mental health staff in VISN 21. As a result of this survey, the Education Division launched a major initiative to provide trauma-related distance learning delivered via video-teleconferencing (real-time training via video-based technology) to selected VA PTSD providers. This delivery format will provide a first-of-its-kind, multidisciplinary curriculum with real-time access to experts in the field of traumatic stress.

Primary Care: A key goal of the Center’s education programs is to increase attention to problems associated with traumatic stress throughout the healthcare system, not just in mental health settings. Primary care practitioners have become a particular focus of effort, because many people with PTSD visit their primary care practitioners rather than mental health professionals.

To address this issue, the Education and Executive Divisions organized the second VA Primary Care/Mental Health Summit and Town Hall Meeting. The session was held in Washington, DC during the Behavioral Healthcare Tomorrow and Behavioral Informatics Tomorrow conferences, the largest annual gathering of mental healthcare provider organizations in the country. A total of 110 participants heard from leaders in government and private healthcare organizations about the advantages of integrating mental health into primary and outpatient care settings.

Also last year, the Education Division staff worked with the MIRECCs to organize a conference, scheduled for 2001, that will have PTSD and anxiety in elderly veterans as one of its major areas of focus.

Disaster and Violent Crime Response: The VA plays an important role in the Federal Emergency Medical Disaster System, and the Center supports this role through its work on disaster mental health care.

As part of a project funded by the Office of Victims of Crime in the Department of Justice, the Center will collaborate with the Center for Mental Health Services to produce recommendations about best practices in the management of natural and human-caused disasters, including incidents of mass violence. Center staff will coordinate reviews of the effectiveness of disaster- and violence-related mental health services, current practices in the field, current training materials used by leading national organizations, and organizational relations of emergency response agencies. The eventual aim will be to develop strategies to improve training of personnel involved in response to disaster and incidents of violence.

Center staff provided a variety of training sessions and presentations last year: examples included two-day training sessions conducted for the Contra Costa and Orange County mental health emergency response programs and for the VA Palo Alto Healthcare System, all in California. Staff specialists also continued to provide direct services as needed in the aftermath of major disasters, including, for example, services to airline employees and victims’ families following the crash of Alaskan Airlines flight 261.

Early Intervention: As research efforts have increasingly focused on early intervention to prevent the development of PTSD, a number of collaborative projects have begun to concentrate on education in this area as well. Education and Executive Division staff co-founded an Early Intervention Special Interest Group within the International Society for Traumatic Stress Studies to draw together international experts in this emerging area.

The Education and Executive Divisions are now regular participants in the U.S. Army Combat Stress Control/Stress Management Team’s monthly video conference calls, working with the DoD to improve management of combat stress among active-duty personnel. They are also working with DoD to plan a major conference for next year on early intervention for acute combat stress reactions.

Education Division staff have also continued a collaboration with the California Coalition Against Sexual Assault, a state organization supporting 97 rape crisis centers throughout California. Center staff helped the Coalition develop a model training manual, and have been working to develop and evaluate new training protocols for the follow-up counseling sessions provided by crisis counselors.

Education Division staff also collaborated with Dr. Joseph Scotti of West Virginia University to develop a semester-long undergraduate course for participants in the University’s forensic identification degree program, the only program of its kind in the world. The course prepares students for encounters with traumatic stressors found at crime scenes, and is designed to reduce the impact of the trauma exposure associated with careers in forensic science.

Bureau of Prisons Program: In FY 2000, the Education Division worked with the Federal Bureau of Prisons to provide a week-long training program for 12 prison psychologists from around the country. The Bureau of Prisons Special Training Session was designed to improve prison psychologists’ ability to provide mental health services to inmates who have survived various forms of trauma, such as military combat, exposure to community violence, and sexual abuse. An important goal of the training program was to increase awareness of the needs of incarcerated veterans with PTSD, and to improve planning for the release of such veterans.

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Berman, R.M., Narasimhan, M., Miller, H.L., Anand, A., Cappiello, A., Oren, D.A., Heninger, G.R., & Charney, D.S. (1999). Transient depressive relapse induced by catecholamine depletion. Archives of General Psychiatry, 56, 395-403.

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Bremner, J.D., Narayan, M., Anderson, E.R., Staib, L.H., Miller, H., & Charney, D.S. (2000). Hippocampal volume reduction in major depression. American Journal of Psychiatry, 157, 115-117.

Bremner, J.D., Narayan, M., Staib, L.H., Southwick, S.M., McGlashan, T., & Charney, D.S. (1999). Neural correlates of memories of childhood sexual abuse in women with and without posttraumatic stress disorder. American Journal of Psychiatry, 156, 1787-1795.

Bremner, J.D., Shobe, K.K., & Kihlstrom, J.F. (2000). False memories in women with self-reported childhood sexual abuse: An empirical study. Psychological Sciences, 11, 333-337.

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D’Souza, D.C., Berman, R.M., Krystal, J.H., & Charney, D.S. (1999). Symptom provocation studies in psychiatric disorders: Scientific value, risks and future. Biological Psychiatry, 46, 1060-1080.

D’Souza, D.C., Gil, R., Cassello, K., Abi-Saab, D., White, J., Sturwold, R., Bennett, A., Karper, L., Zuzarte, E., Charney, D.S., & Krystal, J.H. (2000). IV glycine and oral D-cycloserine effects on plasma and CSF amino acids in healthy humans. Biological Psychiatry, 47, 450-462.

Duman, R.S., & Charney, D.S. (1999). New vistas for an old neurotransmitter. Biological Psychiatry, 46, 1121-1123.

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Duman, R.S., & Nestler, E.J. (2000). Role of gene expression in stress and drug induced neural plasticity. The Economics of Neuroscience, 2, 53-56.

