Gates Et Al 2012

Psychological Services
2012, Vol. 9, No. 4, 361382
In the public domain

DOI: 10.1037/a0027649
Posttraumatic Stress Disorder in Veterans and Military Personnel:

Epidemiology, Screening, and Case Recognition
Margaret A. Gates
Darren W. Holowka,
Jennifer J. Vasterling, Terence M. Keane,
and Brian P. Marx
New England Research Institutes, Inc., Watertown,

Massachusetts
VA Boston Healthcare System, Boston,

Massachusetts and Boston University School
of Medicine
Raymond C. Rosen
New England Research Institutes, Inc., Watertown, Massachusetts
Posttraumatic stress disorder (PTSD) is a psychiatric disorder that affects 7 8% of the
general U.S. population at some point during their lifetime; however, the prevalence is
much higher among certain subgroups, including active duty military personnel and
veterans. In this article, we review the empirical literature on the epidemiology and
screening of PTSD in military and veteran populations, including the availability of
sensitive and reliable screening tools. Although estimates vary across studies, evidence
suggests that the prevalence of PTSD in deployed U.S. military personnel may be as
high as 14 16%. Prior studies have identified trauma characteristics and pre- and
posttrauma factors that increase risk of PTSD among veterans and military personnel.
This information may help to inform prevention and screening efforts, as screening
programs could be targeted to high-risk populations. Large-scale screening efforts have
recently been implemented by the U.S. Departments of Defense and Veterans Affairs.
Given the prevalence and potential consequences of PTSD among veterans and active
duty military personnel, development and continued evaluation of effective screening
methods is an important public health need.
Keywords: epidemiology, military personnel, posttraumatic stress disorder, screening, veterans
Posttraumatic stress disorder (PTSD) is a

psychiatric condition that is experienced by a
subset of individuals after exposure to an event
that involved life threat and elicited feelings of
fear, helplessness, and/or horror in the individual. PTSD is characterized by several interrelated symptom clusters including reexperienc-
This article was published Online First March 5, 2012.

Margaret A. Gates and Raymond C. Rosen, New England
Research Institutes, Inc., Watertown, Massachusetts; Darren
W. Holowka, Jennifer J. Vasterling, Terence M. Keane, and
Brian P. Marx, National Center for PTSD, VA Boston
Healthcare System, and Department of Psychiatry, Boston
University School of Medicine.
This work was funded by U.S. Department of Defense
Awards W81XWH-08-2-0102 and W81XWH-08-2-0100.
Correspondence concerning this article should be addressed to Margaret A. Gates, New England Research
Institutes, Inc., 9 Galen Street, Watertown, MA 02472.
E-mail: mgates@neriscience.com
ing symptoms (e.g., intrusive thoughts, recurrent dreams, flashbacks, distress and
physiologic reactivity upon exposure to trauma
cues), avoidance and emotional numbing symptoms (e.g., avoidance of traumatic reminders,
anhedonia, detachment from others, restricted
emotional experiences, sense of foreshortened
future), and hyperarousal symptoms (e.g., sleep
difficulties, irritability and anger, concentration
problems, hypervigilence, exaggerated startle)
(American Psychiatric Association, 2000). Active duty military personnel and veterans are
two highly vulnerable, at-risk groups for development of PTSD (Dohrenwend et al., 2006;
Hoge, Auchterlonie, & Milliken, 2006; Hoge et
al., 2004).
The true prevalence of PTSD among veterans
and service members is controversial (Burkett
& Whitley, 1998; McHugh & Treisman, 2007;
McNally, 2006, 2007; Sundin, Fear, Iversen,
361
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GATES, HOLOWKA, VASTERLING, KEANE, MARX, AND ROSEN
Rona, & Wessely, 2010; Young, 1995), in part

because of concerns over possible overdiagnosis related to patients seeking secondary gain
(Department of Veterans Affairs Office of Inspector General, 2005; McHugh & Treisman,
2007). However, recent, large-scale studies indicate that PTSD may be a highly prevalent
disorder among U.S. service men and women
returning from current military deployments,
with prevalence estimates as high as 14 16%
(Hoge et al., 2004; Hoge, Terhakopian, Castro,
Messer, & Engel, 2007; Milliken, Auchterlonie, &
Hoge, 2007; Tanielian & Jaycox, 2008). Importantly, prior studies may actually underestimate
the true number of military personnel and veterans
suffering from PTSD and other trauma-related
disorders, because of stigma and potential negative consequences associated with disclosing
mental health difficulties (e.g., compromising
ones military career, delays in returning home)
(Hoge et al., 2004). Nonetheless, on the basis of
the available research findings, PTSD has been
referred to as one of the signature injuries of
active duty service men and women who are
deployed to Afghanistan for Operation Enduring Freedom (OEF) or Iraq for Operation Iraqi
Freedom (OIF) (Testimony of Jason Altmire,
2007).
PTSD is associated with numerous deleterious outcomes for veterans and active duty service personnel, and the costs of PTSD to the
individual, their immediate family, and society
at large are substantial. In addition to the emotional and cognitive symptoms of PTSD, individuals with PTSD are more likely to experience marital and family problems (Jordan et al.,
1992), job instability (Smith, Schnurr, & Rosenheck, 2005), legal difficulties (Kulka et al.,
1990), and physical health problems (Boscarino, 2004; OToole, Catts, Outram, Pierse, &
Cockburn, 2009). Veterans with a history of
PTSD have a higher risk of cardiovascular, respiratory, gastrointestinal, infectious, nervous
system, and autoimmune disorders (Boscarino,
1997, 2004; Hoge et al., 2007; Kubzansky,
Koenen, Spiro, Vokonas, & Sparrow, 2007) and
are more likely to experience anxiety, depression, substance abuse, and other psychiatric disorders (Kulka et al., 1990; Long, MacDonald, &
Chamberlain, 1996). Some studies also have
reported a higher risk of suicidal ideation
among veterans with PTSD (Jakupcak et al.,
2009; Pietrzak, Goldstein et al., 2009). PTSD
often occurs in combination with persistent

postconcussive symptoms and chronic pain,
complicating the diagnosis and treatment of
PTSD (Lew et al., 2009). The economic costs of
PTSD and major depression for all currently
deployed service members could be more
than 6.2 billion dollars during only the first two
years after return from deployment (Tanielian &
Jaycox, 2008). A large proportion of these costs
are expected to be attributable to lost work
productivity. Eibner and colleagues (Eibner,
Ringel, Kilmer, Pacula, & Diaz, 2008) hypothesized that the economic burden of PTSD could
be reduced through the proper identification of
those with PTSD and use of evidence-based
treatments within the first two years after an
individuals return from war zone deployment.
In response to the recent estimates of PTSD
prevalence among military personnel deployed
to OEF/OIF and the associated public health
and economic consequences, the U.S. Department of Defense (DoD) and VA have increased
the number of available mental health providers
and instituted mandatory primary care screenings for PTSD and other associated disorders
for military personnel and veterans. In addition,
the VA has developed and implemented specialized programs for evidence-based treatment
of PTSD, including Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) therapy (Karlin et al., 2010). However, the provision of adequate services depends upon the use
of accurate and reliable screening procedures to
identify individuals either at risk for or currently
affected by the disorder. Continued evaluation
of the current screening efforts is needed to
assess their effectiveness in properly identifying
individuals with PTSD and reducing the amount
of PTSD-related suffering among veterans and
active duty military personnel.
In considering the rationale for the development and implementation of PTSD screening
programs for armed services personnel and veterans, we first provide an overview of the prevalence and etiology of PTSD in military and
veteran populations, followed by a review of
current screening initiatives within the DoD and
VA and the available screening instruments. We
conclude by discussing potential gaps and future research needs in the area of screening for
PTSD in veteran and military populations. The
primary goal of this article is to provide an
overview of PTSD epidemiology and screening
PTSD IN VETERANS AND MILITARY PERSONNEL
for clinicians and researchers, as well as to

serve as a resource to guide clinicians in the
selection of screening instruments and implementation of screening programs.
Method
We searched the U.S. National Library of
Medicines PubMed database and the PsycINFO database for articles related to the prevalence, epidemiology, or screening of PTSD
among armed forces personnel and veterans.
We identified studies related to the prevalence
or epidemiology of PTSD in veterans and military personnel by searching for references with
the terms posttraumatic stress disorder or
PTSD and veterans, military, or combat in the title or abstract, as well as prevalence (n 229) or epidemiology, risk factor, or predictor (n 101) in the title/
abstract or subject heading. We reviewed the
abstracts for the resulting articles to identify
those relevant to our topic, and we also reviewed the references for the most relevant articles to identify additional studies of interest.
To identify articles related to screening for
PTSD in veterans and active duty military personnel, we searched for articles with the terms
posttraumatic or PTSD in the major subject
heading, veteran or military in the subjects
field, and screen in any field, which yielded
177 articles. We reviewed the results to determine whether the study addressed screening for
PTSD and the screening measures used. After
identifying relevant screening measures, we
performed additional searches to locate articles
about the measures in question, including original validation studies.
Results
Prevalence of PTSD in Veterans and
Military Personnel
Figure 1 displays estimates of the prevalence
of lifetime (any history) and current PTSD from
studies of active duty military personnel and
veterans of the Vietnam War (Boscarino, 1995;
Eisen et al., 2004; Goldberg, True, Eisen, &
Henderson, 1990; Kulka et al., 1990; OToole et
al., 2009; OToole et al., 1996; Stretch, 1985),
Gulf War (Al-Turkait & Ohaeri, 2008; Department of National Defence, 2002; Gray, Reed,
363
Kaiser, Smith, & Gastanaga, 2002; Holmes,

Tariot, & Cox, 1998; Ikin et al., 2004; Jones,
Rona, Hooper, & Wesseley, 2006; Kang, Natelson, Mahan, Lee, & Murphy, 2003; Lee, Gabriel, Bolton, Bale, & Jackson, 2002; Perconte,
Wilson, Pontius, Dietrick, & Spiro, 1993;
Pierce, 1997; Proctor et al., 1998; Stretch et al.,
1996; The Iowa Persian Gulf Study Group,
1997; Toomey et al., 2007; Unwin et al., 1999;
Wolfe, Erickson, Sharkansky, King, & King,
1999), and OEF/OIF (Duma, Reger, Canning,
McNeil, & Gahm, 2010; Fear et al., 2010;
Haskell et al., 2010; Hoge & Castro, 2006;
Hoge et al., 2004; Hoge et al., 2007; Hotopf et
al., 2006; Milliken et al., 2007; Seal, Bertenthal,
Miner, Sen, & Marmar, 2007; Seal et al., 2009;
Smith et al., 2008; Tanielian & Jaycox, 2008;
Vasterling et al., 2006; Vasterling et al., 2010).
Although the prevalence estimates vary widely
across studies, overall the data in Figure 1 suggest that a large proportion of military personnel
and veterans are affected by PTSD. Several
factors may contribute to differences in the
prevalence estimates across studies, including
the study design and methods, the diagnostic
criteria used, and characteristics of the study
population, such as the intensity of combat exposure or number of deployments (Ramchand et
al., 2010). Two recent review articles summarized the data on the prevalence of combatrelated PTSD (Richardson, Frueh, & Acierno,
2010; Sundin et al., 2010); we therefore briefly
summarize the most recent prevalence data below and refer readers to specific publications for
details of older studies.
Prevalence of military-related PTSD in the
United States. The most recent prevalence
estimates of deployment-related PTSD come
from the ongoing military operations in Iraq and
Afghanistan. In a review of the prevalence literature on combat-related PTSD, Richardson et
al. reported estimates for current PTSD in U.S.
OEF/OIF veterans ranging from 4% to 17%
(Richardson et al., 2010). In a recent study not
included in the reviews noted above, 21.8% of
289,328 OEF/OIF veterans who first received
care at a VA facility between 2002 and 2008
were diagnosed with PTSD during the 6-year
study period, based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes from inpatient and
outpatient visits (Seal et al., 2009). However,
this study population sought health care at VA
364
Figure 1. Current/lifetime prevalence of posttraumatic stress disorder in military and veteran populations.
facilities and therefore may not be representative of the larger population of OEF/OIF veterans. In addition, PTSD diagnoses were based on
electronic medical records and were not confirmed by other methods, likely resulting in
false positive as well as false negative diagnoses. In contrast to the study by Seal et al., a
study published by the RAND Corporation in
2008 reported that 14% of a representative sample of 1,965 OEF/OIF veterans interviewed by
telephone met diagnostic criteria for PTSD (Tanielian & Jaycox, 2008). Extrapolating from
these results, the authors estimated that 226,000

individuals who served in OEF/OIF through
October 31, 2007 currently have PTSD.
Prevalence of military-related PTSD internationally. Studies of non-U.S. veteran populations generally report similar or lower prevalence estimates than studies of U.S. veterans
(Richardson et al., 2010; Sundin et al., 2010).
For example, prevalence estimates for U.K. veterans who served in Iraq and Afghanistan range
from 3.4% to 6%, based on studies using selfadministered questionnaires (Browne et al.,
2007; Fear et al., 2010; Hotopf et al., 2006;

