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Does trauma-focused exposure therapy exacerbate symptoms among patients with comorbid PTSD and substance use disorders?

Published online by Cambridge University Press:  23 April 2019

Cynthia L. Lancaster ,
Daniel F. Gros ,
Michael C. Mullarkey ,
Christal L. Badour ,
Therese K. Killeen ,
Kathleen T. Brady  and
Sudie E. Back
Cynthia L. Lancaster*
Affiliation:
Department of Psychology, University of Nevada Reno, Reno, NV, USA
Daniel F. Gros
Affiliation:
Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA Mental Health Service, Ralph H. Johnson Veteran’s Affairs Medical Center, Charleston, SC, USA
Michael C. Mullarkey
Affiliation:
Department of Psychology, University of Texas, Austin, TX, USA
Christal L. Badour
Affiliation:
Department of Psychology, University of Kentucky, Lexington, KY, USA
Therese K. Killeen
Affiliation:
Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
Kathleen T. Brady
Affiliation:
Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
Sudie E. Back
Affiliation:
Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA Mental Health Service, Ralph H. Johnson Veteran’s Affairs Medical Center, Charleston, SC, USA
*
*Corresponding author. Email: cynthialancaster@unr.edu
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Abstract

Background: Although exposure-based therapy is a well-established, effective treatment for post-traumatic stress disorder (PTSD), some practitioners report reluctance to implement it due to concerns that it may exacerbate symptoms of PTSD and commonly comorbid disorders, such as substance use disorders (SUD).

Aim: This study compared the exacerbation of psychological symptoms among participants with comorbid PTSD and SUD who received either SUD treatment alone or SUD treatment integrated with exposure therapy for PTSD.

Method: Participants (N = 71) were treatment-seeking, military Veterans with comorbid PTSD and SUD who were randomized to 12 individual sessions of either (1) an integrated, exposure-based treatment (Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure; COPE); or (2) a non-exposure-based, SUD-only treatment (Relapse Prevention; RP). We examined between-group differences in the frequency of statistically reliable exacerbations of PTSD, SUD and depression symptoms experienced during treatment.

Results: At each of the 12 sessions, symptom exacerbation was minimal and generally equally likely in either treatment group. However, an analysis of treatment completers suggests that RP participants experienced slightly more exacerbations of PTSD symptoms during the course of treatment.

Conclusions: This study is the first to investigate symptom exacerbation throughout trauma-focused exposure therapy for individuals with comorbid PTSD and SUD. Results add to a growing literature which suggests that trauma-focused, exposure-based therapy does not increase the risk of symptom exacerbation relative to non-exposure-based therapy.

Keywords

combined treatmentdepressionpost-traumatic stress disordersubstance usetherapy outcomeVeteran
Type
Main
Information
Behavioural and Cognitive Psychotherapy , Volume 48 , Issue 1 , January 2020 , pp. 38 - 53
Copyright
© British Association for Behavioural and Cognitive Psychotherapies 2019 

