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THE NATIONAL CENTER FOR PTSD: of PTSD (Wilson & Keane). The Division has
devel-
THE PAST 10 YEARS
Paula P. Schnurr, PhD
Matthew J. Friedman, MD, PhD
National Center for PTSD and
White River Junction VAM&ROC
Dartmouth Medical School
Scientific and clinical interest in PTSD has grown exponentially in the past
20 years. No longer con-sidered an isolated problem for Vietnam veterans, PTSD
is now recognized as a major public health problem for all military veterans
and active-duty personnel, given their heightened exposure to the traumatic
stress of war, dangerous peacekeeping operations, and interpersonal violence.
Moreover, the prevalence of disaster, severe accidents, and violence in the
civilian arena makes PTSD a serious public health problem in the general population.
In 1989, the VA established the National Center for PTSD in response to a
congressional mandate to address the needs of veterans with military-related
PTSD. Under this mandate, the new program was charged with ³carry[ing] out and
promot[ing] the training of health-care and related personnel in, and research
into, the causes and diagnosis of PTSD and the treatment of veterans for PTSD.²
In its opera-tions, the Center would ³serve as a resource center for, and promote
and seek to coordinate the ex-change of, information regarding all research
and training activities carried out by the Veterans Ad-ministration, and by
other Federal and non-Federal entities, with respect to PTSD.²
After a VA-wide competition determined that no single VA site could adequately
serve this unique mission, the present National Center was estab-lished as a
consortium of five VA centers of excel-lence in PTSD, each distinguished by
a particular area of expertise while also sharing common inter-ests and concerns.
Two Divisions have been added since 1989, bringing the number of sites to seven.
In its first decade of operation, the Center has come to be regarded as one
of the major sources of information and activity related to PTSD, and is widely
sought out for its research, education, and consultation expertise. This issue
of the PTSD Re-search Quarterly presents a sampling of the almost 1,100 articles
published by Center staff since 1989.
Assessment and diagnosis. For the past 10 years, the Center has focused on
developing and refining measures to improve diagnostic accuracy and to assess
traumatic exposure. Most of this work is conducted under the leadership of the
Centerıs Behavioral Science Division, which, in 1997, co-edited a comprehensive
volume on the assessment of PTSD (Wilson & Keane). The Division has devel-oped
some of the most widely used measures in the world, such as the Clinician Administered
PTSD Scale (CAPS). The CAPS has excellent psychometric properties (Blake et
al., 1995). A recent paper pre-sented 9 scoring rules for using the CAPS for
differ-ent purposes (Weathers et al., 1999). Another recent paper reported the
results of a large VA Cooperative Study on the utility of psychophysiological
mea-sures for assessing PTSD (Keane et al., 1998).
Etiology. Because individuals with PTSD show a variety of changes in memory
and attention, as well as changes in brain structures and functioning, psy-chobiology
is an important part of the Centerıs research program. Most of this work is
conducted at or coordinated by the Clinical Neurosciences Divi-sion, which played
a critical role identifying the altered function of the hypothalamic-pituitary-adrenocortical
axis in PTSD (Mason et al., 1990; Yehuda et al., 1991). Other investigations
have fo-cused on related aspects of the stress response in PTSD, such as elevations
of corticotrophin-releas-ing- factor (Bremner, Licinio et al., 1997) and cat-echolamines
(Southwick et al., 1993). In recent years, another line of investigation has
demonstrated struc-tural abnormalities of the hippocampus, a key brain structure
that plays a significant role in learning and memory (Bremner et al., 1995).
A good summary of the psychobiological research program in the Cen-ter, as well
as in the rest of the world, is provided in the volume by Friedman et al. (1995).
Yet another line of investigation involves the study of sleep, which is conducted
at the Sleep Laboratory housed at the Education Division (Woodward et al., 1996).
Other work aims to better understand the symptoms of PTSD, such as numbing (Litz,
1992), and how numbing and other symptoms affect atten-tion and memory (Litz
et al., 1996).
Center investigators were among the first to study risk factors for PTSD by
using measures that were collected from trauma-exposed individuals prior to
exposure (Schnurr et al., 1993a). The Behavioral Science and Womenıs Health
Sciences Divisions have been at the forefront of state-of-the-art statisti-cal
approaches to studying the etiology of PTSD, using structural equation modeling
to examine how premilitary, war-zone, and postmilitary factors re-late to the
severity of PTSD symptoms in Vietnam veterans (King et al., 1996; King et al.,
1998).
Outcomes. Although Center research has demon-strated that traumatization can
lead to positive growth under certain circumstances (Schnurr et al., 1993b),
PTSD usually has profound negative effects
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on functioning and well-being, especially in chronic cases
(Friedman & Rosenheck, 1996). Center research addresses
the numerous outcomes associated with PTSD and trau-
matization. For example, studies have looked at how psy-
chological trauma affects interpersonal relationships, such
as marriage, and the link between PTSD and perpetration
of violence (Byrne & Riggs, 1996). Another important area
concerns the negative physical health consequences asso-
ciated with PTSD (Friedman & Schnurr, 1995; Schnurr et
al., in press; Taft et al., 1999).
Treatment. The development and evaluation of treat-
ments for PTSD has always been a focus of the Center's
research activity (Abueg & Fairbank, 1992; Chemtob et al.,
1997; Kosten et al., 1991). Center investigators also have
produced articles and books to guide clinicians in the use
of these techniques (Follette et al., 1998; Friedman, 1991;
Young & Blake, 1999). One of the most significant publica-
tions, produced in collaboration with the International
Society for Traumatic Stress Studies, is the first compre-
hensive practice guideline for treating PTSD (Foa et al., in
press).
Evaluation. Since 1989, the Northeast Program Evalua-
tion Center has served as the Evaluation Division of the
Center and has monitored the performance of treatment
for PTSD at medical centers across the VA system. One
aspect of this work has involved an evaluation of long-
term and short-term inpatient care (Fontana & Rosenheck,
1997). Another aspect has been the development of a
performance monitoring system based on the accessibility
of services, quality of care, efficiency of service delivery,
and veterans' satisfaction (Rosenheck et al., 1999). The goal
of this work is to provide clinicians and policymakers with
information to guide them in developing and refining
systems of care (e.g., Fontana & Rosenheck, 1996).