Iversen et al., 2008; Mulligan et al., 2010) or a
structured telephone interview (Iversen et al.,
2009); the lower prevalence of PTSD in these
studies, compared with studies of U.S. OEF/
OIF veterans, may be attributable in part to
lower levels of combat exposure among U.K.
soldiers (Hoge & Castro, 2006) or methodological differences in the studies.
Prevalence of military-related PTSD in
women and racial/ethnic minorities. Some
evidence suggests that the prevalence of PTSD
may differ among female and minority service
members and veterans, when compared with
white, non-Hispanic males. Women generally
have lower levels of combat exposure than men
but significantly higher rates of military sexual
trauma, which is strongly associated with development of PTSD (Kang, Dalager, Mahan, &
Ishii, 2005). In a large study of male and female
OEF/OIF veterans seen at VA facilities, the
prevalence of PTSD was similar, although statistically more prevalent, in men versus women
(13% vs. 11%) (Seal et al., 2007). In this study
the prevalence of PTSD also was similar by
race/ethnicity, although black veterans were
slightly more likely to be diagnosed with PTSD
(14%) than white or Hispanic veterans (13%)
(Seal et al., 2007). However, several older studies that examined prevalence differences by
race/ethnicity reported marked differences in
the prevalence of PTSD by minority status. For
example, in the NVVRS the prevalence of
PTSD was 20.6% among black veterans
and 27.9% among Hispanic veterans, compared
with 13.7% among white veterans (Frueh,
Brady, & de Arellano, 1998). Additional analyses of the NVVRS data also reported a higher
prevalence of PTSD among American-Indian
veterans, compared with white veterans (Frueh
et al., 1998), and high levels of race-related
stress and subsequent PTSD among AsianAmerican veterans (Loo, Fairbank, & Chemtob,
2005). Although other individual-level or trauma-related characteristics may have contributed
to these differences, as discussed in greater detail below, disparities by gender or race/
ethnicity are important to consider in studies of
PTSD.
Trends in the prevalence of PTSD. Disparities in estimates of the prevalence of PTSD
for different wars could be a function of differences in the study measures or methods (e.g.,
365
the diagnostic criteria and the methods of sampling and assessment) or characteristics of the
conflict. In addition, differences in population
characteristics, such as the duration or intensity
of combat exposure or the number of deployments also may contribute to the differing prevalence estimates across studies (Ramchand et
al., 2010). However, despite these methodological challenges, it is clear that PTSD affects a
large number of current and former service men
and women at some point during their lifetime.
The high prevalence of PTSD in military and
veteran populations highlights the importance
of screening these populations for PTSD and
identifying factors that influence risk and recovery from PTSD.
Risk Factors for PTSD in Veterans and
Military Personnel
The majority of individuals exposed to
trauma do not develop clinical PTSD, suggesting that other factors strongly influence the onset and course of this disorder (Keane, Marx, &
Sloan, 2009). Risk factors for PTSD are commonly divided into three categories: individuallevel (pretrauma) factors, characteristics of the
trauma, and posttrauma factors (Keane, Marshall, & Taft, 2006). Knowledge of pretrauma
factors and trauma characteristics that influence
risk may help to identify populations at higher
risk of developing PTSD and who are therefore
more likely to benefit from screening, whereas
posttrauma factors may help to inform prevention and treatment programs among men and
women with trauma exposure.
Table 1 summarizes the epidemiologic factors shown in multiple studies to influence risk
of PTSD in veterans and military personnel.
Characteristics of the trauma (e.g., trauma severity, perceived life threat, and combat-related
injury) and posttrauma factors (e.g., lack of
social support and exposure to additional life
stressors) have been strongly associated with
risk of PTSD in multiple studies. In contrast,
weak to moderate associations generally have
been reported for pretrauma factors, such as
younger age at trauma and prior psychiatric
history.
Gender, race/ethnicity, and risk of PTSD.
In addition to the risk factors included in Table 1, some studies have suggested that gender
and race/ethnicity may be important in the de-
366
Table 1
Epidemiologic Factors Associated With Increased Risk of Posttraumatic Stress Disorder in Veterans and
Military Personnel
Risk factor
Pre-trauma factors
Younger age at trauma
Lower education
Lower intelligence
Lower military rank
Lower socioeconomic status
Prior trauma
Prior psychiatric history/symptoms
Family psychiatric history
Behavioral problems in childhood
Childhood abuse or adversity
Trauma characteristics
Trauma/combat exposure severity
References
(Brewin et al., 2000; Nasky, Hines, & Simmer, 2009)
(Brewin et al., 2000; Iversen et al., 2008; Schnurr et al.,
2004; Zohar et al., 2009)
(Brewin et al., 2000; Gale et al., 2008; Zohar et al., 2009)
(Iversen et al., 2008; Nasky et al., 2009; Zohar et al., 2009)
(Brewin et al., 2000; Schnurr et al., 2004)
(Brewin et al., 2000; Ozer et al., 2003)
(Brewin et al., 2000; Rona et al., 2009)
(Helzer, Robins, & McEvoy, 1987; King, King, Foy, &
Gudanowski, 1996; Koenen et al., 2005)
(Brewin et al., 2000; Cabrera, Hoge, Bliese, Castro, &
Messer, 2007; Gahm et al., 2007; Iversen et al., 2008)
(Brewin et al., 2000; Cabrera et al., 2007; Gahm et al.,

2007; Koenen et al., 2003; OToole et al., 1996; Rona et
al., 2009; Schnurr et al., 2004)
(King et al., 1998; Schnurr et al., 2004)
(Koren, Norman, Cohen, Berman, & Klein, 2005;
MacGregor et al., 2009)
(Gahm et al., 2007; Iversen et al., 2008; Maguen et al.,
2010; Marx et al., 2010; McCarroll, Ursano, Fullerton,
Liu, & Lundy, 2001)
(Ozer et al., 2003; Schnurr et al., 2004)

(Johnson et al., 1997; Koenen et al., 2003)
(Brewin et al., 2000)
Perceived life threat

Combat-related injury
Exposure to death, killing, or

abusive violence
Peritraumatic distress or dissociation

Post-trauma factors
Lack of social support
Negative homecoming experience
Exposure to additional life stressors
Strength of
association
Weak effect (), intermediate effect (), or strong effect ().
velopment of military-related PTSD (Brewin,

Andrews, & Valentine, 2000; Gahm, Lucenko,
Retzlaff, & Fukuda, 2007; Koenen, Stellman,
Stellman, & Sommer, 2003). In a meta-analysis
of 25 studies, Brewin et al. (2000) observed a
significantly higher risk of PTSD among
women compared with men in civilian but not
military populations, although only two military
studies of gender and PTSD were included.
More recent studies are mixed, with some reporting a higher risk among women and others
reporting no association (Street, Vogt, & Dutra,
2009). Similarly, minority race/ethnicity was
associated with an increased risk of PTSD in
military populations in the meta-analysis by
Brewin et al. (2000), but other studies do not
support an association (Baker et al., 2009; Frueh
et al., 1998). Several factors may contribute to
differences in the associations with gender and
race observed across studies, including premilitary trauma exposure or confounding by trauma
characteristics, social support during deployment, or other stressors (Dohrenwend, Turner,
Turse, Lewis-Fernandez, & Yager, 2008; Kimerling, Gima, Smith, Street, & Frayne, 2007;
Loo et al., 2005; Street et al., 2009; Vogt, Pless,
King, & King, 2005). For example, premilitary/
military sexual trauma is an important cause of
PTSD that disproportionately affects women
(Himmelfarb, Yaeger, & Mintz, 2006; Kimerling et al., 2007); however, studies of military and veteran populations that focus on
PTSD resulting from combat, rather than all
military-related trauma, may fail to report cases
of PTSD that are primarily attributable to military sexual trauma.
Complexity of PTSD etiology. Multivariate and meta-analytic studies (Brewin et al.,
2000; King, King, Foy, Keane, & Fairbank,

1999; Ozer, Best, Lipsey, & Weiss, 2003;
Wolfe et al., 1999) highlight the complexity of
predicting who will and will not develop
chronic PTSD. Risk and resilience factors, including the quality of the family environment
during childhood, age at trauma exposure, history of prior adversity, severity of trauma exposure, breadth and strength of the social support
network, exposure to additional life stressors,
and individual-level characteristics such as hardiness and neurobiology have consistently been
found to influence the development of PTSD
(King et al., 1999; King, King, Fairbank, Keane,
& Adams, 1998; Pietrzak et al., 2010; Pietrzak,
Johnson, Goldstein, Malley, & Southwick,
2009). This research suggests that vulnerability
to PTSD is not simply a function of trauma
exposure but a function of the interaction between trauma exposure, preexisting psychological and biological vulnerabilities, and the posttrauma environment. Other research indicates
that the factors influencing development and
maintenance of PTSD may differ (Schnurr,
Lunney, & Sengupta, 2004).
Genetics of PTSD. Finally, although familial studies support a heritable component of
PTSD, limited data are available on genetic
polymorphisms that may influence risk in military and veteran populations (Afifi, Asmundson,
Taylor, & Jang, 2010; Koenen, 2007). In a study
of male twin pairs who served during the Vietnam era, True et al. observed that approximately
30% of the variability in PTSD symptoms was
attributable to genetic factors, whereas shared
family environment did not appear to influence
the development of PTSD (True et al., 1993).
Studies of specific genetic variants have focused
on the dopaminergic, serotonergic, and other
neurobiochemical pathways (Nugent, Amstadter, & Koenen, 2008). Polymorphisms in the
dopamine receptor D2 (DRD2) gene have been
associated with risk of PTSD in some but not all
studies of combat-exposed populations (Nugent
et al., 2008; Voisey et al., 2009), and one study
reported lower dopamine beta-hydroxylase
(DBH) activity among veterans with PTSD
compared with those without PTSD, suggesting a
possible role of the DBH gene in the development
of PTSD (Mustapic et al., 2007). However, studies
of genes in other pathways generally have been
null in military and veteran populations, although
the number of available studies is small (re-
367
viewed in Koenen, 2007; Nugent et al., 2008).