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References

Adkins, J. W., Weathers, F. W., McDevitt-Murphy, M., & Daniels, J. B. (2008). Psychometric properties of seven self-report measures of posttraumatic stress disorder in college students with mixed civilian trauma exposure. Journal of Anxiety Disorders, 22, 1393–1402. doi: 10.1016/j.janxdis.2008.02.002 CrossRefGoogle ScholarPubMed
American Psychiatric Association (APA) (2000). Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. Washington, DC: American Psychiatric Association.Google Scholar
Back, S. E., Foa, E. B., Killeen, T. K., Mills, K. L., Teesson, M., Cotton, B. D., … Brady, K. T. (2014a). Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPE): Therapist Guide. New York, NY, USA: Oxford University Press.Google Scholar
Back, S. E., Killeen, T. K., Teer, A. P., Hartwell, E. E., Federline, A., Beylotte, F., & Cox, E. (2014b). Substance use disorders and PTSD: an exploratory study of treatment preferences among military Veterans. Addictive Behaviors, 39, 369–373. doi: 10.1016/j.addbeh.2013.09.017 CrossRefGoogle ScholarPubMed
Back, S. E., Killeen, T., Badour, C. L., Flanagan, J. C., Allan, N. P., Ana, E. S., … Brady, K. T. (2019). Concurrent treatment of substance use disorders and PTSD using prolonged exposure: a randomized clinical trial in military Veterans. Addictive Behaviors, 90, 369–377. doi: 10.1016/j.addbeh.2018.11.032 CrossRefGoogle ScholarPubMed
Beck, A., Steer, R., & Brown, G. (1996). Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation.Google Scholar
Becker, C. B., Zayfert, C., & Anderson, E. (2004). A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 42, 277–292. doi: 10.1016/S0005-7967(03)00138-4 CrossRefGoogle ScholarPubMed
Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., & Keane, T. M. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8, 75–90. Retrieved from: https://link.springer.com/article/10.1007/BF02105408 CrossRefGoogle ScholarPubMed
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 CrossRefGoogle ScholarPubMed
Brady, K. T., Dansky, B. S., Back, S. E., Foa, E. B., & Carroll, K. M. (2001). Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: preliminary findings. Journal of Substance Abuse Treatment, 21, 47–54. doi: 10.1016/S0740-5472(01)00182-9 CrossRefGoogle ScholarPubMed
Carroll, K. M. (1998). Therapy Manuals for Drug Addiction, Manual 1: A Cognitive-Behavioral Approach: Treating Cocaine Addiction. Bethesda, MD: National Institute on Drug Abuse.Google Scholar
Coffey, S. F., Saladin, M. E., Drobes, D. J., Brady, K. T., Dansky, B. S., & Kilpatrick, D. G. (2002). Trauma and substance cue reactivity in individuals with comorbid posttraumatic stress disorder and cocaine or alcohol dependence. Drug and Alcohol Dependence, 65, 115–127. doi: 10.1016/S0376-8716(01)00157-0 CrossRefGoogle ScholarPubMed
Coffey, S. F., Schumacher, J. A., Nosen, E., Littlefield, A. K., Henslee, A. M., Lappen, A., & Stasiewicz, P. R. (2016). Trauma-focused exposure therapy for chronic posttraumatic stress disorder in alcohol and drug dependent patients: a randomized controlled trial. Psychology of Addictive Behaviors, 30, 778–790. doi: 10.1037/adb0000201 CrossRefGoogle ScholarPubMed
Coffey, S. F., Stasiewicz, P. R., Hughes, P. M., & Brimo, M. L. (2006). Trauma-focused imaginal exposure for individuals with comorbid posttraumatic stress disorder and alcohol dependence: revealing mechanisms of alcohol craving in a cue reactivity paradigm. Psychology of Addictive Behaviors, 20, 425–435. doi: 10.1037/0893-164X.20.4.425 CrossRefGoogle Scholar
Fals-Stewart, W., O’Farrell, T. J., Freitas, T. T., McFarlin, S. K., & Rutigliano, P. (2000). The timeline followback reports of psychoactive substance use by drug-abusing patients: psychometric properties. Journal of Consulting and Clinical Psychology, 68, 134–144. http://psycnet.apa.org/record/2000-13544-014 CrossRefGoogle ScholarPubMed
Fisher, A. J., Medaglia, J. D., & Jeronimus, B. F. (2018). Lack of group-to-individual generalizability is a threat to human subjects research. Proceedings of the National Academy of Sciences, 115, E6106–6115. doi: 10.1073/pnas.1711978115 CrossRefGoogle ScholarPubMed
Foa, E., Hembree, E., & Rothbaum, B. O. (2007). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Therapist Guide. USA: Oxford University Press.CrossRefGoogle Scholar
Foa, E. B., & Rothbaum, B. O. (1998). Treating the Trauma of Rape: Cognitive-Behavioral Therapy for PTSD. New York, NY, USA: Guilford Press.Google Scholar