Special populations. Some research efforts are aimed at
understanding and dealing with the unique circumstances
of special populations. Research on the needs of women
veterans has been a priority since the Center's inception.
The substantial growth of this research resulted in the
creation of a Women's Health Sciences Division in 1994.
One of the earliest efforts to serve the need of women
veterans was the construction of a scale specifically de-
signed to assess the types of traumatic exposures women
are likely to experience in a war zone (Wolfe et al., 1993). An
important aspect of Center research is a focus on the study
of how sexual harassment during military service relates to
the development of PTSD (Fontana & Rosenheck, 1998;
Wolfe et al., 1998).
The Center has conducted a number of studies of veter-
ans who served in the Persian Gulf War. The Women's
Health Sciences Division began a large longitudinal project
with a group of over 3,000 Gulf War veterans, who were
assessed initially within 5 days of their return from the
Gulf. The latest publication on this sample reported on the
relationship between PTSD and self-reported health prob-
lems (Wolfe et al., 1999). The Clinical Neurosciences Divi-
sion has been following a different cohort, on which stud-
ies investigated topics including memory (Southwick et
al., 1997) and the startle response (Morgan et al., 1996).
The Center also has a program of research on the needs
of minority veterans, with the Pacific Island Division tak-
ing the lead in this area. A conference on ethnocultural
aspects of PTSD, co-sponsored with the National Institute
of Mental Health, resulted in a widely cited book on the
topic (Marsella et al., 1996). One focus of Center publica-
tions on ethnocultural issues has been on ways that race
affects treatment (Rosenheck et al., 1995) and the treatment
needs of minority veterans (Loo et al., 1998).
Center researchers have collaborated with the Depart-
ment of Defense in order to study active-duty personnel,
"the veterans of tomorrow." This collaboration has yielded
unique information about the stress associated with peace-
keeping (Litz et al., 1997). Another unique program of
research is using neurobiological measures to assess the
effects of a mock captivity paradigm employed by the
military to select individuals for especially hazardous duty
(Morgan et al., in press).
The Future. One objective of studying active-duty per-
sonnel is the development of strategies aimed at preven-
tion, a topic that will be a particular focus for the Center in
the coming decade. Treatment also will be a particular
focus. Several clinical trials are underway, including the
largest study of psychotherapy for PTSD ever conducted
and a study of a structured brief group treatment that
targets ambivalence about changing PTSD symptoms and
comorbid problem behaviors in male Vietnam veterans.
One project is examining effective treatments for anger in
veterans with PTSD. Another, conducted in conjunction
with the Department of Defense, is a randomized clinical
trial to evaluate a cognitive approach to treating female
victims of spousal battering. The Clinical Neurosciences
also continues to evaluate drug treatments, such as clonidine
and those that affect serotonin function.
During the past decade, Center investigators have val-
ued the many opportunities provided by the Center and
the VA to advance the diagnosis, understanding, and
treatment of PTSD. We are grateful for the support and
collaboration of individuals throughout the VA, and around
the world. This input has been crucial to the development
of numerous initiatives, and we look forward to continua-
tion and expansion of these relationships.
SELECTED ABSTRACTS
BLAKE, D.D., WEATHERS, F.W., NAGY, L.M., KALOUPEK,
D.G., GUSMAN, F.D., CHARNEY, D.S., & KEANE, T.M. (1995).
The development of a Clinician-Administered PTSD Scale.
Journal of Traumatic Stress, 8, 75-90. Several interviews are avail-
able for assessing PTSD. These interviews vary in merit when
compared on stringent psychometric and utility standards. Of all
the interviews, the Clinician-Administered PTSD Scale appears
to satisfy these standards most uniformly. The CAPS-1 is a
structured interview for assessing core and associated symptoms
of PTSD. It assesses the frequency and intensity of each symptom
using standard prompt questions and explicit, behaviorally an-
chored rating scales. The CAPS-1 yields both continuous and
dichotomous scores for current and lifetime PTSD symptoms.
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Intended for use by experienced clinicians, it also can be admin-
istered by appropriately trained paraprofessionals. Data from a
large scale psychometric study of the CAPS-1 have provided
impressive evidence of its reliability and validity.
BREMNER, J.D., RANDALL, P.K., SCOTT, T.M., BRONEN,
R.A., SEIBYL, J.P., SOUTHWICK, S.M., DELANEY, R.C.,
MCCARTHY, G., CHARNEY, D.S., & INNIS, R.B. (1995). MRI-
based measurement of hippocampal volume in patients with
combat-related posttraumatic stress disorder. American Journal
of Psychiatry, 152, 973-981. OBJECTIVE: Studies in nonhuman
primates suggest that high levels of cortisol associated with stress
have neurotoxic effects on the hippocampus, a brain structure
involved in memory. The authors previously showed that pa-
tients with combat-related PTSD had deficits in short-term
memory. The purpose of this study was to compare the hippo-
campal volume of patients with PTSD to that of subjects without
psychiatric disorder. METHOD: Magnetic resonance imaging
was used to measure the volume of the hippocampus in 26
Vietnam combat veterans with PTSD and 22 comparison subjects
selected to be similar to the patients in age, sex, race, years of
education, socioeconomic status, body size, and years of alcohol
abuse. RESULTS: The PTSD patients had a statistically significant
8 percent smaller right hippocampal volume relative to that of the
comparison subjects, but there was no difference in the volume of
other brain regions (caudate and temporal lobe). Deficits in short-
term verbal memory as measured with the Wechsler Memory
Scale were associated with smaller right hippocampal volume in
the PTSD patients only. CONCLUSIONS: These findings are
consistent with a smaller right hippocampal volume in PTSD that
is associated with functional deficits in verbal memory.