Large, genome-wide association studies would
be helpful in identifying other chromosomal
regions that may be important in PTSD. Although future genetic studies may help to elucidate the mechanisms involved in the development of PTSD and may be informative for risk
prediction and screening or prevention, currently the evidence is too limited for widespread
use of genetic data for screening purposes in
military and veteran populations.
Screening Programs for PTSD in Veterans
and Military Personnel
The high prevalence of PTSD in military and
veteran populations and the potential seriousness of the symptoms and associated emotional/
physical health consequences highlight the importance of effective screening and early intervention efforts for these groups. The goal of
screening in this population is to identify traumaexposed individuals with undiagnosed or subsyndromal PTSD, or those at risk for developing the disorder, to intervene earlier in the
course of disease than would occur in the absence of screening. Although screening for
PTSD differs from screening for chronic diseases, such as cancer, in that symptoms often
are present at the time of screening, the goal of
reducing morbidity or mortality from disease is
similar, as early intervention may result in a
shorter course of disease and fewer negative
outcomes related to PTSD (Bryant et al., 2008;
Kessler, Sonnega, Bromet, Hughes, & Nelson,
1995; ODonnell, Bryant, Creamer, & Carty,
2008). Screening may also be of value in identifying subgroups of individuals or specific cohorts at increased risk for developing PTSD,
tracking changes in prevalence over time, and
assessing the degree of unmet need for services.
In 2003, the DoD instituted a military-wide
screening programthe Post-Deployment
Health Assessment (PDHA)that assesses service members physical and mental health status after deployment. Specific mental health
areas addressed include depression, suicidal
ideation, aggression, and PTSD (Hoge et al.,
2006). Screening occurs within 12 weeks of
return from deployment and consists of a threepage self-report questionnaire followed by a
brief interview with a health care professional,
who documents any concerns, determines
368
whether additional evaluation is needed, and

provides information on available resources for
dealing with postdeployment issues (U.S. Department of Defense Deployment Health Clinical Center). Results of this large-scale screening
program suggest that a substantial percentage of
service members who served in Iraq and Afghanistan screen positive for probable PTSD;
during the first year after implementation of the
PHDA, 9.8% of Army soldiers and Marines
returning from Iraq and 4.7% returning from
Afghanistan screened positive for probable
PTSD (Hoge et al., 2006). Although it is possible that these estimates overstate the prevalence
of PTSD because of patients seeking secondary
gain, it is also possible that these studies underestimate the prevalence of PTSD among active
duty military personnel who may not report the
presence of PTSD symptoms because of concerns that public knowledge of their symptoms
may damage their personal or professional reputations. As part of this ongoing screening program, the DoD mandated in 2005 that service
members be assessed again 3 6 months after
return from deployment (Milliken et al., 2007).
Screening at two time points yielded even
higher positive screening rates for probable
PTSD and other mental health concerns; at the
reassessment, 16.7% of active soldiers
and 24.5% of National Guard and Reserve soldiers screened positive for PTSD (Milliken et
al., 2007). A second study found that the proportion of individuals screening positive for
PTSD and other mental health conditions was
higher when screening was delayed until several
months postdeployment, indicating that screening soon after return from deployment may miss
a large number of cases as a result of delayed
onset or false negative screens (Bliese, Wright,
Adler, Thomas, & Hoge, 2007).
Despite the apparent success of these screening efforts by the DoD, some researchers have
voiced concerns, citing limited evidence of the
effectiveness of screening in military populations (Rona, Hyams, & Wessely, 2005). Rona
and colleagues argued that the number of positive screens requiring prompt psychological attention is small relative to the total number of
individuals screening positive and that several
factors may influence over- or underreporting of
symptoms in military populations (Rona et al.,
2005). However, in a study of 1,578 military
personnel returning from a year-long deploy-
ment to Iraq, Bliese et al. reported a sensitivity

of 0.73 and specificity of 0.88 for the four-item
Primary Care PTSD Screen (PC-PTSD) used in
the PDHA compared with a structured interview, indicating that the PDHA has reasonably
good validity (Bliese, Wright, Thomas, Adler,
& Hoge, 2004, December).
In 2004, the VA implemented the Afghan and
Iraq Post-Deployment Screen, a 10 15 minute
assessment for PTSD, depression, and high-risk
alcohol use (Seal et al., 2008). Veterans seeking
care at Veterans Health Administration (VHA)
primary care and specialty clinics are routinely
screened by their clinician, who is prompted to
complete the assessment by an automatic reminder in the VHAs computerized medical record system (Seal et al., 2008; Veterans Health
Administration, 2004). PTSD symptoms are assessed using the four-item PC-PTSD, and clinicians are encouraged to refer veterans with a
positive screen to a specialty mental health
clinic (Seal et al., 2008). In a study by Seal and
colleagues (2008), 45% of OEF/OIF veterans
seen at a VHA Medical Center or associated
clinic were screened, and 50% of those screened
met the criteria for probable PTSD. This is
consistent with a study of active duty military
personnel seen at outpatient mental health clinics in which 44% screened positive for probable
PTSD (Gahm & Lucenko, 2008). Although the
prevalence of PTSD likely is elevated among
active duty military personnel and veterans
seen at VHA facilities, as this population
includes individuals seeking care for symptoms of PTSD or related conditions, these
studies highlight the importance of screening
for PTSD in this setting. Beginning in 2010,
the VA required that all OEF/OIF veterans
being actively treated for PTSD at a VHA
facility be evaluated for PTSD symptoms every 90 days using the PTSD Checklist (PCL),
to monitor changes in PTSD symptoms and
assess whether individuals previously diagnosed with PTSD continue to meet diagnostic
criteria (Department of Veterans Affairs,
2009).
Ongoing evaluation of the efforts to screen
active duty military personnel and veterans is
needed to maximize the effectiveness of these
screening programs. For example, studies of the
optimal timing of the PDHA and the optimal
frequency of the VA screen would help to ensure that cases are detected and treatment is
initiated early but that the number of cases

missed because of delayed onset is minimized.
In addition, validation studies should be conducted where none are available, to evaluate the
effectiveness of the screening programs as well
as to assess the psychometric properties and
diagnostic accuracy of new screening measures
in these populations.
Overview of Screening Instruments for
Identifying PTSD in Military and Veteran
Populations
Various methods have been used to assess the
signs and symptoms of PTSD in military and
veteran populations; however, the most common approach involves the use of self-report
questionnaires. In a review of screening instruments for assessing symptoms of PTSD in the
general population, Brewin noted that screening
tools designed to assess Diagnostic and Statistical Manual of Mental Disorders, 4th Edition
(DSMIV) symptoms were superior to other instruments, and that measures with fewer items,
simpler response scales, and simpler methods of
scoring usually were superior (Brewin, 2005).
Some screening instruments, including those
reviewed by Brewin (2005), more generally assess the presence of PTSD that may or may not
be combat related. In contrast, other screening
measures are specifically designed to assess
combat-related PTSD. Combat-specific PTSD
screening instruments may have higher sensitivity and specificity in military and veteran
populations than screening tools designed for
use in the general population. However, more
focused screening tools may fail to identify
PTSD cases that are unrelated to combat, such
as PTSD resulting from military sexual trauma
(Suris & Lind, 2008); screening measures
should therefore be broad enough to effectively
screen for both combat-related PTSD and PTSD
related to other trauma in military settings.
Screening instruments for PTSD assess some
or all of the characteristic symptoms of PTSD
and are typically validated against a gold standard of clinical diagnosis by a qualified clinician. Additional validation tests include discriminant or known groups validity (does the
test distinguish between individuals with and
without the disorder?), predictive validity
(does the test predict who will develop the
disorder?), and convergent validity (do the
369
test results correlate with other similar measures?). Reliability assessment (test-retest, internal consistency) is also necessary. Ideally,
PTSD screening tools should have a high degree
of sensitivity and at least modest specificity,
when compared with expert diagnosis. Although the negative consequences of a false
positive screen for PTSD may be acceptable,
because a positive screen should always be followed by in-depth diagnostic assessment by a
qualified mental health professional, the number
of false positives should not be so large as to
overwhelm the available resources for diagnosing
and treating PTSD. In contrast, false negative
screens have potentially serious consequences and
should be minimized, as individuals with PTSD
who are not identified may not receive further
assessment and could potentially be symptomatic
for several years without receiving diagnosis or
treatment.
Review of self-report screening instruments. In Table 2 we provide an overview of
the self-report scales and screening instruments
that have been used to detect probable PTSD in
military and veteran populations (Blanchard,
Jones-Alexander, Buckley, & Forneris, 1996;
Brewin, 2005; Carlson, 2001; Davidson et al.,
1997; Foa, Cashman, Jaycox, & Perry, 1997;
Gore, Engel, Freed, Liu, & Armstrong, 2008;
Hammarberg, 1992; Horowitz, Wilner, & Alvarez, 1979; Hovens, Bramsen, & van der Ploeg,
2002; Keane, Caddell, & Taylor, 1988; Marx et
al., 2008; Meltzer-Brody, Churchill, & Davidson, 1999; Neal et al., 1994; ODonnell,
Creamer et al., 2008; Prins et al., 2003; Weathers, Litz, Herman, Huska, & Keane, 1993;
Weathers et al., 1996). In the interest of space
we are unable to discuss all of the instruments
included in Table 2, but additional information
regarding some of the most widely used and/or
innovative instruments is presented below.
Early studies, including the NVVRS, used
two self-report instruments to screen for PTSD:
the 15-item Impact of Events Scale (Horowitz et
al., 1979) and the 35-item Mississippi Scale
(Keane et al., 1988). The Mississippi Scale was
ultimately the biggest contributor to the diagnostic algorithm developed to establish prevalence in
the NVVRS. More recently, the PCL has emerged
as the standard self-report instrument for screening military and veteran populations (Weathers et
al., 1993). The PCL includes 17 items which
align with DSMIV criteria and assess symp-
35
25
Mississippi PTSD Scale (Keane et al.,

1988)
Single Item PTSD Screen (SIPS) (Gore et

al., 2008)
War-Zone Related PTSD Scale (WZ-PTSD)

(Brewin, 2005; Weathers et al., 1996)
17
15
0.94
Startle, Physiological arousal, Anger, and

Numbness (SPAN) (Meltzer-Brody et al.,
1999)
Screen for Posttraumatic Stress Disorder
(SPTSS) (Carlson, 2001)
Impact of Event Scale (IES) (Horowitz et

al., 1979; Neal et al., 1994)
0.84
17
Davidson Trauma Scale (DTS) (Davidson et

al., 1997)
0.870.90
0.76
0.93
0.89
0.69
0.78
Primary Care Posttraumatic Stress Disorder

Screen (PC-PTSD) (Prins et al., 2003)
0.780.94
Sensitivity
17
No. of
items
PTSD Checklist (PCL) (Blanchard et al.,

1996; Weathers et al., 1993)
Name
Table 2
Posttraumatic Stress Disorder Screening Instruments
0.650.72
0.79
0.89
0.88
0.60
0.91
0.95
0.87
0.830.86
Specificity
Psychometrics
0.810.82
0.90
0.88
0.88
0.83
0.85
0.830.90
Efficiency
Rate frequency of symptoms over the

past two weeks from 0 (never) to 10
(every day)
Rate frequency of symptoms in past
week (not at all, rarely, sometimes,
and often) in response to a specific
life event
Items rated on a five-point scale
(responses vary by item), time
period since the event
Not bothered at all, bothered a
little, or bothered a lot by a past
traumatic experience
Rate current PTSD symptoms
(occurring in the past 7 days) on a
five-point scale
Rate how much specific problems have

bothered patient in the past month
ranging from 1 (not at all) to 5
(extremely)
Indicate presence/absence of
nightmares, avoidance,
hypervigilance, and numbness in the
past month resulting from a
traumatic event
Rate frequency/severity of each
symptom in the past week from
0 not at all to 4 every day/
extremely distressing.
Reexperiencing symptoms are tied to
a specific event.
Rate frequency/severity of symptoms
from 04
Item structure and description
107
35
40
1.3
Bothered a little
Varies
Cutoff score
370
35
52
Optimally efficient at 6, optimally

sensitive at 3
16
0.75
49
Posttraumatic Diagnostic Scale (PTDS)
(Foa et al., 1997)
0.89
0.941.00
26
Penn Inventory for PTSD (Hammarberg,
1992)
0.900.98
0.78
0.71
0.86
22
Self-Rating Inventory for PTSD (SRIP)
(Hovens et al., 2002)
0.84
0.82
10
0.940.97
Twelve items that significantly predict

PTSD diagnostic status
Five-item severity-based Likert scale
ranging from Not at all to
Totally
Four-point Likert scale from not at
all to very much rating symptom
intensity
4 scaled sentences measuring presence/
absence of PTSD symptoms, along
with degree, frequency, or intensity
of symptoms.
Symptom frequency in the past month
rated on a 4-point scale from
0not at all to 3five or more
times a week
0.780.87
0.360.8
0.860.99
12
PTSD Statistical Prediction Instrument