Foa, E. B., Zoellner, L. A., Feeny, N. C., Hembree, E. A., & Alvarez-Conrad, J. (2002). Does imaginal exposure exacerbate PTSD symptoms? Journal of Consulting and Clinical Psychology, 70, 1022–1028. Retrieved from: http://psycnet.apa.org/record/2002-17393-016 CrossRefGoogle ScholarPubMed
Gros, D. F. (2014). Development and initial evaluation of Transdiagnostic Behavior Therapy (TBT) for Veterans with affective disorders. Psychiatry Research, 220, 275–282. doi: 10.1016/j.psychres.2014.08.018 CrossRefGoogle ScholarPubMed
Gros, D. F., Szafranski, D. D., & Shead, S. D. (2017). A real world dissemination and implementation of Transdiagnostic Behavior Therapy (TBT) for Veterans with affective disorders. Journal of Anxiety Disorders, 46, 72–77. doi: 10.1016/j.janxdis.2016.04.010.CrossRefGoogle ScholarPubMed
Hien, D. A., Ruglass, L.M., Lopez-Castro, T., Papini, S., Killeen, T., & Back, S. (2016). Concurrent treatment with prolonged exposure for co-occurring PTSD and substance use disorders: a randomized clinical trial. Presented at the annual meeting of the College on Problems of Drug Dependence, Palm Springs, CA, June 2016.Google Scholar
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, 13–22. doi: 10.1056/NEJMoa040603 CrossRefGoogle ScholarPubMed
Hoeppner, B. B., Stout, R. L., Jackson, K. M., & Barnett, N. P. (2010). How good is fine-grained Timeline Follow-back data? Comparing 30-day TLFB and repeated 7-day TLFB alcohol consumption reports on the person and daily level. Addictive Behaviors, 35, 1138–1143. doi: 10.1016/j.addbeh.2010.08.013 CrossRefGoogle ScholarPubMed
Jacobsen, L. K., Southwick, S. M., & Kosten, T. R. (2001). Substance use disorders in patients with posttraumatic stress disorder: a review of the literature. American Journal of Psychiatry, 158, 1184–1190. doi: 10.1176/appi.ajp.158.8.1184 CrossRefGoogle ScholarPubMed
Jacobsen, N. S., & Truax, P. (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12–19. doi: 10.1037/0022-006X.59.1.12 CrossRefGoogle Scholar
Jarnecke, A. M., Allan, N. P., Badour, C. L., Flanagan, J. C., Killeen, T. K., & Back, S. E. (2019). Substance use disorders and PTSD: examining substance use, PTSD symptoms, and dropout following imaginal exposure. Addictive Behaviors, 90, 35–39. doi: 10.1016/j.addbeh.2018.10.020 CrossRefGoogle ScholarPubMed
Jayawickreme, N., Cahill, S. P., Riggs, D. S., Rauch, S. A. M., Resick, P. A., Rothbaum, B. O., & Foa, E. B. (2014). Primum non nocere (first do no harm): symptom worsening and improvement in female assault victims after prolonged exposure for PTSD. Depression and Anxiety, 31, 412–419. doi: 10.1002/da.22225.CrossRefGoogle ScholarPubMed
Kadden, R, Carroll, K, Donovan, D, Cooney, N, Monti, P, Abrams, D, … Hester, R. (1995). Cognitive-Behavioral Coping Skills Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals with Alcohol Abuse and Dependence. In Mattson, M. E. (ed), Project MATCH Monograph Series (vol. 3). Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism.Google Scholar
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593–602. doi: 10.1001/archpsyc.62.6.593 CrossRefGoogle ScholarPubMed
Larntz, K. (1978). Small-sample comparisons of exact levels for chi-squared goodness-of-fit statistics. Journal of the American Statistical Association, 73, 253–263. doi: 10.1080/01621459.1978.10481567 CrossRefGoogle Scholar
Larsen, S. E., Stirman, S. W., Smith, B. N., & Resick, P. A. (2016). Symptom exacerbations in trauma-focused treatments: associations with treatment outcome and non-completion. Behaviour Research and Therapy, 77, 68–77. doi: 10.1016/j.brat.2015.12.009.CrossRefGoogle ScholarPubMed
Leeman, R. F., Hefner, K., Frohe, T., Murray, A., Rosenheck, R. A., Watts, B. V., & Sofuoglu, M. (2017). Exclusion of participants based on substance use status: Findings from randomized controlled trials of treatments for PTSD. Behaviour Research and Therapy, 89, 33–40. doi: 10.1016/j.brat.2016.10.006 CrossRefGoogle ScholarPubMed
Maassen, G. H. (2004). The standard error in the Jacobson and Truax Reliable Change Index: the classical approach to the assessment of reliable change. Journal of the International Neuropsychological Society, 10, 888–893. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/15637779 CrossRefGoogle ScholarPubMed
McCauley, J. L., Killeen, T., Gros, D. F., Brady, K. T., & Back, S. E. (2012). Posttraumatic stress disorder and co‐occurring substance use disorders: advances in assessment and treatment. Clinical Psychology: Science and Practice, 19, 283–304. doi: 10.1111/cpsp.12006 Google ScholarPubMed