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Fontana, A., Litz, B., & Rosenheck, R. (2000). Impact of combat and sexual harassment on the severity of PTSD among men and women peacekeepers in Somalia. Journal of Nervous and Mental Disease, 188, 163-169.

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Fujita, M., Seibyl, J.P., Verhoeff, N.P., Ichise, M., Baldwin, R.M., Zoghbi, S.S., Burger, C., Staley, J.K., Rajeevan, N., Charney, D.S., & Innis, R.B. (1999). Kinetic and equilibrium analyses of [123I]epidepride binding to striatal and extrastriatal dopamine D2 receptors. Synapse, 34, 290-304.

Goddard, A.W., Coplan, J.D., Gorman, J.M., & Charney, D.S. (1999). Principles of the pharmacotherapy of the anxiety disorders. In D.S. Charney, E.J. Nestler, & B.S. Bunney (Eds.), Neurobiology of mental illness (pp. 548-563). New York: Oxford University Press.

Goddard, A.W., Woods, S.W., Money, R., Pande, A.C., Charney, D.S., Goodman, W.K., Heninger, G.R., & Price, L.H. (1999). Effects of the CCKB antagonist CI-988 on responses to mCPP in generalized anxiety disorder. Psychiatry Research, 85, 225-240.

Grilo, C.M., Sanislow, C., Fehon, D.C., Lipschitz, D., Martino, S., & McGlashan, T.H. (1999). Correlates of suicide risk in adolescent inpatients who report histories of childhood abuse. Comprehensive Psychiatry, 40, 422-428.

Ichise, M., Fujita, M., Seiby, l.J.P., Verhoeff, N.P., Baldwin, R.M., Zoghbi, S.S., Rajeevan, N., Charney, D.S., & Innis, R.B. (1999). Graphical analysis and simplified quantification of striatal and extrastriatal dopamine D2 receptor binding with [123I]epidepride SPECT. Journal of Nuclear Medicine, 40, 1902-1912.

Jacobs-Rebhun, S., Schnurr, P.P., Friedman, M.J., Peck, R., Brophy, M., & Fuller, D. (2000). Posttraumatic stress disorder and sleep difficulty [Letter to the Editor]. American Journal of Psychiatry, 157, 1525.

Kaufman, J., & Henrich, C. (2000). Exposure to violence and early childhood trauma. In C. Zeanah (Ed.), Handbook of infant mental health (pp. 195-207). New York: Guilford.

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Keane, T.M., Kaufman, M., & Kimble, M.O. (2000). Peritraumatic dissociative symptoms, acute stress disorder, and posttraumatic stress disorder: Causation, correlation or epiphenomenona. In L. Sanchez-Planell & C. Diez-Quevedo (Eds.), Dissociative states (pp. 21-43). Barcelona: Springer-Verlag.

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Kilpatrick, D.G., Acierno, R., Saunders, B., Resnick, H.S., Best, C.L., & Schnurr, P.P. (2000). Risk factors for adolescent substance abuse: Data from a national sample. Journal of Consulting and Clinical Psychology, 68, 19-30.

Kimble, M.O., Kaloupek, D., Kaufman, M., & Deldin, P. (2000). Stimulus novelty differentially affects attentional allocation in PTSD. Biological Psychiatry, 47, 880-890.

Kimerling, R., Clum, G.A., & Wolfe, J. (2000). Relationship among trauma exposure, chronic posttraumatic stress disorder, and self reported health in women: Replication and extension. Journal of Traumatic Stress, 13, 115-128.

Kleespies, P.M., Deleppo, J.D., Gallagher, P.L., & Niles, B.L. (1999). Managing suicidal emergencies: Recommendations for the practitioner. Professional Psychology: Research and Practice, 30, 454-463.

Krystal, J.H., Bennett, A., Abi-Saab, D., Belger, A., Karper, L.P., D’Souza, D.C., Lipschitz, D., Abi-Dargham, A., & Charney, D.S. (2000). Dissociation of ketamine effects on rule acquisition and rule implementation: Possible relevance to NMDA receptor contributions to executive cognitive functions. Biological Psychiatry, 47, 137-143.

Krystal, J.H., Bremner, J.D., D’Souza, D.C., Anand, A., Southwick, S.M., & Charney, D.S. (2000). The emerging neurobiology of dissociation states. In A.Y. Shalev, R.Yehuda, & A.C. McFarlane (Eds.), International handbook of human response to trauma (pp. 307-320). New York: Kluwer Academic/Plenum.

Krystal, J.H., D’Souza, D.C., Belger, A., Anand, A., Charney, D.S., Aghajanian, G.K., & Moghaddam, B. (1999). Therapeutic implications of the hyperglutamatergic effects of NMDA antagonists. Neuropsychopharmacology, 22, 143-S157.

Krystal, J.H., D’Souza, D.C., Petrakis, I.L., Belger, A., Berman, R., Charney, D.S., Abi-Saab, W., & Madonick, S. (1999). NMDA agonists and antagonists as probes of glutamatergic dysfunction and pharmacotherapies for neuropsychiatric disorders. Harvard Review of Psychiatry, 7, 125-133.

Lindley, S., Carlson, E., & Sheikh, J. (2000). Psychotic symptoms in PTSD. CNS Spectrum, 5, 52-57.

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Morgan, C.A. III, Wang, S., Mason, J., Southwick, S.M., Fox, P., Hazlett, G., Charney, D.S., & Greenfield, G. (2000). Hormone profiles in humans experiencing military survival training. Biological Psychiatry, 47, 891-901.

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Narayan, M., Bremner, J.D., & Kumar, A. (1999). Neuroanatomical substrates of late-life mental disorders. Journal of Geriatric Psychiatry and Neurology, 12, 95-106.

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