(PSPI) (Marx et al., 2008)
Posttraumatic Adjustment Scale (PAS-P)
(ODonnell, Creamer et al., 2008)
Specificity
Name
Table 2 (continued)
No. of
items
Sensitivity
Psychometrics
Efficiency
Item structure and description
Cutoff score
371
toms during the past month, using a scale

from 1 (not at all) to 5 (extremely). A positive
screen for PTSD is typically determined based
on either a cutoff score (e.g., a score of 50 or
higher) or DSM criteria (i.e., the presence of
one reexperiencing symptom, three avoidance
symptoms, and two arousal symptoms), or a
combination of both criteria (Hoge et al., 2007).
In a sample of Vietnam veterans, the PCL demonstrated excellent testretest reliability (0.96)
and internal consistency (0.97), and adequate
sensitivity (0.82) and specificity (0.83) using a
cutoff score of 50 (Weathers et al., 1993). However, more recent studies in veteran populations
support the use of a lower cutoff for the PCL
(Bliese et al., 2008; Yeager, Magruder, Knapp,
Nicholas, & Frueh, 2007); Yeager et al. (2007)
reported a sensitivity and specificity of 0.81
using a cutoff of 31, versus a sensitivity of 0.53
and a specificity of 0.95 using a cutoff of 50,
while a recent study by Dunn et al. (2011)
reported an optimal cutoff of 44 based on a
receiver operating characteristic curve, with a
sensitivity of 0.81 and a specificity of 0.83.
Differences in the sensitivity and specificity for
a given cutoff score and the optimal cutoff score
across studies may be attributable to population
characteristics such as the severity of PTSD
symptoms, the interrater reliability of the
screening instrument, or differences in the gold
standard diagnostic assessment to which the
screening instrument is compared (Warner,
2004). Because it is a relatively brief measure,
the PCL is easily implemented in survey studies
and has been widely used in military (Hoge et
al., 2004; Smith et al., 2008) and veteran populations (Hoge et al., 2007; Kline et al., 2010) as
a measure of probable PTSD and PTSD symptom severity. In addition, a brief screening instrument has been derived from the PCL (Lang
& Stein, 2005).
The Davidson Trauma Scale consists of 17
items, with self-ratings of both frequency and
severity for each symptom on a five-point
scale (Davidson et al., 1997). It has been
validated for use in military and veteran populations (McDonald, Beckham, Morey, &
Calhoun, 2009) and demonstrated adequate testretest reliability (0.86) and internal consistency (0.97 0.99) in a mixed trauma sample of
353 individuals, including 110 male war veterans (Davidson et al., 1997). In a study of U.S.
veterans who served after September 11, 2001,
372
a cutoff score of 32 resulted in a sensitivity

of 0.97, a specificity of 0.91, and an overall
efficiency of 0.94 (McDonald et al., 2009).
A general trend in screening instrument development is the drive to create measures that
are as brief as possible but still retain excellent
psychometric properties. This, coupled with the
fact that PTSD is commonly unrecognized in
primary care settings, led to the development of
the PC-PTSD, a brief screening tool for PTSD
that is easily administered and scored by nonmental health professionals (Prins et al., 2003).
The PC-PTSD consists of four items that assess
symptoms of reexperiencing, numbing, avoidance, and hyperarousal (Prins et al., 2003). In a
validation study conducted among 352 postdeployment soldiers, Bliese et al. (2008) reported
a weighted sensitivity and specificity of 0.76
and 0.92, respectively, using a cutoff score of 3.
The Startle, Physiological Arousal, Anger,
and Numbness instrument is another four-item
self-report measure developed from the severity
items of the Davidson Trauma Scale (MeltzerBrody et al., 1999). Among veterans seen in a
VA primary care setting, the sensitivity and
specificity were 0.74 and 0.82, respectively, using a cutoff score of 5 and comparing the results
to the Clinician-Administered PTSD Scale
(Yeager et al., 2007).
Gore and colleagues (2008) recently developed
a single-item PTSD measure with a three-point
response scale ranging from not bothered to
bothered a lot. However, the psychometric
properties of the single-item measure were inferior to the four-item PC-PTSD; the sensitivity
and specificity in a military primary care setting
were 0.76 and 0.79, respectively, for those who
were bothered a little by a past traumatic
experience. In contrast, the PC-PTSD had a
sensitivity of 0.91 and a specificity of 0.84 in
this population, based on a cutoff score of 2
(Gore et al., 2008).
Screening for PTSD resulting from premilitary or military sexual trauma. In addition to combat, PTSD symptoms among veterans and military personnel may originate from
premilitary or military sexual trauma. VA surveillance data suggest that 22% of females and
1% of males experience sexual trauma while in
the military (Suris & Lind, 2008); however,
estimates vary across studies and the true prevalence may be even higher because of underreporting (Suris & Lind, 2008; Valente & Wight,
2007). Given the scope of the problem, specific

screening measures have been developed to assess PTSD symptoms related to military sexual
trauma. For example, the VHA implemented
universal screening for military sexual trauma
using a two-item instrument, which has been
successful in identifying individuals for referral
to mental health services (Kimerling et al.,
2007; Kimerling, Street, Gima, & Smith, 2008).
Both questions have high sensitivity (0.89
0.92) and specificity (0.89 0.90), compared
with a clinical interview, and a positive screen
has been associated with a significantly increased odds of PTSD (adjusted odds ratio 8.83 for women and 3.00 for men) (Kimerling et al., 2007).
Screening for PTSD in women and racial/
ethnic minorities. As noted above, military
sexual trauma is an important consideration
when screening women for PTSD. Screening
instruments should be designed to accurately
diagnose PTSD regardless of the gender or race/
ethnicity of the individual being screened, and
the reliability and validity of instruments should
be assessed in diverse populations (Frueh et al.,
1998). Because several studies have reported
racial/ethnic differences and a high prevalence
of PTSD among minority veterans (Frueh et al.,
1998; Loo et al., 2005; Seal et al., 2007), validation studies of current and future screening
instruments should include adequate numbers
of minority participants to ensure the representativeness of relevant domains and items in minority respondents.
Predictive assessments for risk of developing PTSD. Although symptom-based PTSD
screening instruments may help to reduce morbidity related to PTSD by allowing for earlier
intervention, they are limited by their inability
to prevent the onset of PTSD in individuals
exposed to trauma. Recent research suggests
that measures designed to quantify information
about risk and resilience factors for PTSD can
be used to identify asymptomatic, traumaexposed individuals who are more likely to develop PTSD. ODonnell and colleagues developed a screening tool that identifies hospitalized
adults at high risk of PTSD or major depression
(ODonnell, Creamer et al., 2008). In this study,
527 civilians hospitalized with nonlethal injuries answered questions related to 13 risk factors for PTSD. Patients were assessed 12
months later for the presence of PTSD or major
depression. Responses from half of the participants were used in factor analyses to derive the
10-item Posttraumatic Adjustment Scale, which
was then validated in the remaining participants. After 12 months, 8% of participants had
developed PTSD, and the scale had moderate
sensitivity (0.82) and specificity (0.84) when
predicting PTSD diagnoses (ODonnell,
Creamer et al., 2008).
In another recent study, Marx et al. (2008)
used data from 1,081 Vietnam era veterans to
develop and test a similar screening instrument
for combat-related PTSD. Participants completed self-report measures and structured interviews for PTSD and supplied information on
risk and resilience variables. Participants were
divided into three subsamples, two of which
were used to identify variables that differentiated between individuals with and without
PTSD. Twelve risk and resilience items were
included in the resulting PTSD Statistical Prediction Instrument, which was validated using
the remaining subsample. This instrument displayed adequate sensitivity (0.86) and moderate
specificity (0.77) in the validation sample, using
a cutoff score of 6, and strong internal consistency (0.84) (Marx et al., 2008). These results
suggest that primary prevention of PTSD may
be possible in military and veteran populations,
which would be expected to result in improved
outcomes and decreased health care utilization
by PTSD patients.
Psychophysiological screening. In addition to traditional questionnaire-based assessments, some research suggests that psychophysiological testing, such as the acoustic startle
response and heart rate variability, may have
potential applications for PTSD screening. Several studies have reported that veterans with
PTSD have decreased heart rate variability
(Tan, Dao, Farmer, Sutherland, & Gevirtz,
2011; Tan et al., 2009) and a heightened acoustic startle response (Butler et al., 1990; Morgan,
Grillon, Southwick, Davis, & Charney, 1996;
Orr, Lasko, Shalev, & Pitman, 1995), raising
the possibility that these measures could be used
to identify individuals with undiagnosed or preclinical PTSD. However, the use of biological
assays and psychophysiological methods for assessment and screening is still in the early developmental stages and additional research on
the utility of these measures for screening purposes is needed.
373
Risks and limitations of screening instruments. Despite the intense effort and interest
in developing methods to screen for symptoms
of PTSD in military and veteran populations, all
of the current methods have inherent limitations. For example, all self-report scales may be
vulnerable to response bias from various
sources (Elhai, Frueh, Davis, Jacobs, & Hamner, 2003). Concerns about the potential implications of positive (or negative) screening results may lead to over- or underreporting of
symptoms, depending on the individual and circumstances of testing. In addition, reliance on a
single measure or assessment methodology may
lead to inaccurate diagnosis in many cases and
a large number of false positives and negatives.
As a result of these limitations, it has become
standard practice to use multiple methods and
measures to better inform diagnostic decisions
(Weathers, Keane, & Foa, 2009). Such multimethod assessment of PTSD takes advantage of
each individual measures relative strengths,
overcoming the potential psychometric limitations of any single instrument and maximizing
correct diagnostic decisions. On the other hand,
the use of multiple assessment methods reduces
cost efficiency and increases the respondent and
clinician burden in proportion to the number of
instruments used. In determining cut points or
criteria for further evaluation, it is generally
preferable to err on the side of increased sensitivity, rather than specificity, in the use of such
screeners. All other things being equal, a modest number of false positives may be acceptable
on the initial shorter screening measure, followed by perhaps longer but increasingly accurate and specific measures. For instance, Felker
and colleagues (Felker, Hawkins, Dobie, Gutierrez, & McFall, 2008) used the four-item
PC-PTSD followed by the longer PCL. Other
researchers found that using a composite measure, created from various self-report symptombased measures, led to increased diagnostic
accuracy, compared with the use of several individual measures (Wright et al., 2007).
Additional resources for clinicians.
In
addition to the references noted above and those
included in Table 2, several resources related to
PTSD screening are available through the VA.
The VA/DoD Clinical Practice Guideline for
the Management of Post-Traumatic Stress (Department of Veterans Affairs, 2004) includes
information on PTSD screening and treatment,
374
as well as monitoring and follow-up of patients

with potential PTSD. The VA National Center
for PTSD website (Department of Veterans Affairs, 2011) includes extensive resources on
PTSD for both clinicians and researchers, including an overview of PTSD screening instruments.
Discussion
Although numerous symptom checklists and
self-administered questionnaires have been developed, there is no compelling evidence that
one screening instrument outperforms the others in veteran and military populations. Several
instruments have adequate psychometric properties and have been used successfully to screen
for PTSD in active duty military personnel and
veterans. In general, short measures seem to do
as well as longer questionnaires and therefore
should be used whenever possible to decrease
the time and effort required to screen for PTSD.
When appropriate, short screening instruments
may be followed by longer measures with
greater specificity to decrease the number of
false positive screens. Continued evaluation of
new and existing screening measures, and in
particular validation against more rigorous diagnostic methods, is needed to ensure that the
screening measures in use are detecting cases of
probable PTSD while minimizing the number
of missed diagnoses.
Screening programs such as those implemented by the DoD and VA have been successful in identifying individuals with presumptive
or probable PTSD. Individuals who screen positive are then referred for further clinical assessment and diagnostic evaluation by a mental
health professional, who might also provide
treatment of the disorder as needed. By detecting and treating patients as soon as possible
after the onset of symptoms, screening may
contribute to a shorter duration of disease and
more favorable outcomes (Kessler et al., 1995).
In addition, screening instruments have been
used in large-scale surveys to evaluate the prevalence of key symptoms of PTSD before and
after deployment, and to identify subgroups of
individuals at increased risk for PTSD and related conditions, such as substance abuse and
depression. However, despite the potential benefits of screening, there are also several limitations. Current screening programs detect symp-
toms of PTSD in individuals who already show

signs of the disorder; therefore, these programs
may lead to earlier diagnosis and treatment, but
may not prevent the onset of PTSD symptoms.
Although some research has evaluated the effectiveness of predeployment screening, the
question remains as to whether screening
asymptomatic individuals can result in accurate
identification of a sufficient number of military
personnel at risk for future PTSD, and whether
those who screen positive are more likely to
obtain and benefit from services. Rona and colleagues found little benefit of predeployment
screening for predicting subsequent onset of
PTSD, in part because of the low prevalence of
PTSD in the sample (Rona et al., 2006). Additional limitations of screening include the fact
that individuals with symptoms of PTSD may
be less likely to participate in screening programs (Rona, Jones, French, Hooper, & Wessely, 2004) or seek treatment (Sayer et al.,
2009). These findings raise serious concerns, as
the individuals with greatest need of diagnosis
and treatment may be least likely to receive it.
Further, individuals exposed to militaryrelated trauma may have multiple adverse effects, and PTSD may not be the most immediate
concern after trauma exposure. For example, in
a recent study of British troops deployed to Iraq
or Afghanistan the prevalence of probable
PTSD was only 4%, compared with 13% for
alcohol abuse and 20% for symptoms of other
psychiatric disorders (Fear et al., 2010). However, several studies have reported an increase
in PTSD prevalence with increasing time since
return from deployment (Bliese et al., 2007;
Kang, Li, Mahan, Eisen, & Engel, 2009; Milliken et al., 2007), suggesting that continued
surveillance and screening for PTSD are
needed.
In summary, PTSD is a potentially disabling
mental disorder that is common among active
duty military personnel and veterans. Prevalence studies and large scale screening programs have helped to define the scope of the
problem in military and veteran populations,
while epidemiologic studies have improved our
understanding of the etiology of the disorder
and the characteristics of those at highest risk.
Although research and interest in this field has
grown in recent years, there is still much to be
learned about the risk, detection, natural history,
and treatment of PTSD. In particular, prospec-
tive studies of military cohorts that begin before