CHEMTOB, C.M., NOVACO, R.W., HAMADA, R.S., & GROSS,
D.M. (1997). Cognitive-behavioral treatment for severe anger in
posttraumatic stress disorder. Journal of Consulting and Clinical
Psychology, 65, 184-189. With a randomized group design, a 12-
session anger treatment was evaluated with severely angry Viet-
nam War veterans suffering combat-related PTSD. 8 participants
in anger treatment and 7 in a routine clinical care control condi-
tion completed multiple measures of anger control, anger reac-
tion, and anger disposition, as well as measures of anxiety,
depression, and PTSD at pre- and posttreatment. Controlling for
pretreatment scores, significant effects were found on anger
reaction and anger control measures but not on anger disposition
or physiological measures. 18-month follow-up (for both
completers and dropouts) supported the posttreatment anger
control findings. The challenges of treatment research with this
refractory population are discussed.
FOA, E.B., KEANE, T.M., & FRIEDMAN, M.J. (in press). PTSD
treatment guidelines. New York: Guilford. This book is the authori-
tative source on the state-of-the-art on evidence-based research
on PTSD treatment. It was officially authorized by the Interna-
tional Society for Traumatic Stress Studies and has involved
National Center personnel as editors and authors. Each chapter is
written by acknowledged experts in their specific clinical area so
that the empirical information can be integrated with clinical
experience. Topics covered are: Assessment; acute interventions
& debriefing; cognitive-behavioral therapy; pharmacotherapy;
group therapy; treatments for children; EMDR; psychodynamic
psychotherapy; in-patient treatment; social rehabilitation thera-
pies; marital & family therapy; hypnotherapy; and creative arts
therapies. This volume is intended for the use of practicing
clinicians as a reference source to guide their practice and pro-
mote evidence-based practice patterns.
FONTANA, A., & ROSENHECK, R.A. (1997). Effectiveness
and cost of the inpatient treatment of posttraumatic stress
disorder: Comparison of three models of treatment. American
Journal of Psychiatry, 154, 758-765. OBJECTIVE: This study com-
pared the outcomes and costs of 3 models of VA inpatient
treatment for PTSD: (1) long-stay specialized inpatient PTSD
units, (2) short-stay specialized evaluation and brief-treatment
PTSD units, and (3) nonspecialized general psychiatric units.
METHOD: Data were drawn from 785 Vietnam veterans under-
going treatment at 10 programs across the country. The veterans
were followed up at 4-month intervals for 1 year after discharge.
Successful data collection averaged 66.1% across the 3 follow-up
intervals. RESULTS: All models demonstrated improvement at
the time of discharge, but during follow-up symptoms and social
functioning rebounded toward admission levels, especially among
participants who had been treated in long-stay PTSD units.
Veterans in the short-stay PTSD units and in the general psychi-
atric units showed significantly more improvement during fol-
low-up than veterans in the long-stay PTSD units. Greatest
satisfaction with their programs was reported by veterans in the
short-stay PTSD units. Finally, the long-stay PTSD units proved
to be 82.4% and 53.5% more expensive over 1 year than the short-
stay PTSD units and general psychiatric units, respectively. CON-
CLUSIONS: The paucity of evidence of sustained improvement
from costly long-stay specialized inpatient PTSD programs and
the indication of high satisfaction and sustained improvement in
the far less costly short-stay specialized evaluation and brief-
treatment PTSD programs suggest that systematic restructuring
of VA inpatient PTSD treatment could result in delivery of
effective services to larger numbers of veterans.
FRIEDMAN, M.J., CHARNEY, D.S., & DEUTCH, A.Y. (1995).
Neurobiological and clinical consequences of stress: From normal adap-
tation to post-traumatic stress disorder. Philadelphia: Lippincott-
Raven. This book is divided into five sections, each of which is
preceded by a brief overview to maintain context and continuity.
Part I includes eight chapters that emphasize basic science studies
of stress from a variety of approaches. Part II moves from primary
to synthesis. Its seven chapters concern animal models of neuro-
biological processes that have heuristic value for clinical theory
on the pathophysiology of PTSD. Part III consists of seven chap-
ters concerning laboratory and clinical abnormalities detected in
human subjects exposed to normal stressors and in PTSD patients
exposed to traumatic stressors. Part IV contains seven chapters
that synthesize findings presented previously and attempt to
show their relevance for the diagnosis and treatment of PTSD.
Part V, the final chapter, is an overview of the work presented
throughout this book. It includes our speculations on its signifi-
cance and on its implications for future research and treatment.
FRIEDMAN, M.J., & SCHNURR, P.P. (1995). The relationship
between trauma, post-traumatic stress disorder, and physical
health. In M.J. Friedman, D.S. Charney, & A.Y. Deutch (Eds.),
Neurobiological and clinical consequences of stress: From normal adap-
tation to post-traumatic stress disorder (pp. 507-524). Philadelphia:
Lippincott-Raven. First we review the literature on the physical
health outcomes associated with traumatic events. Despite the
extensive literature suggesting that exposure to stressful events
may be associated with adverse health outcomes, much less has
been written on the medical and somatic consequences of expo-
sure to extreme stress. Nonetheless, reviewers have suggested
that physical health may be severely and chronically impaired
following traumatic experiences. Second, we review the litera-
ture on the physical health outcomes associated with PTSD. We
argue that PTSD is an important mediator through which trauma
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may be related to adverse outcomes. Third, we review biological
and psychological correlates of PTSD that might predispose
affected individuals toward increased risk for medical problems.
KEANE, T.M., KOLB, L.C., KALOUPEK, D.G., ORR, S.P.,
BLANCHARD, E.B., THOMAS, R.G., HSIEH, F.Y., & LAVORI,
P.W. (1998). Utility of psychophysiological measurement in the
diagnosis of posttraumatic stress disorder: Results from a De-
partment of Veterans Affairs cooperative study. Journal of Con-
sulting and Clinical Psychology, 66, 914-923. This multisite study
tested the ability of psychophysiological responding to predict
PTSD diagnosis (current, lifetime, or never) in a large sample of
male Vietnam veterans. Predictor variables for a logistic regres-
sion equation were drawn from a challenge task involving scenes
of combat. The equation was tested and cross-validated, demon-
strating correct classification of approximately 2/3 of the current
and never PTSD participants. Results replicate the finding of
heightened psychophysiological responding to trauma-related
cues by individuals with current PTSD, as well as differences in
a variety of other domains between groups with and without the
disorder. Follow-up analyses indicate that veterans with current
PTSD who do not react physiologically to the challenge task
manifest fewer reexperiencing symptoms, depression, and guilt.