deployment and follow individuals for trauma
exposure and its sequelae will help to improve
our understanding of the epidemiology and detection of PTSD, while longitudinal registries of
PTSD patients will help to elucidate the most
effective treatment regimens and other factors
influencing recovery. Given the debilitating nature of the symptoms of PTSD and the seriousness of the associated medical conditions, additional research on PTSD should be an area of
high priority.
References
Afifi, T. O., Asmundson, G. J., Taylor, S., & Jang,
K. L. (2010). The role of genes and environment
on trauma exposure and posttraumatic stress disorder symptoms: A review of twin studies. Clinical Psychology Review, 30, 101112. doi:10.1016/
j.cpr.2009.10.002
Al-Turkait, F. A. & Ohaeri, J. U. (2008). Prevalence
and correlates of posttraumatic stress disorder
among Kuwaiti military men according to level of
involvement in the first Gulf War. Depression and
Anxiety, 25, 932941. doi:10.1002/da.20373
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.). Washington, DC: American Psychiatric Association.
Baker, D. G., Heppner, P., Afari, N., Nunnink, S.,
Kilmer, M., Simmons, A., . . . Bosse, B. (2009).
Trauma exposure, branch of service, and physical
injury in relation to mental health among U.S.
veterans returning from Iraq and Afghanistan. Military Medicine, 174, 773778.
Blanchard, E. B., Jones-Alexander, J., Buckley,
T. C., & Forneris, C. A. (1996). Psychometric
properties of the PTSD Checklist (PCL). Behaviour Research and Therapy, 34, 669 673. doi:
10.1016/0005-7967(96)00033-2
Bliese, P. D., Wright, K. M., Adler, A. B., Cabrera,
O., Castro, C. A., & Hoge, C. W. (2008). Validating the primary care posttraumatic stress disorder
screen and the posttraumatic stress disorder checklist with soldiers returning from combat. Journal
of Consulting and Clinical Psychology, 76, 272
281. doi:10.1037/0022-006X.76.2.272
Bliese, P. D., Wright, K. M., Adler, A. B., Thomas,
J. L., & Hoge, C. W. (2007). Timing of postcombat
mental health assessments. Psychological Services, 4, 141148. doi:10.1037/1541-1559.4.3.141
Bliese, P. D., Wright, K. M., Thomas, J. L., Adler,
A. B., & Hoge, C. W. (2004, December). Postdeployment mental health screening instruments:
How good are they? Paper presented at the Pro-
375
ceedings for the Army Science Conference (24th),

Orlando, FL. Retrieved November 5, 2010, from
http://www.dtic.mil/cgi-bin/GetTRDoc?AD
ADA433073&LocationU2&docGetTRDoc.pdf
Boscarino, J. A. (1995). Post-traumatic stress and
associated disorders among Vietnam veterans: The
significance of combat exposure and social support. Journal of Trauma Stress, 8, 317336. doi:
10.1002/jts.2490080211
Boscarino, J. A. (1997). Diseases among men 20
years after exposure to severe stress: Implications
for clinical research and medical care. Psychosomatic Medicine, 59, 605 614.
Boscarino, J. A. (2004). Posttraumatic stress disorder
and physical illness: Results from clinical and epidemiologic studies. Annals of the New York Academy of Sciences, 1032, 141153. doi:10.1196/annals
.1314.011
Brewin, C. R., Andrews, B., & Valentine, J. D.
(2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma exposed adults.
Journal of Consulting and Clinical Psychology, 68, 748 766. doi:10.1037/0022-006X.68
.5.748
Brewin, C. R. (2005). Systematic review of screening
instruments for adults at risk of PTSD. Journal of
Trauma Stress, 18, 53 62. doi:10.1002/jts.20007
Browne, T., Hull, L., Horn, O., Jones, M., Murphy,
D., Fear, N. T., . . . Hotopf, M. (2007). Explanations for the increase in mental health problems in
UK reserve forces who have served in Iraq. British
Journal of Psychiatry, 190, 484 489. doi:
10.1192/bjp.bp.106.030544
Bryant, R. A., Mastrodomenico, J., Felmingham,
K. L., Hopwood, S., Kenny, L., Kandris,
E., . . . Creamer, M. (2008). Treatment of acute
stress disorder: A randomized controlled trial. Archives of General Psychiatry, 65, 659 667. doi:
10.1001/archpsyc.65.6.659
Burkett, B. G., & Whitley, G. (1998). Stolen valor:
How the Vietnam generation was robbed of its
heroes and its history. Dallas, TX: Verity Press.
Butler, R. W., Braff, D. L., Rausch, J. L., Jenkins,
M. A., Sprock, J., & Geyer, M. A. (1990). Physiological evidence of exaggerated startle response
in a subgroup of Vietnam veterans with combatrelated PTSD. American Journal of Psychiatry,
147, 1308 1312.
Cabrera, O. A., Hoge, C. W., Bliese, P. D., Castro,
C. A., & Messer, S. C. (2007). Childhood adversity and combat as predictors of depression and
post-traumatic stress in deployed troops. American
Journal of Preventive Medicine, 33, 77 82. doi:
10.1016/j.amepre.2007.03.019
Carlson, E. B. (2001). Psychometric study of a brief
screen for PTSD: Assessing the impact of multiple
traumatic events. Assessment, 8, 431 441. doi:
10.1177/107319110100800408
376
Davidson, J. R., Book, S. W., Colket, J. T., Tupler, L. A.,

Roth, S., David, D., . . . Feldman, M. E. (1997). Assessment of a new self-rating scale for post-traumatic stress
disorder. Psychological Medicine, 27, 153160. doi:
10.1017/S0033291796004229
Department of National Defence (2002). The Canadian Forces 2002 supplement of the Statistics Canada Canadian Community Health Survey. Retrieved November 5, 2010, from http://www
.forces.gc.ca/health-sante/pub/rpt/mh-sm-eng.asp
Department of Veterans Affairs (2004). VA/DoD
clinical practice guideline for the management of
post-traumatic stress. Retrieved June 15, 2011,
from https://www.qmo.amedd.army.mil/ptsd/
CompleteGuideline.pdf
Department of Veterans Affairs (2009). Memorandum on implementation of posttraumatic stress
disorder (PTSD) outcome measure. Washington,
DC: Department of Veterans Affairs.
Department of Veterans Affairs (2011). National
center for PTSD. Retrieved June 15, 2011, from
http://www.ptsd.va.gov/professional/index.asp
Department of Veterans Affairs Office of Inspector
General. (2005). Review of state variances in VA
disability compensation payments, report no. 05
00765-137. Retrieved November 5, 2010, from
http://www4.va.gov/oig/52/reports/2005/vaoig05 00765-137.pdf
Dohrenwend, B. P., Turner, J. B., Turse, N. A.,
Adams, B. G., Koenen, K. C., & Marshall, R.
(2006). The psychological risks of Vietnam for
U.S. veterans: A revisit with new data and methods. Science, 313, 979 982. doi:10.1126/science
.1128944
Dohrenwend, B. P., Turner, J. B., Turse, N. A.,
Lewis-Fernandez, R., & Yager, T. J. (2008). Warrelated posttraumatic stress disorder in Black, Hispanic, and majority White Vietnam veterans: The
roles of exposure and vulnerability. Journal of
Trauma Stress, 21, 133141. doi:10.1002/jts
.20327
Duma, S. J., Reger, M. A., Canning, S. S., McNeil,
J. D., & Gahm, G. A. (2010). Longitudinal mental
health screening results among postdeployed U.S.
soldiers preparing to deploy again. Journal of
Trauma Stress, 23, 5258.
Dunn, A. S., Julian, T., Formolo, L. R., Green, B. N.,
& Chicoine, D. R. (2011). Preliminary analysis of
posttraumatic stress disorder screening within specialty clinic setting for OIF/OEF veterans seeking
care for neck or back pain. Journal of Rehabilitation Research and Development, 48, 493502. doi:
10.1682/JRRD.2010.05.0104
Eibner, C., Ringel, J. S., Kilmer, B., Pacula, R. L., &
Diaz, C. (2008). The cost of post-deployment mental health and cognitive conditions. In T. Tanielian
& L. H. Jaycox (Eds.), Invisible wounds of war:
Psychological and cognitive injuries, their conse-
quences, and services to assist recovery. Santa

Monica, CA: RAND Corporation.
Eisen, S. A., Griffith, K. H., Xian, H., Scherrer, J. F.,
Fischer, I. D., Chantarujikapong, S., . . . Tsuang,
M. T. (2004). Lifetime and 12-month prevalence
of psychiatric disorders in 8,169 male Vietnam
War era veterans. Military Medicine, 169, 896
902.
Elhai, J. D., Frueh, B. C., Davis, J. L., Jacobs, G. A.,
& Hamner, M. B. (2003). Clinical presentations in
combat veterans diagnosed with posttraumatic
stress disorder. Journal of Clinical Psychology, 59,
385397. doi:10.1002/jclp.10135
Fear, N. T., Jones, M., Murphy, D., Hull, L., Iversen,
A. C., Coker, B., . . . Wessely, S. (2010). What are
the consequences of deployment to Iraq and Afghanistan on the mental health of the UK armed
forces? A cohort study. Lancet, 375, 16951709.
doi:10.1016/S0140-6736(10)60672-1
Felker, B., Hawkins, E., Dobie, D., Gutierrez, J., &
McFall, M. (2008). Characteristics of deployed
Operation Iraqi Freedom military personnel who
seek mental health care. Military Medicine, 173,
155158.
Foa, E. B., Cashman, L., Jaycox, L., & Perry, K.
(1997). The validation of a self-report measure of
posttraumatic stress disorder: The Posttraumatic
Diagnostic Scale. Psychological Assessment, 9,
445 451. doi:10.1037/1040-3590.9.4.445
Frueh, B. C., Brady, K. L., & de Arellano, M. A.
(1998). Racial differences in combat-related
PTSD: Empirical findings and conceptual issues.
Clinical Psychology Review, 18, 287305. doi:
10.1016/S0272-7358(97)00087-1
Gahm, G. A., Lucenko, B. A., Retzlaff, P., & Fukuda,
S. (2007). Relative impact of adverse events and
screened symptoms of posttraumatic stress disorder and depression among active duty soldiers
seeking mental health care. Journal of Clinical
Psychology, 63, 199 211. doi:10.1002/jclp.20330
Gahm, G. A. & Lucenko, B. A. (2008). Screening
soldiers in outpatient care for mental health concerns. Military Medicine, 173, 1724.
Gale, C. R., Deary, I. J., Boyle, S. H., Barefoot, J.,
Mortensen, L. H., & Batty, G. D. (2008). Cognitive ability in early adulthood and risk of 5 specific
psychiatric disorders in middle age: The Vietnam
experience study. Archives of General Psychiatry, 65, 1410 1418. doi:10.1001/archpsyc.65
.12.1410
Goldberg, J., True, W. R., Eisen, S. A., & Henderson,
W. G. (1990). A twin study of the effects of the
Vietnam War on posttraumatic stress disorder. Journal of the American Medical Association, 263, 1227
1232. doi:10.1001/jama.1990.03440090061027
Gore, K. L., Engel, C. C., Freed, M. C., Liu, X., &
Armstrong, D. W., 3rd. (2008). Test of a single-item
posttraumatic stress disorder screener in a military
primary care setting. General Hospital Psychiatry, 30, 391397. doi:10.1016/j.genhosppsych.2008

.05.002
Gray, G. C., Reed, R. J., Kaiser, K. S., Smith, T. C.,
& Gastanaga, V. M. (2002). Self-reported symptoms and medical conditions among 11,868 Gulf
War-era veterans: The Seabee Health Study. American Journal of Epidemiology, 155, 10331044.
doi:10.1093/aje/155.11.1033
Hammarberg, M. (1992). Penn Inventory for posttraumatic stress disorder: Psychometric properties.
Psychological Assessment, 4, 6776. doi:10.1037/
1040-3590.4.1.67
Haskell, S. G., Gordon, K. S., Mattocks, K., Duggal,
M., Erdos, J., Justice, A., & Brandt, C. A. (2010).
Gender differences in rates of depression, PTSD,
pain, obesity, and military sexual trauma among
Connecticut War Veterans of Iraq and Afghanistan. Journal of Womens Health, 19, 267271.
doi:10.1089/jwh.2008.1262
Hearing before the Subcommittee on Health of the
House Committee on Veterans Affairs, 110th
Cong., 1st Sess. (2007). (Testimony of Jason Altmire). Retrieved November 5, 2010, from http://
veterans.house.gov/hearings/transcript.aspx?
newsid21.
Helzer, J. E., Robins, L. N., & McEvoy, L. (1987).
Post-traumatic stress disorder in the general population. Findings of the epidemiologic catchment area
survey. New England Journal of Medicine, 317,
1630 1634. doi:10.1056/NEJM198712243172604
Himmelfarb, N., Yaeger, D., & Mintz, J. (2006).
Posttraumatic stress disorder in female veterans
with military and civilian sexual trauma. Journal
of Trauma Stress, 19, 837 846. doi:10.1002/
jts.20163
Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S.
(2006). Mental health problems, use of mental
health services, and attrition from military service
after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association, 295, 10231032. doi:10.1001/jama.295
.9.1023
Hoge, C. W., Castro, C. A., Messer, S. C., McGurk,
D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health
problems, and barriers to care. New England Journal of Medicine, 351, 1322. doi:10.1056/
NEJMoa040603
Hoge, C. W. & Castro, C. A. (2006). Post-traumatic
stress disorder in UK and US forces deployed to
Iraq. Lancet, 368, 837; author reply 837. doi:
10.1016/S0140-6736(06)69315-X
Hoge, C. W., Terhakopian, A., Castro, C. A., Messer,
S. C., & Engel, C. C. (2007). Association of posttraumatic stress disorder with somatic symptoms,
health care visits, and absenteeism among Iraq war
377
veterans. American Journal of Psychiatry, 164,

150 153. doi:10.1176/appi.ajp.164.1.150
Holmes, D. T., Tariot, P. N., & Cox, C. (1998).
Preliminary evidence of psychological distress
among reservists in the Persian Gulf War. Journal
of Nervous and Mental Disease, 186, 166 173.
doi:10.1097/00005053-199803000-00005
Horowitz, M., Wilner, N., & Alvarez, W. (1979).
Impact of Event Scale: A measure of subjective
stress. Psychosomatic Medicine, 41, 209 218.
Hotopf, M., Hull, L., Fear, N. T., Browne, T., Horn,
O., Iversen, A., . . . Wessely, S. (2006). The health
of UK military personnel who deployed to the
2003 Iraq war: A cohort study. Lancet, 367, 1731
1741. doi:10.1016/S0140-6736(06)68662-5
Hovens, J. E., Bramsen, I., & van der Ploeg, H. M.
(2002). Self-rating inventory for posttraumatic
stress disorder: Review of the psychometric properties of a new brief Dutch screening instrument.
Perceptual and Motor Skills, 94, 996 1008. doi:
10.2466/pms.2002.94.3.996
Ikin, J. F., Sim, M. R., Creamer, M. C., Forbes, A. B.,
McKenzie, D. P., Kelsall, H. L., . . . Schwarz, H.
(2004). War-related psychological stressors and
risk of psychological disorders in Australian veterans of the 1991 Gulf War. British Journal of
Psychiatry, 185, 116 126. doi:10.1192/
bjp.185.2.116
Iversen, A. C., Fear, N. T., Ehlers, A., Hacker
Hughes, J., Hull, L., Earnshaw, M., . . . Hotopf, M.
(2008). Risk factors for post-traumatic stress disorder among UK Armed Forces personnel. Psychological Medicine, 38, 511522. doi:10.1017/
S0033291708002778
Iversen, A. C., van Staden, L., Hughes, J. H.,
Browne, T., Hull, L., Hall, J., . . . Fear, N. T.
(2009). The prevalence of common mental disorders and PTSD in the UK military: Using data
from a clinical interview-based study. BMC Psychiatry, 9, 68. doi:10.1186/1471-244X-9-68
Jakupcak, M., Cook, J., Imel, Z., Fontana, A., Rosenheck, R., & McFall, M. (2009). Posttraumatic
stress disorder as a risk factor for suicidal ideation
in Iraq and Afghanistan War veterans. Journal of
Trauma Stress, 22, 303306. doi:10.1002/jts
.20423
Johnson, D. R., Lubin, H., Rosenheck, R., Fontana,
A., Southwick, S., & Charney, D. (1997). The
impact of the homecoming reception on the development of posttraumatic stress disorder. The West
Haven Homecoming Stress Scale (WHHSS). Journal of Trauma Stress, 10, 259 277. doi:10.1002/
jts.2490100207
Jones, M., Rona, R. J., Hooper, R., & Wesseley, S.
(2006). The burden of psychological symptoms in
UK Armed Forces. Occupational Medicine (Oxford, England), 56, 322328. doi:10.1093/occmed/
kql023
378
Jordan, B. K., Marmar, C. R., Fairbank, J. A., Schlenger, W. E., Kulka, R. A., Hough, R. L., &
Weiss, D. S. (1992). Problems in families of male
Vietnam veterans with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology,
60,
916 926.
doi:10.1037/0022006X.60.6.916
Kang, H., Dalager, N., Mahan, C., & Ishii, E. (2005).
The role of sexual assault on the risk of PTSD
among Gulf War veterans. Annals of epidemiology, 15, 191195. doi:10.1016/j.annepidem
.2004.05.009
Kang, H. K., Li, B., Mahan, C. M., Eisen, S. A., &
Engel, C. C. (2009). Health of US veterans of 1991
Gulf War: A follow-up survey in 10 years. Journal
of Occupational and Environmental Medicine, 51,
401 410. doi:10.1097/JOM.0b013e3181a2feeb
Kang, H. K., Natelson, B. H., Mahan, C. M., Lee,
K. Y., & Murphy, F. M. (2003). Post-traumatic
stress disorder and chronic fatigue syndrome-like
illness among Gulf War veterans: A populationbased survey of 30,000 veterans. American Journal of Epidemiology, 157, 141148. doi:10.1093/
aje/kwf187
Karlin, B. E., Ruzek, J. I., Chard, K. M., Eftekhari,
A., Monson, C. M., Hembree, E. A., . . . Foa, E. B.
(2010). Dissemination of evidence-based psychological treatments for posttraumatic stress disorder
in the Veterans Health Administration. Journal of
Trauma Stress, 23, 663 673. doi:10.1002/
jts.20588
Keane, T. M., Caddell, J. M., & Taylor, K. L. (1988).
Mississippi Scale for Combat-Related Posttraumatic Stress Disorder: Three studies in reliability
and validity. Journal of Consulting and Clinical
Psychology, 56, 8590. doi:10.1037/0022006X.56.1.85
Keane, T. M., Marshall, A. D., & Taft, C. T. (2006).
Posttraumatic stress disorder: Etiology, epidemiology and treatment outcome. Annual Review of
Clinical Psychology, 2, 161197. doi:10.1146/
annurev.clinpsy.2.022305.095305
Keane, T. M., Marx, B. P., & Sloan, D. M. (2009).
Post-traumatic stress disorder: Definition, prevalence, and risk factors. In P. J. Shiromani, T. M.
Keane & J. E. LeDoux (Eds.), Post-traumatic
stress disorder: Basic science and clinical practice.
New York, NY: Humana Press. doi:10.1007/9781-60327-329-9_1
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M.,
& Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048 1060. doi:
10.1001/archpsyc.1995.03950240066012
Kimerling, R., Gima, K., Smith, M. W., Street, A., &
Frayne, S. (2007). The Veterans Health Administration and military sexual trauma. American Jour-
nal of Public Health, 97, 2160 2166. doi:10.2105/

AJPH.2006.092999
Kimerling, R., Street, A. E., Gima, K., & Smith,
M. W. (2008). Evaluation of universal screening
for military-related sexual trauma. Psychiatric Services (Washington, D.C.), 59, 635 640. doi:
10.1176/appi.ps.59.6.635
King, D. W., King, L. A., Foy, D. W., & Gudanowski, D. M. (1996). Prewar factors in combatrelated 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. doi:
10.1037/0022-006X.64.3.520
King, D. W., King, L. A., Foy, D. W., Keane, T. M.,
& Fairbank, J. A. (1999). Posttraumatic stress disorder in a national sample of female and male
Vietnam veterans: Risk factors, war-zone stressors, and resilience-recovery variables. Journal of
Abnormal Psychology, 108, 164 170. doi:
10.1037/0021-843X.108.1.164
King, L. A., King, S. W., Fairbank, J. A., Keane,
T. M., & Adams, G. A. (1998). Resiliencerecovery factors in post-traumatic stress disorder
among female and male Vietnam veterans: Hardiness, postwar social support and additional stressful life events. Journal of Personality and Social
Psychology, 74, 420 434. doi:10.1037/00223514.74.2.420
Kline, A., Falca-Dodson, M., Sussner, B., Ciccone,
D. S., Chandler, H., Callahan, L., & Losonczy, M.
(2010). Effects of repeated deployment to Iraq and
Afghanistan on the health of New Jersey Army
National Guard troops: Implications for military
readiness. American Journal of Public Health,
100, 276 283. doi:10.2105/AJPH.2009.162925
Koenen, K. C., Fu, Q. J., Lyons, M. J., Toomey, R.,
Goldberg, J., Eisen, S. A., . . . Tsuang, M. (2005).
Juvenile conduct disorder as a risk factor for
trauma exposure and posttraumatic stress disorder.
Journal of Trauma Stress, 18, 2332. doi:10.1002/
jts.20010
Koenen, K. C., Stellman, J. M., Stellman, S. D., &
Sommer, J. F., Jr. (2003). Risk factors for course
of posttraumatic stress disorder among Vietnam
veterans: A 14-year follow-up of American Legionnaires. Journal of Consulting and Clinical
Psychology, 71, 980 986. doi:10.1037/0022006X.71.6.980
Koenen, K. C. (2007). Genetics of posttraumatic
stress disorder: Review and recommendations for
future studies. Journal of Trauma Stress, 20, 737
750. doi:10.1002/jts.20205
Koren, D., Norman, D., Cohen, A., Berman, J., &
Klein, E. M. (2005). Increased PTSD risk with
combat-related injury: A matched comparison
study of injured and uninjured soldiers experiencing the same combat events. American Journal of
Psychiatry, 162, 276 282. doi:10.1176/appi