Discussion addresses the value of psychophysiological measures
for assessment of PTSD.
KING, L.A., KING, D.W., FAIRBANK, J.A., KEANE, T.M., &
ADAMS, G.A. (1998). Resilience-recovery factors in post-trau-
matic stress disorder among female and male Vietnam veter-
ans: Hardiness, postwar social support, and additional stress-
ful life events. Journal of Personality and Social Psychology, 74, 420-
434. Structural equation modeling procedures were used to ex-
amine relationships among several war zone stressor dimen-
sions, resilience-recovery factors, and PTSD symptoms in a na-
tional sample of 1,632 Vietnam veterans (26% women and 74%
men). A 9-factor measurement model was specified on a mixed-
gender subsample of the data and then replicated on separate
subsamples of female and male veterans. For both genders, the
structural models supported strong mediation effects for the
intrapersonal resource characteristic of hardiness, postwar struc-
tural and functional social support, and additional negative life
events in the postwar period. Support for moderator effects or
buffering in terms of interactions between war zone stressor level
and resilience-recovery factors was minimal.
KING, D.W., KING, L.A., FOY, D.W., & GUDANOWSKI, D.M.
(1996). Prewar factors in combat-related posttraumatic stress
disorder: Structural equation modeling with a national sample
of female and male Vietnam veterans. Journal of Consulting and
Clinical Psychology, 64, 520-531. Structural equation modeling
was used to examine relationships among prewar factors, dimen-
sions of war-zone stress, and current PTSD symptomatology
using data from 1,632 female and male participants in the Na-
tional Vietnam Veterans Readjustment Study. For men, previous
trauma history (accidents, assaults, and natural disasters) di-
rectly predicted PTSD and also interacted with war-zone stressor
level to exacerbate PTSD symptoms for high combat-exposed
veterans. Male veterans who entered the war at a younger age
displayed more symptoms. Family instability, childhood antiso-
cial behavior, and age had indirect effects on PTSD for men. For
women, indirect prewar effects emanated from family instability.
More attention should be given to critical developmental condi-
tions, especially family instability and earlier trauma exposure, in
conceptualizing PTSD in adults.
KOSTEN, T.R., FRANK, J.B., DAN, E., MCDOUGLE, C.J., &
GILLER, E.L. (1991). Pharmacotherapy for posttraumatic stress
disorder using phenelzine or imipramine. Journal of Nervous and
Mental Disease, 179, 366-370. 60 male veterans with PTSD partici-
pated in an 8-week, randomized trial comparing phenelzine
(n=19), imipramine (n=23), and placebo (n=18). Mean treatment
retention was better on phenelzine (7.4 weeks) than on imi-
pramine (5.6 weeks) or placebo (5.5 weeks). By week 5, both
medications significantly reduced PTSD symptoms, as assessed
by the Impact of Event Scale (IES), but the 44% improvement on
phenelzine was greater than the 25% improvement on imipramine.
The intrusion, but not the avoidance, subscale of the IES showed
significant improvement, and the initial mild to moderate de-
pressive symptoms did not significantly improve.
LITZ, B.T. (1992). Emotional numbing in combat-related post-
traumatic stress disorder: A critical review and reformulation.
Clinical Psychology Review, 12, 417-432. Emotional numbing symp-
toms are considered in the clinical literature as cardinal signs of
PTSD and have been formally codified in DSM-III-R. However,
the term has not been consistently defined nor adequately re-
searched. The present paper critically reviews the extant empiri-
cal and theoretical literature in combat-related PTSD that has
explored emotional numbing systems. A theoretical framework,
based on Levanthal's perceptual-motor theory of emotion, is
posited to account for the parameters of emotional processing in
PTSD, and specific hypotheses concerning selective or differen-
tial emotional processing deficits in PTSD are described in order
to clarify empirical issues about the development and mainte-
nance of processing deficits in PTSD and to stimulate future
research in this underexplored, yet clinically important area.
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. OBJECTIVE: The end
of the Cold War has marked a period when the U.S. military is
asked to secure peace under conditions in which peace is tenuous,
yet the need for resolution of the conflict is great. Combat-trained
soldiers are highly visible and are exposed to threats to their lives,
yet are asked to exhibit restraint and neutrality. The psychiatric
consequences of peacekeeping duty under these conflicting and
volatile conditions have been underresearched. The authors ex-
amined the prevalence of PTSD associated with exposure to
peacekeeping duty in Somalia. METHOD: A large cohort of
active duty personnel deployed to Somalia (n=3,461) were sur-
veyed approximately 5 months after their return to the United
States. A variety of military service characteristics and exposure
variables and PTSD symptoms were examined. RESULTS: 8% of
peacekeepers were found to meet diagnostic criteria for PTSD.
PTSD symptom severity was best predicted by the rewards of
military service, war zone stress, and frustrations with peace-
keeping (e.g., restrictive rules of engagement). CONCLUSIONS:
It is likely that the mission in Somalia represents a new paradigm
of dangerous military operations for the United States. These data
suggest that peacekeeping may be difficult to reconcile for some
combat-trained soldiers and can create a risk for PTSD.
MARSELLA, A.J., FRIEDMAN, M.J., GERRITY, E.T., &
SCURFIELD, R.M. (1996). Ethnocultural aspects of posttraumatic
stress disorder: Issues, research, and clinical applications. Washing-
ton: American Psychological Association. The purpose of this
volume is to explore and examine the role of ethnocultural
aspects of PTSD through a thorough and comprehensive discus-
sion of current theory, research, and practice on the topic. Chap-
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ter authors address the topic of ethnocultural variations and
similarities in the etiology, distribution, expression, clinical diag-
nosis, and treatment of PTSD and related stress disorders.