.ajp.162.2.276
Kubzansky, L. D., Koenen, K. C., Spiro, A., 3rd,
Vokonas, P. S., & Sparrow, D. (2007). Prospective
study of posttraumatic stress disorder symptoms
and coronary heart disease in the Normative Aging
Study. Archives of General Psychiatry, 64, 109
116. doi:10.1001/archpsyc.64.1.109
Kulka, R. A., Schlenger, W. E., Fairbank, J. A.,
Hough, R. L., Jordan, B. K., Marmar, C. R., &
Weiss, D. S. (1990). Trauma and the Vietnam War
generation: Report of findings from the National
Vietnam Veterans Readjustment Study. New York,
NY: Brunner/Mazel.
Lang, A. J. & Stein, M. B. (2005). An abbreviated
PTSD checklist for use as a screening instrument
in primary care. Behaviour Research and Therapy, 43, 585594. doi:10.1016/j.brat.2004.04.005
Lee, H. A., Gabriel, R., Bolton, J. P., Bale, A. J., &
Jackson, M. (2002). Health status and clinical diagnoses of 3000 UK Gulf War veterans. Journal of
the Royal Society of Medicine, 95, 491 497. doi:
10.1258/jrsm.95.10.491
Lew, H. L., Otis, J. D., Tun, C., Kerns, R. D., Clark,
M. E., & Cifu, D. X. (2009). Prevalence of chronic
pain, posttraumatic stress disorder, and persistent
postconcussive symptoms in OIF/OEF veterans:
Polytrauma clinical triad. Journal of Rehabilitation Research and Development, 46, 697702. doi:
10.1682/JRRD.2009.01.0006
Long, N., MacDonald, C., & Chamberlain, K. (1996).
Prevalence of posttraumatic stress disorder, depression and anxiety in a community sample of New
Zealand Vietnam War veterans. Australian and New
Zealand Journal of Psychiatry, 30, 253256. doi:
10.3109/00048679609076102
Loo, C. M., Fairbank, J. A., & Chemtob, C. M.
(2005). Adverse race-related events as a risk factor
for posttraumatic stress disorder in Asian American Vietnam veterans. Journal of Nervous and
Mental Disease, 193, 455 463. doi:10.1097/
01.nmd.0000168239.51714.e6
MacGregor, A. J., Corson, K. S., Larson, G. E., Shaffer,
R. A., Dougherty, A. L., Galarneau, M. R., . . . Golomb,
B. A. (2009). Injury-specific predictors of posttraumatic
stress disorder. Injury, 40, 10041010. doi:10.1016/
j.injury.2009.04.006
Maguen, S., Lucenko, B. A., Reger, M. A., Gahm,
G. A., Litz, B. T., Seal, K. H., . . . Marmar, C. R.
(2010). The impact of reported direct and indirect
killing on mental health symptoms in Iraq war
veterans. Journal of Trauma Stress, 23, 86 90.
Marx, B. P., Foley, K. M., Feinstein, B. A., Wolf,
E. J., Kaloupek, D. G., & Keane, T. M. (2010).
Combat-related guilt mediates the relations between exposure to combat-related abusive violence
and psychiatric diagnoses. Depression and Anxiety, 27, 287293. doi:10.1002/da.20659
379
Marx, B. P., Humphreys, K. L., Weathers, F. W., Martin,

E. K., Sloan, D. M., Grove, W. M., . . . Keane, T. M.
(2008). Development and initial validation of a statistical prediction instrument for assessing combat-related
posttraumatic stress disorder. Journal of Nervous and
Mental Disease, 196, 605 611. doi:10.1097/
NMD.0b013e318181326d
McCarroll, J. E., Ursano, R. J., Fullerton, C. S., Liu,
X., & Lundy, A. (2001). Effects of exposure to
death in a war mortuary on posttraumatic stress
disorder symptoms of intrusion and avoidance.
Journal of Nervous and Mental Disease, 189, 44
48. doi:10.1097/00005053-200101000-00008
McDonald, S. D., Beckham, J. C., Morey, R. A., &
Calhoun, P. S. (2009). The validity and diagnostic
efficiency of the Davidson Trauma Scale in military veterans who have served since September
11th, 2001. Journal of Anxiety Disorders, 23, 247
255. doi:10.1016/j.janxdis.2008.07.007
McHugh, P. R. & Treisman, G. (2007). PTSD: A
problematic diagnostic category. Journal of Anxiety
Disorders, 21, 211222. doi:10.1016/j.janxdis
.2006.09.003
McNally, R. J. (2006). Psychology. Psychiatric casualties of war. Science, 313, 923924. doi:10.1126/
science.1132242
McNally, R. J. (2007). Can we solve the mysteries of
the National Vietnam Veterans Readjustment
Study? Journal of Anxiety Disorders, 21, 192200.
doi:10.1016/j.janxdis.2006.09.005
Meltzer-Brody, S., Churchill, E., & Davidson, J. R.
(1999). Derivation of the SPAN, a brief diagnostic
screening test for post-traumatic stress disorder.
Psychiatry Research, 88, 6370. doi:10.1016/
S0165-1781(99)00070-0
Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W.
(2007). Longitudinal assessment of mental health
problems among active and reserve component
soldiers returning from the Iraq war. Journal of the
American Medical Association, 298, 21412148.
doi:10.1001/jama.298.18.2141
Morgan, C. A., 3rd, Grillon, C., Southwick, S. M.,
Davis, M., & Charney, D. S. (1996). Exaggerated
acoustic startle reflex in Gulf War veterans with
posttraumatic stress disorder. American Journal of
Psychiatry, 153, 64 68.
Mulligan, K., Jones, N., Woodhead, C., Davies, M.,
Wessely, S., & Greenberg, N. (2010). Mental
health of UK military personnel while on deployment in Iraq. British Journal of Psychiatry, 197,
405 410. doi:10.1192/bjp.bp.110.077263
Mustapic, M., Pivac, N., Kozaric-Kovacic, D.,
Dezeljin, M., Cubells, J. F., & Muck-Seler, D.
(2007). Dopamine beta-hydroxylase (DBH) activity and 1021C/T polymorphism of DBH gene in
combat-related post-traumatic stress disorder.
American Journal of Medical Genetics. Part B,
Neuropsychiatric Genetics: The Official Publica-
380
tion of the International Society of Psychiatric

Genetics, 144B, 10871089. doi:10.1002/
ajmg.b.30526
Nasky, K. M., Hines, N. N., & Simmer, E. (2009).
The USS Cole bombing: Analysis of pre-existing
factors as predictors for development of posttraumatic stress or depressive disorders. Military
Medicine, 174, 689 694.
Neal, L. A., Busuttil, W., Rollins, J., Herepath, R.,
Strike, P., & Turnbull, G. (1994). Convergent validity of measures of post-traumatic stress disorder
in a mixed military and civilian population. Journal of Trauma Stress, 7, 447 455. doi:10.1002/
jts.2490070310
Nugent, N. R., Amstadter, A. B., & Koenen, K. C.
(2008). Genetics of post-traumatic stress disorder:
Informing clinical conceptualizations and promoting future research. American Journal of Medical
Genetics. Part C, Seminars in Medical Genetics,
148C, 127132. doi:10.1002/ajmg.c.30169
ODonnell, M. L., Bryant, R. A., Creamer, M., &
Carty, J. (2008). Mental health following traumatic
injury: Toward a health system model of early
psychological intervention. Clinical Psychology
Review, 28, 387 406. doi:10.1016/j.cpr.2007
.07.008
ODonnell, M. L., Creamer, M. C., Parslow, R.,
Elliott, P., Holmes, A. C., Ellen, S., . . . Bryant,
R. A. (2008). A predictive screening index for
posttraumatic stress disorder and depression following traumatic injury. Journal of Consulting and
Clinical Psychology, 76, 923932. doi:10.1037/
a0012918
Orr, S. P., Lasko, N. B., Shalev, A. Y., & Pitman,
R. K. (1995). Physiologic responses to loud tones
in Vietnam veterans with posttraumatic stress disorder. Journal of Abnormal Psychology, 104, 75
82. doi:10.1037/0021-843X.104.1.75
OToole, B. I., Catts, S. V., Outram, S., Pierse, K. R.,
& Cockburn, J. (2009). The physical and mental
health of Australian Vietnam veterans 3 decades
after the war and its relation to military service,
combat, and post-traumatic stress disorder. American Journal of Epidemiology, 170, 318 330. doi:
10.1093/aje/kwp146
OToole, B. I., Marshall, R. P., Grayson, D. A.,
Schureck, R. J., Dobson, M., French, M., . . . Vennard, J. (1996). The Australian Vietnam Veterans
Health Study: III. psychological health of Australian Vietnam veterans and its relationship to combat. International Journal of Epidemiology, 25,
331340. doi:10.1093/ije/25.2.331
Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S.
(2003). Predictors of posttraumatic stress disorder
and symptoms in adults: A meta-analysis. Psychological Bulletin, 129, 5273. doi:10.1037/00332909.129.1.52
Perconte, S. T., Wilson, A. T., Pontius, E. B., Dietrick, A. L., & Spiro, K. J. (1993). Psychological
and war stress symptoms among deployed and
non-deployed reservists following the Persian Gulf
War. Military Medicine, 158, 516 521.
Pierce, P. F. (1997). Physical and emotional health of
Gulf War veteran women. Aviation, Space, and
Environmental Medicine, 68, 317321.
Pietrzak, R. H., Goldstein, M. B., Malley, J. C.,
Rivers, A. J., Johnson, D. C., & Southwick, S. M.
(2010). Risk and protective factors associated with
suicidal ideation in veterans of Operations Enduring Freedom and Iraqi Freedom. Journal of Affective Disorders, 123, 102107
Pietrzak, R. H., Johnson, D. C., Goldstein, M. B.,
Malley, J. C., Rivers, A. J., Morgan, C. A., &
Southwick, S. M. (2010). Psychosocial buffers of
traumatic stress, depressive symptoms, and psychosocial difficulties in veterans of Operations Enduring Freedom and Iraqi Freedom: The role of
resilience, unit support, and postdeployment social
support. Journal of Affective Disorders, 120, 188
192. doi:10.1016/j.jad.2009.04.015
Pietrzak, R. H., Johnson, D. C., Goldstein, M. B.,
Malley, J. C., & Southwick, S. M. (2009). Psychological resilience and postdeployment social support protect against traumatic stress and depressive
symptoms in soldiers returning from Operations
Enduring Freedom and Iraqi Freedom. Depression
and Anxiety, 26, 745751. doi:10.1002/da.20558
Prins, A., Ouimette, P., Kimerling, R., Cameron,
R. P., Hugelshofer, D. S., Shaw-Hegwer,
J., . . . Sheikh, J. I. (2003). The primary care
PTSD screen (PC-PTSD): development and operating characteristics. Primary Care Psychiatry, 9, 9 14. doi:10.1185/135525703125002360
Proctor, S. P., Heeren, T., White, R. F., Wolfe, J.,
Borgos, M. S., Davis, J. D., . . . Ozonoff, D.
(1998). Health status of Persian Gulf War veterans:
Self-reported symptoms, environmental exposures
and the effect of stress. International Journal of
Epidemiology, 27, 1000 1010. doi:10.1093/ije/
27.6.1000
Ramchand, R., Schell, T. L., Karney, B. R., Osilla,
K. C., Burns, R. M., & Caldarone, L. B. (2010).
Disparate prevalence estimates of PTSD among
service members who served in Iraq and Afghanistan: Possible explanations. Journal of Trauma
Stress, 23, 59 68.
Richardson, L. K., Frueh, B. C., & Acierno, R.
(2010). Prevalence estimates of combat-related
post-traumatic stress disorder: Critical review.
Australian and New Zealand Journal of Psychiatry, 44, 4 19. doi:10.3109/00048670903393597
Rona, R. J., Hooper, R., Jones, M., Hull, L., Browne,
T., Horn, O., . . . Wessely, S. (2006). Mental
health screening in armed forces before the Iraq
war and prevention of subsequent psychological
morbidity: Follow-up study. British Medical Journal, 333, 991. doi:10.1136/bmj.38985.610949.55

Rona, R. J., Hooper, R., Jones, M., Iversen, A. C.,
Hull, L., Murphy, D., . . . Wessely, S. (2009). The
contribution of prior psychological symptoms and
combat exposure to post Iraq deployment mental
health in the UK military. Journal of Trauma
Stress, 22, 1119. doi:10.1002/jts.20383
Rona, R. J., Hyams, K. C., & Wessely, S. (2005).
Screening for psychological illness in military personnel. Journal of the American Medical Association, 293, 12571260. doi:10.1001/jama.293
.10.1257
Rona, R. J., Jones, M., French, C., Hooper, R., &
Wessely, S. (2004). Screening for physical and
psychological illness in the British Armed Forces:
I: The acceptability of the programme. Journal of
Medical Screening, 11, 148 152. doi:10.1258/
0969141041732193
Sayer, N. A., Friedemann-Sanchez, G., Spoont, M., Murdoch, M., Parker, L. E., Chiros, C., & Rosenheck, R.
(2009). A qualitative study of determinants of PTSD
treatment initiation in veterans. Psychiatry, 72, 238
255. doi:10.1521/psyc.2009.72.3.238
Schnurr, P. P., Lunney, C. A., & Sengupta, A. (2004).
Risk factors for the development versus maintenance of posttraumatic stress disorder. Journal of
Trauma Stress, 17, 8595. doi:10.1023/B:
JOTS.0000022614.21794.f4
Seal, K. H., Bertenthal, D., Maguen, S., Gima, K.,
Chu, A., & Marmar, C. R. (2008). Getting beyond
Dont ask; dont tell: an evaluation of US Veterans Administration postdeployment mental
health screening of veterans returning from Iraq
and Afghanistan. American Journal of Public
Health, 98, 714 720. doi:10.2105/AJPH.2007
.115519
Seal, K. H., Bertenthal, D., Miner, C. R., Sen, S., &
Marmar, C. (2007). Bringing the war back home:
Mental health disorders among 103 788 US veterans returning from Iraq and Afghanistan seen at
Department of Veterans Affairs facilities. Archives
of Internal Medicine, 167, 476 482. doi:10.1001/
archinte.167.5.476
Seal, K. H., Metzler, T. J., Gima, K. S., Bertenthal,
D., Maguen, S., & Marmar, C. R. (2009). Trends
and risk factors for mental health diagnoses among
Iraq and Afghanistan veterans using Department of
Veterans Affairs health care, 20022008. American Journal of Public Health, 99, 16511658. doi:
10.2105/AJPH.2008.150284
Smith, M. W., Schnurr, P. P., & Rosenheck, R. A.
(2005). Employment outcomes and PTSD symptom severity. Mental Health Services Research, 7,
89 101. doi:10.1007/s11020-005-3780-2
Smith, T. C., Ryan, M. A., Wingard, D. L., Slymen, D. J.,
Sallis, J. F., & Kritz-Silverstein, D. (2008). New onset
and persistent symptoms of post-traumatic stress disor-
381
der self reported after deployment and combat exposures: Prospective population based US military cohort
study. British Medical Journal, 336, 366371. doi:
10.1136/bmj.39430.638241.AE
Street, A. E., Vogt, D., & Dutra, L. (2009). A new
generation of women veterans: Stressors faced by
women deployed to Iraq and Afghanistan. Clinical
Psychology Review, 29, 685 694. doi:10.1016/
j.cpr.2009.08.007
Stretch, R. H., Marlowe, D. H., Wright, K. M.,
Bliese, P. D., Knudson, K. H., & Hoover, C. H.
(1996). Post-traumatic stress disorder symptoms
among Gulf War veterans. Military Medicine, 161,
407 410.
Stretch, R. H. (1985). Posttraumatic stress disorder
among U.S. Army Reserve Vietnam and Vietnamera veterans. Journal of Consulting and Clinical
Psychology, 53, 935936. doi:10.1037/0022006X.53.6.935
Sundin, J., Fear, N. T., Iversen, A., Rona, R. J., &
Wessely, S. (2010). PTSD after deployment to
Iraq: Conflicting rates, conflicting claims. Psychological Medicine, 40, 367382. doi:10.1017/
S0033291709990791
Suris, A. & Lind, L. (2008). Military sexual trauma: A
review of prevalence and associated health consequences in veterans. Trauma, Violence & Abuse, 9,
250 269. doi:10.1177/1524838008324419
Tan, G., Dao, T. K., Farmer, L., Sutherland, R. J., &
Gevirtz, R. (2011). Heart rate variability (HRV)
and posttraumatic stress disorder (PTSD): a pilot
study. Applied Psychophysiology and Biofeedback, 36, 2735. doi:10.1007/s10484-010-9141-y
Tan, G., Fink, B., Dao, T. K., Hebert, R., Farmer, L. S.,
Sanders, A., . . . Gevirtz, R. (2009). Associations among
pain, PTSD, mTBI, and heart rate variability in veterans
of Operation Enduring and Iraqi Freedom: A pilot
study. Pain Medicine, 10, 12371245. doi:10.1111/
j.1526-4637.2009.00712.x
Tanielian, T., & Jaycox, L. H. (Eds.). (2008). Invisible Wounds of War: Psychological and cognitive
injuries, their consequences, and services to assist
recovery. Santa Monica, CA: RAND Corporation.
The Iowa Persian Gulf Study Group. (1997). Selfreported illness and health status among Gulf War
veterans. A population-based study. Journal of the
American Medical Association, 277, 238 245.
doi:10.1001/jama.1997.03540270064028
Toomey, R., Kang, H. K., Karlinsky, J., Baker, D. G.,
Vasterling, J. J., Alpern, R., . . . Eisen, S. A.
(2007). Mental health of US Gulf War veterans 10
years after the war. British Journal of Psychiatry,
190, 385393. doi:10.1192/bjp.bp.105.019539
True, W. R., Rice, J., Eisen, S. A., Heath, A. C.,
Goldberg, J., Lyons, M. J., & Nowak, J. (1993). A
twin study of genetic and environmental contributions to liability for posttraumatic stress symp-
382
toms. Archives of General Psychiatry, 50, 257

264. doi:10.1001/archpsyc.1993.01820160019002
Unwin, C., Blatchley, N., Coker, W., Ferry, S., Hotopf, M., Hull, L., . . . Wessely, S. (1999). Health
of UK servicemen who served in Persian Gulf
War. Lancet, 353, 169 178. doi:10.1016/S01406736(98)11338-7
U.S. Department of Defense Deployment Health
Clinical Center. Enhanced post-deployment health
assessment (PDHA) process (DD Form 2796). Retrieved November 5, 2010, from http://www
.pdhealth.mil/dcs/dd_form_2796.asp
Valente, S. & Wight, C. (2007). Military sexual trauma: Violence and sexual abuse. Military Medicine,
172, 259 265.
Vasterling, J. J., Proctor, S. P., Amoroso, P., Kane,
R., Heeren, T., & White, R. F. (2006). Neuropsychological outcomes of Army personnel following
deployment to the Iraq war. Journal of the American Medical Association, 296, 519 529. doi:
10.1001/jama.296.5.519
Vasterling, J. J., Proctor, S. P., Friedman, M. J.,
Hoge, C. W., Heeren, T., King, L. A., & King,
D. W. (2010). PTSD symptom increases in Iraqdeployed soldiers: Comparison with nondeployed
soldiers and associations with baseline symptoms,
deployment experiences, and postdeployment
stress. Journal of Trauma Stress, 23, 4151.
Veterans Health Administration (2004). VHA Directive 2004 015: Implementation of the new national clinical reminder, the Afghan and Iraq
Post-deployment Screen. Washington, DC: Department of Veterans Affairs.
Vogt, D. S., Pless, A. P., King, L. A., & King, D. W.
(2005). Deployment stressors, gender, and mental
health outcomes among Gulf War I veterans. Journal of Trauma Stress, 18, 115127. doi:10.1002/
jts.20018
Voisey, J., Swagell, C. D., Hughes, I. P., Morris,
C. P., van Daal, A., Noble, E. P., . . . Lawford,
B. R. (2009). The DRD2 gene 957CT polymorphism is associated with posttraumatic stress disorder in war veterans. Depression and Anxiety, 26,
28 33. doi:10.1002/da.20517
Warner, J. (2004). Clinicians guide to evaluating
diagnostic and screening tests in psychiatry. Advances in Psychiatric Treatment, 10, 446 454.
doi:10.1192/apt.10.6.446
Weathers, F. W., Keane, T. M., & Foa, E. B. (2009).

Assessment and diagnosis of adults. In E. B. Foa,
T. M. Keane, M. J. Friedman & J. A. Cohen (Eds.),
Effective treatments for PTSD: Practice guidelines
from the International Society for Traumatic Stress
Studies (2nd ed., pp. 23 61). New York, NY: The
Guilford Press.
Weathers, F. W., Litz, B. T., Herman, D. S., Huska,
J. A., & Keane, T. M. (1993). The PTSD Checklist
(PCL): Reliability, validity, and diagnostic utility.
Paper presented at the Annual Meeting of the
International Society for Traumatic Stress Studies.
Weathers, F. W., Litz, B. T., Keane, T. M., Herman,
D. S., Steinberg, H. R., Huska, J. A., & Kraemer,
H. C. (1996). The utility of the SCL-90-R for the
diagnosis of war-zone related posttraumatic stress
disorder. Journal of Trauma Stress, 9, 111128.
doi:10.1002/jts.2490090110
Wolfe, J., Erickson, D. J., Sharkansky, E. J., King,
D. W., & King, L. A. (1999). Course and predictors of posttraumatic stress disorder among Gulf
War veterans: A prospective analysis. Journal of
Consulting and Clinical Psychology, 67, 520 528.
doi:10.1037/0022-006X.67.4.520
Wright, K. M., Bliese, P. D., Thomas, J. L., Adler,
A. B., Eckford, R. D., & Hoge, C. W. (2007).
Contrasting approaches to psychological screening
with U.S. combat soldiers. Journal of Trauma
Stress, 20, 965975. doi:10.1002/jts.20279
Yeager, D. E., Magruder, K. M., Knapp, R. G.,
Nicholas, J. S., & Frueh, B. C. (2007). Performance characteristics of the posttraumatic stress
disorder checklist and SPAN in Veterans Affairs
primary care settings. General Hospital Psychiatry, 29, 294 301. doi:10.1016/j.genhosppsych
.2007.03.004
Young, A. (1995). Reasons and causes for posttraumatic stress disorder. Transcultural Psychiatric Research Review, 32, 287298. doi:10.1177/
136346159503200303
Zohar, J., Fostick, L., Cohen, A., Bleich, A., Dolfin,
D., Weissman, Z., . . . Shalev, A. Y. (2009). Risk
factors for the development of posttraumatic stress
disorder following combat trauma: A semiprospective study. Journal of Clinical Psychiatry, 70,
1629 1635. doi:10.4088/JCP.08m04378blu
Received December 17, 2010
Revision received December 7, 2011
Accepted December 29, 2011

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Psychological Services

2012, Vol. 9, No. 4, 361382

In the public domain

Posttraumatic Stress Disorder in Veterans and Military Personnel:

New England Research Institutes, Inc., Watertown,

VA Boston Healthcare System, Boston,

Posttraumatic stress disorder (PTSD) is a

This article was published Online First March 5, 2012.

GATES, HOLOWKA, VASTERLING, KEANE, MARX, AND ROSEN

Rona, & Wessely, 2010; Young, 1995), in part

often occurs in combination with persistent

PTSD IN VETERANS AND MILITARY PERSONNEL

for clinicians and researchers, as well as to

Kaiser, Smith, & Gastanaga, 2002; Holmes,

GATES, HOLOWKA, VASTERLING, KEANE, MARX, AND ROSEN

these results, the authors estimated that 226,000

PTSD IN VETERANS AND MILITARY PERSONNEL

2007; Fear et al., 2010; Hotopf et al., 2006;

GATES, HOLOWKA, VASTERLING, KEANE, MARX, AND ROSEN

Childhood abuse or adversity

(Brewin et al., 2000; Cabrera et al., 2007; Gahm et al.,

(Brewin et al., 2000; Ozer et al., 2003)

Perceived life threat

Exposure to death, killing, or

Peritraumatic distress or dissociation

Weak effect (), intermediate effect (), or strong effect ().

velopment of military-related PTSD (Brewin,

PTSD IN VETERANS AND MILITARY PERSONNEL

2000; King, King, Foy, Keane, & Fairbank,

viewed in Koenen, 2007; Nugent et al., 2008).

GATES, HOLOWKA, VASTERLING, KEANE, MARX, AND ROSEN

whether additional evaluation is needed, and

ment to Iraq, Bliese et al. reported a sensitivity

PTSD IN VETERANS AND MILITARY PERSONNEL

initiated early but that the number of cases

Mississippi PTSD Scale (Keane et al.,

Single Item PTSD Screen (SIPS) (Gore et

War-Zone Related PTSD Scale (WZ-PTSD)

Startle, Physiological arousal, Anger, and

Impact of Event Scale (IES) (Horowitz et

Davidson Trauma Scale (DTS) (Davidson et

Primary Care Posttraumatic Stress Disorder

PTSD Checklist (PCL) (Blanchard et al.,

Rate frequency of symptoms over the

Rate how much specific problems have

Item structure and description

Optimally efficient at 6, optimally

Twelve items that significantly predict

PTSD Statistical Prediction Instrument

Item structure and description

PTSD IN VETERANS AND MILITARY PERSONNEL

toms during the past month, using a scale

GATES, HOLOWKA, VASTERLING, KEANE, MARX, AND ROSEN

a cutoff score of 32 resulted in a sensitivity

2007). Given the scope of the problem, specific

PTSD IN VETERANS AND MILITARY PERSONNEL

GATES, HOLOWKA, VASTERLING, KEANE, MARX, AND ROSEN

as well as monitoring and follow-up of patients