MASON, J.W., KOSTEN, T.R., SOUTHWICK, S.M., & GILLER,
E.L. (1990). The use of psychoendocrine strategies in post-
traumatic stress disorder. Journal of Applied Social Psychology, 20,
1822-1846. An overview is presented of a pilot psychoendocrine
study of PTSD inpatients in comparison with several subgroups
of schizophrenic and affective disorder patients. Using a hor-
monal profile including cortisol, norepinephrine, epinephrine,
testosterone, and thyroxine, it was found that the mean values for
the PTSD group were at or near the extreme end of the range for
every hormone measured, i.e., relatively low for cortisol and high
for the remaining hormones. The possible clinical meaning of
these findings is considered in the light of prior psychoendocrine
research on chronic stress. The hormonal alterations in PTSD
appear to be persistent and suggest the possibility of being linked
largely to traits or character structure, perhaps particularly to
cognitive variables related to defense and coping mechanisms, as
reviewed in detail for each hormonal system. There appears to be
a potential for a fruitful union between the traumatic stress and
some psychoendocrine fields and future strategies for develop-
ing and strengthening such a union are suggested.
MORGAN, C.A., WANG, S., SOUTHWICK, S.M.,
RASSMUSSON, A., & CHARNEY, D.S. (in press). Plasma NPY in
humans experiencing acute uncontrollable stress. Biological Psy-
chiatry. Neuropeptide-Y (NPY) is present in extensive neuronal
systems of the brain and is present in high concentrations in cell
bodies and terminals in the amygdala. Preclinical studies have
shown that injections of NPY into the central nucleus of the
amygdala function as a central anxiolytic and buffer against the
effects of stress. The objective of this study was to assess plasma
neuropeptide-Y immunoreactivity in healthy soldiers participat-
ing in high intensity military training at the U.S. Army survival
school. The Army survival school provides a means of observing
individuals under high levels of physical, environmental, and
psychological stress and consequently, is considered a reason-
able analogue to stress incurred as a result of war or other
catastrophic experiences. METHOD: Plasma levels of NPY were
assessed at baseline (prior to initiation of training), and 24 hours
after the conclusion of survival training in 49 subjects, and at
baseline and during the Prisoner of War (POW) experience
(immediately after exposure to a military interrogation (in 21
additional subjects. RESULTS: Plasma NPY levels were signifi-
cantly increased, compared to baseline, following interrogations
and were significantly higher in Special Forces soldiers compared
to non-Special Forces soldiers. NPY elicited by interrogation
stress was significantly correlated to the subjects' behavior dur-
ing interrogations and tended to be negatively correlated to
symptoms of reported dissociation. Twenty-four hours after the
conclusion of survival training, NPY had returned to baseline in
Special Forces soldiers, but remained signficiantly lower than
baseline values in non-Special Forces soldiers. DISCUSSION:
These results provide evidence that uncontrollable stress signifi-
cantly increases plasma NPY in humans, and when extended,
produces a significant depletion of plasma NPY. Stress induced
alterations of plasma NPY were significantly different in Special
Forces soldiers compared to non-Special Forces soldiers. NPY
was positively correlated with behavioral performance under
stress and negatively correlated with psychological symptoms of
dissociation. These data support the idea that NPY may be
involved in the enhanced stress resilience seen in humans.
ROSENHECK, R.A., FONTANA, A., & COTTROL, C. (1995).
Effect of clinician-veteran racial pairing in the treatment of
posttraumatic stress disorder. American Journal of Psychiatry, 152,
555-563. OBJECTIVE: This study explored the effect of veterans'
race and of the pairing of veterans' and clinicians' race on the
process and outcome of treatment for war-related PTSD. METHOD:
As part of the national evaluation of the PTSD Clinical Teams
program of the VA, data on assessment of 4,726 white and black
male veterans at admission to the program and on the race and
other characteristics of their 315 primary clinicians were obtained.
Measures of service delivery and treatment emphasis were ob-
tained 2, 4, 8, and 12 months after program entry, along with
clinicians' ratings of improvements. RESULTS: After control for
sociodemographic characteristics, clinical status, and clinicians'
characteristics, multivariate analysis showed that black veterans
had significantly lower program participation ratings than white
veterans on 10 of 24 measures, but no differences in clinicians'
improvement ratings were noted. Additional analyses showed
that pairing of white clinicians with black veterans was associated
with lower program participation on 4 of the 24 measures and with
lower improvement ratings on 1 of 15 measures. When treated by
either black or white clinicians, black veterans had poorer atten-
dance than white veterans, seemed less committed to treatment,
received more treatment for substance abuse, were less likely to be
prescribed antidepressant medications, and showed less improve-
ment in control of violent behavior. CONCLUSIONS: Although no
differences were noted on most measures, the pairing of black
veterans with white clinicians was associated with receiving fewer
services. According to some other measures, black veterans re-
ceived less intensive services regardless of the clinician's race.
SCHNURR, P.P., ROSENBERG, S.D., & FRIEDMAN, M.J. (1993a).
Change in MMPI scores from college to adulthood as a function
of military service. Journal of Abnormal Psychology, 102, 288-296.
We examined changes in MMPI scores from adolescence to adult-
hood in a longitudinal study of 540 men who attended college
during the Vietnam War. Using change scores that were adjusted
for initial values, we compared civilians to veterans who were
grouped according to combat exposure: None, peripheral, or
direct. In cross-sectional analyses, the groups differed only as
adults. Groups were similar in relative stability but differed by
multivariate analysis in absolute change on the clinical scales. Only
veterans with peripheral exposure differed from civilians in mul-
tivariate contrasts, even after controlling for premilitary variables.
Effect sizes were small. Results suggest that combat exposure does
not produce uniformly negative outcomes and may have positive
effects in select populations.
SCHNURR, P.P., SPIRO, A., & PARIS, A.H. (in press). Physi-
cian-diagnosed medical disorders in relation to PTSD symptoms
in older male military veterans. Health Psychology. The association
between physician-diagnosed medical disorders and combat-re-
lated PTSD symptoms was examined in 605 male combat veterans
of World War II and the Korean conflict. Physician exams were
performed at periodic intervals beginning in the 1960s. PTSD
symptoms were assessed in 1990. Cox regression was used to
examine the onset of each of 12 disorder categories as a function of
PTSD symptoms, controlling for age, and smoking, alcohol use,
and body weight at study entry. Even with control for these factors,
PTSD symptoms were associated with increased onset of arterial,
lower gastrointestinal, dermatologic, and musculoskeletal disor-
ders. There was only weak evidence that PTSD mediated the
effects of combat exposure on morbidity. Possible mediators of the
relationship between combat exposure, PTSD, and physical mor-
bidity are discussed.
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SOUTHWICK, S.M., KRYSTAL, J.H., MORGAN, C.A.,
JOHNSON, D.R., NAGY, L.M., NICOLAOU, A.L., HENINGER,
G.R., & CHARNEY, D.S. (1993). Abnormal noradrenergic func-
tion in posttraumatic stress disorder. Archives of General Psychia-
try, 50, 266-274. To evaluate possible abnormal noradrenergic
neuronal regulation in patients with PTSD, the behavioral, bio-
chemical, and cardiovascular effects of intravenous yohimbine
hydrochloride (0.4 mg/kg) were determined in 18 healthy male
subjects and 20 male patients with PTSD. A subgroup of patients
with PTSD were observed to experience yohimbine-induced
panic attacks (70 percent [14/20]) and flashbacks (40 percent [8/
20]), and they had larger yohimbine-induced increases in plasma
3-methoxy-4-hydroxyphenylglycol levels, sitting systolic blood
pressure, and heart rate than those in healthy subjects. In addi-
tion, in the patients with PTSD, yohimbine induced significant
increases in core PTSD symptoms, such as intrusive thoughts,
emotional numbing, and grief. These data were consistent with a
large body of preclinical data that indicated that uncontrollable
stress produces substantial increases in noradrenergic neuronal
function. We discuss the implications of these abnormalities in
noradrenergic functional regulation in relation to the long-term
neurobiological sequelae of severe uncontrollable stress and the
pathophysiological relationship between PTSD and other anxi-
ety disorders, such as panic disorder.
WILSON, J.P., & KEANE, T.M. (1997). Assessing psychological
trauma and PTSD. New York: Guilford Press. This volume devel-
oped out of the recognition that there was a need to fill a void in
the standardized references in the field of traumatology, espe-
cially in the area of assessing the response to trauma and PTSD.
There are three distinct parts to the organizational structure of
this volume. Part I focuses on conceptual approaches and stan-
dardized measures of trauma and PTSD. Part II of this volume is
devoted to the assessment of traumatic reactions among victim
and survivor populations. In Part III are seven chapters that
directly concern specific techniques for the assessment of trau-
matic reactions, dissociative tendencies, and PTSD. Taken to-
gether as a set, the three parts of the book provide the reader with
readily usable information with direct application to clinical
practice, research projects, and educational curricula in colleges
and universities.
WOLFE, J., PROCTOR, S.P., ERICKSON, D.J., HEEREN, T.,
FRIEDMAN, M.J., HUANG, M.T., SUTKER, P.B., VASTERLING,
J.J., & WHITE, R.F. (1999). Relationship of psychiatric status to
Gulf War veterans' health problems. Psychosomatic Medicine, 61,
532-540. OBJECTIVE: A growing body of research has shown that
there are important links between certain psychiatric disorders
and health symptom reporting. Two disorders in particular (PTSD
and major depression) have been the most widely implicated to
date, and this association has sometimes been used to explain the
occurrence of ill-defined medical problems and increased so-
matic symptoms in certain groups, most recently Gulf War veter-
ans. METHODS: Structured psychiatric diagnostic interviews
were used to examine the presence of major psychiatric (axis I)
disorders and their relation to health symptom reporting in a
well-characterized, stratified subset of Gulf War veterans and a
non-Gulf-deployed veteran comparison group. RESULTS: Rates
of most psychiatric disorders were substantially lower than na-
tional comorbidity estimates, consistent with prior studies show-
ing heightened physical and emotional well-being among active-
duty military personnel. Rates of PTSD and major depression,
however, were significantly elevated relative to the veteran com-
parison group. The diagnosis of PTSD showed a small but signifi-
cant association with increased health symptom reports. How-
ever, nearly two-thirds of Gulf participants reporting moderate to
high health symptoms had no axis I psychiatric diagnosis. CON-
CLUSIONS: Results suggest that rates of psychiatric illness were
generally low with the exception of PTSD and major depression.
Although PTSD was associated with higher rates of reported
health problems, this disorder did not entirely account for symp-
toms reported by participants. Factors other than psychiatric
status may play a role in Gulf War health problems.
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 Interper-
sonal Violence, 13, 40-57. Rates and sequelae of sexual harassment
and assault among women in a wartime military sample were
examined. A second goal was to explore the comparative impacts
of these stressors and combat exposure on PTSD symptomatol-
ogy. Army women (n=160) were interviewed on return from the
Persian Gulf War and again 18 to 24 months later. Rates of sexual
assault (7.3%), physical sexual harassment (33.1%), and verbal
sexual harassment (66.2%) were higher than those typically found
in civilian and peacetime military samples. Sexual assault had a
larger impact on PTSD symptomatology than combat exposure.
Frequency of physical sexual harassment was significantly pre-
dictive of PTSD symptomatology. Furthermore, the number of
postwar stressful life events mediated the relationship between
physical sexual harassment and symptomatology but was not
related to combat exposure. Sexual assault, sexual harassment,
and combat exposure appear to be qualitatively different stressors
for women, with different correlates and mechanisms of action.
WOODWARD, S.H., BLIWISE, D.L., FRIEDMAN, M.J., &
GUSMAN, F.D. (1996). Subjective versus objective sleep in
Vietnam combat veterans hospitalized for PTSD. Journal of
Traumatic Stress, 9, 137-143. 25 Vietnam combat veterans with
chronic severe PTSD completed a sleep self-report questionnaire
on admission to an inpatient treatment program. Between 1 and
2 months later each spent 3 or more nights in the sleep laboratory.
When self-report and laboratory findings were compared, signifi-
cant relationships were observed between sleep schedule items
such as time-to-bed/time-out-of-bed and polysomnographic
measures of sleep. In contrast, global ratings of sleep quality were
generally unrelated to polysomnographic measures. These find-
ings may have implications for survey research assessing sleep
quality in traumatized populations.
YEHUDA, R., LOWY, M.T., SOUTHWICK, S.M., SHAFFER, D.,
& GILLER, E.L. (1991). Lymphocyte glucocorticoid receptor num-
ber in posttraumatic stress disorder. American Journal of Psychia-
try, 148, 499-504. OBJECTIVE: The authors' objective was to
investigate the possibility that glucocorticoid receptor changes
may be involved in the dysregulation of the hypothalamic-pitu-
itary-adrenal (HPA) axis in PTSD. METHOD: They measured the
number of lymphocyte cytosolic glucocorticoid receptors and
plasma cortisol concentrations in 15 consecutively admitted male
combat Vietnam veterans with PTSD and in a normal comparison
group of 11 subjects. RESULTS: Both the patients and the normal
comparison subjects showed a morning-to-afternoon decline in
glucocorticoid receptor concentrations, paralleling the normal
diurnal decline in cortisol levels. The number of glucocorticoid
receptors was 63% greater in the morning and 26% greater in the
afternoon in the patients with PTSD than in the normal subjects.
No group differences in cortisol levels were observed, nor were
glucocorticoid receptor number and cortisol levels correlated. The
number of morning glucocorticoid receptors was positively corre-
Prev Page 7 Next
lated with symptoms of PTSD and anxiety. CONCLUSIONS:
These results provide further evidence for a dysregulation of the
HPA axis in PTSD. The finding that patients with PTSD had a
substantially greater number of lymphocyte glucocorticoid recep-
tors than normal comparison subjects is consistent with the au-
thors' previous observations of low 24-hour urinary cortisol excre-
tion in subjects with PTSD. Furthermore, the receptor changes
observed are opposite of those reported in major depressive disor-
der. The present data, along with other findings of HPA abnor-
malities in PTSD, support the possibility of a greater negative
feedback sensitivity at one or more levels of the HPA axis.
YOUNG, B.H., & BLAKE, D.D. (1999). Group treatments for post-
traumatic stress disorder. Philadelphia: Brunner/Mazel. Group
therapy is arguably the most common mode of psychotherapy
treatment for trauma survivors. This book offers detailed clinical
guidelines for group treatment provided to trauma survivors.
Chapters include treatment for sexual assault victims, disaster
relief workers, combat veterans, motor vehicle accidents survi-
vors, trauma survivors with co-morbid substance abuse, survivors
of disaster, families of trauma survivors, homicide witnesses and
survivors, adult survivors of childhood abuse, and an overview of
group psychotherapy.
ADDITIONAL PUBLICATIONS
ABUEG, F.R., & FAIRBANK, J.A. (1992). Behavioral treatment of
posttraumatic stress disorder and co-occurring substance abuse.
In P.A. Saigh (Ed.), Posttraumatic stress disorder: A behavioral ap-
proach to assessment and treatment (pp. 111-146). Boston: Allyn and
Bacon.
BREMNER, J.D., INNIS, R.B., NG, C.K., STAIB, L.H., SALOMON,
R.M., BRONEN, R.A., DUNCAN, J., SOUTHWICK, S.M.,
KRYSTAL, J.H., RICH, D., ZUBAL, G., DEY, H., SOUFER, R., &
CHARNEY, D.S. (1997). Positron emission tomography mea-
surement of cerebral metabolic correlates of yohimbine admin-
istration in combat-related posttraumatic stress disorder. Ar-
chives of General Psychiatry, 54, 246-254.
BREMNER, J.D., LICINIO, J., DARNELL, A., KRYSTAL, J.H.,
OWENS, M.J., SOUTHWICK, S.M., NEMEROFF, C.B., &
CHARNEY, D.S. (1997). Elevated CSF corticotropin-releasing
factor concentrations in posttraumatic stress disorder. American
Journal of Psychiatry, 154, 624-629.
BYRNE, C.A., & RIGGS, D.S. (1996). The cycle of trauma: Rela-
tionship aggression in male Vietnam veterans with symptoms
of posttraumatic stress disorder. Violence and Victims, 11, 213-225.
FOLLETTE, V.M., RUZEK, J.I., & ABUEG, F.R. (1998). Cognitive-
behavioral therapies for trauma. New York: Guilford.
FONTANA, A.F., & ROSENHECK, R.A. (1996). Improving the
efficiency of resource utilization in outpatient treatment of
posttraumatic stress disorder. Administration and Policy in Mental
Health, 23, 197-210.
FONTANA, A.F., & ROSENHECK, R.A. (1998). Duty-related and
sexual stress in the etiology of PTSD among women veterans
who seek treatment. Psychiatric Services, 49, 658-662.
FRIEDMAN, M.J. (1991). Biological approaches to the diagnosis
and treatment of post-traumatic stress disorder. Journal of Trau-
matic Stress, 4, 67-91.
FRIEDMAN, M.J., & ROSENHECK, R.A. (1996). PTSD as a
persistent mental illness. In S.M. Soreff (Ed.), Handbook for the
treatment of the seriously mentally ill (pp. 369-389). Seattle: Hogrefe
& Huber.
KING, L.A., & KING, D.W. (1994). Latent structure of the Missis-
sippi Scale for Combat-Related Post-Traumatic Stress Disor-
der: Exploratory and higher-order confirmatory factor analy-
ses. Assessment, 1, 275-291.
KUBANY, E.S., & MANKE, F.P. (1995) Cognitive therapy for
trauma-related guilt: Conceptual bases and treatment outlines.
Cognitive and Behavioral Practice, 2, 27-61.
LITZ, B.T., WEATHERS, F.W., MONACO, V., HERMAN, D.S.,
WULFSOHN, M., MARX, B., & KEANE, T.M. (1996). Attention,
arousal, and memory in post-traumatic stress disorder. Journal
of Traumatic Stress, 9, 497-519.
LOO, C., SINGH, K., SCURFIELD, R., & KILAUANO, B. (1998).
Race-related stress among Asian American veterans: A model
to enhance diagnosis and treatment. Cultural Diversity and Men-
tal Health, 4, 75-90.
MORGAN, C.A., GRILLON, C.G., SOUTHWICK, S.M., DAVIS,
M., & CHARNEY, D.S. (1996). Exaggerated acoustic startle reflex
in Gulf War veterans with posttraumatic stress disorder. Ameri-
can Journal of Psychiatry, 153, 64-68.
ROSENHECK, R.A., FONTANA, A., & STOLAR, M. (1999).
Assessing quality of care: Administrative indicators and clini-
cal outcomes in posttraumatic stress disorder. Medical Care, 37,
180-188.
SCHNURR, P.P., FRIEDMAN, M.J., & ROSENBERG, S.D. (1993b).
Premilitary MMPI scores as predictors of combat-related PTSD
symptoms. American Journal of Psychiatry, 150, 479-483.
SOUTHWICK, S.M., KRYSTAL, J.H., BREMNER, J.D., MOR-
GAN, C.A., NICOLAOU, A.L., NAGY, L.M., JOHNSON, D.R.,
HENINGER, G.R., & CHARNEY, D.S. (1997). Noradrenergic and
serotonergic function in posttraumatic stress disorder. Archives
of General Psychiatry, 54, 749-758.
SOUTHWICK, S.M., MORGAN, C.A., NICOLAOU, A.L., &
CHARNEY, D.S. (1997). Consistency of memory for combat-
related traumatic events in veterans of Operation Desert Storm.
American Journal of Psychiatry, 154, 173-177.
TAFT, C.T., STERN, A.S., KING, L.A., & KING, D.W. (1999).
Modeling physical health and functional health status: The
role of combat exposure, posttraumatic stress disorder, and
personal resource attributes. Journal of Traumatic Stress, 12, 3-23.
WEATHERS, F.W., RUSCIO, A.M., & KEANE, T.M. (1999). Psy-
chometric properties of nine scoring rules for the Clinician-
Administered Posttraumatic Stress Disorder Scale. Psychologi-
cal Assessment, 11, 124-133.
WOLFE, J., BROWN, P.J., FUREY, J.A., & LEVIN, K.B. (1993).
Development of a wartime stressor scale for women. Psychologi-
cal Assessment, 5, 330-335.
Prev Page 8 Next
THE PTSD RESOURCE CENTER AND THE
PILOTS DATABASE
Over the past ten years, the National Center for PTSD has
become known worldwide as one of the leading sources for
reliable information on post-traumatic stress disorder. The
work of our PTSD Resource Center has made a substantial
contribution to research and clinical work, and to public
understanding of PTSD.
One of the National Center's first projects was the cre-
ation of a bibliographical database to index the traumatic
stress literature. Despite the existence of major databases
such as MEDLINE and PSYCINFO, none covers this litera-
ture in its entirety. Both its producers and its users come
from a wide range of disciplines: psychiatry, psychology,
social work, criminology, law, religion, and many others.
In designing and creating the PILOTS database, almost
every decision taken was affected by the interdisciplinary
nature of both the literature itself and the constituency to
be served.
An important choice was that of an indexing vocabulary.
The breadth of both MEDLINE's Medical Subject Headings
and PSYCINFO's Thesaurus of Psychological Index Terms
made them cumbersome to use in a relatively narrow
branch of literature. While both included a term specific to
PTSD, neither appeared well suited to a detailed analysis
of one narrow subdivision of an entire disciplinary do-
main. So we decided to create our own indexing vocabu-
lary for the traumatic stress literature. The resulting PI-
LOTS Thesaurus was published in the first PILOTS User's
Guide, in October 1991.
At that time, PILOTS was too small to be of interest to a
commercial database host. By joining the Combined Health
Information Database-the joint product of several federal
health agencies-we were able to make our bibliographi-
cal work accessible outside the National Center. The fol-
lowing year, we placed the PILOTS database on the
Dartmouth College Library Online System, allowing users
worldwide to search the database free of charge.
Since then the PILOTS database has grown substantially.
In April 1991, when it was first made available online as
part of CHID, there were 1,950 records in the file. Today
there are 16,295 documents indexed in PILOTS, including
* 11,994 journal articles
* 2,901 book chapters
* 405 books
* 800 doctoral dissertations
as well as master's theses, technical reports, and pam-
phlets. Complete copies of all of these documents (except-
ing dissertations and theses) are kept in our PTSD Resource
Center, which has become one of the world's largest
psychotrauma libraries.
A second edition of the PILOTS Database User's Guide
appeared in November 1994, and a third edition is in the
planning stages. This will describe the procedures for most
effectively using the Dartmouth College Information
System's graphical interface on the World Wide Web. Its
ease of use has attracted new users to PILOTS, as is evident
from the number of connections to the database:
October 1992
121
October 1996
427
October 1993
254
October 1997
1353
October 1994
345
October 1998
1947
October 1995
561
October 1999
2956
Since its debut in Fall 1995, our website has provided not
only access to the PILOTS database but also a growing
collection of informational resources drawing upon the
expertise of all seven National Center divisions. These
represent our efforts to provide accurate, dependable ma-
terial on PTSD to researchers, clinicians, and lay people.
Our website has been included on virtually every pub-
lished list of information resources on PTSD, and is heavily
used by students, librarians, and journalists. We are in the
process of restructuring the site, to make it even more
useful.
We look forward to the era of international cooperation
that will be fostered by the new Psychotrauma Documen-
tation Network, of which our PTSD Resource Center is a
founding member. We hope that this will enable us to
improve our coverage of traumatic stress literature from
countries and languages not fully represented in the PI-
LOTS database, and to make the research findings and
clinical experience of our colleagues overseas more readily
available to the men and women treating the veterans we
serve.
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