Meyer, J. M., Farrell, N. R., Kemp, J. J., Blakey, S. M., & Deacon, B. J. (2014). Why do clinicians exclude anxious clients from exposure therapy? Behaviour Research and Therapy, 54, 49–53. doi: 10.1016/j.brat.2014.01.004 CrossRefGoogle ScholarPubMed
Miller, M. W., Wolf, E. J., Kilpatrick, D., Resnick, H., Marx, B. P., Holowka, D. W., Keane, T. M., Rosen, R. C., & Friedman, M. J. (2012). The prevalence and latent structure of proposed DSM-5 posttraumatic stress disorder symptoms in U.S. National and Veteran samples. Psychological Trauma: Theory, Research, Practice, and Policy, 5, 501–512. doi: 10.1037/a0029730 CrossRefGoogle Scholar
Mills, K. L., Teesson, M., Back, S. E., Brady, K. T., Baker, A. L., Hopwood, S., … Ewer, P. L. (2012). Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: a randomized controlled trial. Journal of the American Medical Association, 308, 690–699. doi: 10.1001/jama.2012.9071 Google ScholarPubMed
Mills, K. L., Barrett, E. L., Merz, S., Rosenfeld, J., Ewer, P. L., Sannibale, C., … Teesson, M. (2016). Integrated exposure-based therapy for co-occurring post traumatic stress disorder (PTSD) and substance dependence: predictors of change in PTSD symptom severity. Journal of Clinical Medicine, 5, 101.CrossRefGoogle ScholarPubMed
Nace, E. P. (1988). Posttraumatic stress disorder and substance abuse clinical issues. Recent Developments in Alcoholism, 6, 9–26. doi: 10.1007/978-1-4615-7718-8_1 CrossRefGoogle ScholarPubMed
Najt, P., Fusar-Poli, P., & Brambilla, P. (2011). Co-occurring mental and substance abuse disorders: a review on the potential predictors and clinical outcomes. Psychiatry Research, 186, 159–164. doi: 10.1016/j.psychres.2010.07.042.CrossRefGoogle ScholarPubMed
National Institute on Alcohol Abuse and Alcoholism (NIAAA) (2016). Rethinking Drinking. Retrieved from: https://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf.Google Scholar
Norman, S. B., & Hamblen, J. L. (2017). Promising directions for treating comorbid PTSD and substance use disorder. Alcoholism: Clininical and Experimental Research, 41, 708–710. doi: 10.1111/acer.13349 CrossRefGoogle ScholarPubMed
Nuro, K. F., Maccarelli, L., Baker, S. M., Ball, S. A., Martino, S., Rounsaville, B. J., & Carroll, K. M. (2005). Yale Adherence and Competence Scale (YACSII) guidelines. West Haven, CT: Yale University Psychotherapy Development Center.Google Scholar
Orsillo, S. (2002). Measures for acute stress disorder and posttraumatic stress disorder. In Antony, M. M., Orsillo, S., and Roemer, L. (eds), Practitioner’s Guide to Empirically Based Measures of Anxiety (pp. 255–307). New York, NY: Kluver Publications. doi: 10.1007/0-306-47628-2_20 CrossRefGoogle Scholar
Pekarik, G. (1992). Relationship of clients’ reasons for dropping out of treatment to outcome and satisfaction. Journal of Clinical Psychology, 48, 91–98. doi: 10.1002/1097-4679(199201)48:1<91::AID-JCLP2270480113>3.0.CO;2-W 3.0.CO;2-W>CrossRefGoogle ScholarPubMed
Persson, A., Back, S. E., Killeen, T. K., Brady, K. T., Schwandt, M. L., Heilig, M., & Magnusson, Å. (2017). Concurrent treatment of PTSD and substance use disorders using prolonged exposure (COPE): a pilot study in alcohol-dependent women. Journal of Addiction Medicine, 11, 119–125. doi: 10.1097/ADM.0000000000000286.CrossRefGoogle ScholarPubMed
Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review, 30, 635–641. doi: 10.1016/j.cpr.2010.04.007.CrossRefGoogle ScholarPubMed
Roberts, N. P., Roberts, P. A., Jones, N., & Bisson, J. I. (2015). Psychological interventions for post-traumatic stress disorder and comorbid substance use disorder: a systematic review and meta-analysis. Clinical Psychology Review, 38, 25–38. doi: 10.1016/j.cpr.2015.02.007.CrossRefGoogle ScholarPubMed
Ruglass, L. M., Lopez-Castro, T., Papini, S., Killeen, T., Back, S. E., & Hien, D. A. (2017). Concurrent treatment with prolonged exposure for co-occurring full or subthreshold posttraumatic stress disorder and substance use disorders: a randomized clinical trial. Psychotherapy and Psychosomatics, 86, 150–161. doi: 10.1159/000462977 CrossRefGoogle ScholarPubMed
Sannibale, C., Teesson, M., Creamer, M., Sitharthan, T., Bryant, R. A., Sutherland, K., … & Peek‐O’Leary, M. (2013). Randomized controlled trial of cognitive behaviour therapy for comorbid post‐traumatic stress disorder and alcohol use disorders. Addiction, 108, 1397–1410. doi: 10.1111/add.12167 CrossRefGoogle ScholarPubMed
Schäfer, I., & Najavits, L. M. (2007). Clinical challenges in the treatment of patients with posttraumatic stress disorder and substance abuse. Current Opinion in Psychiatry, 20, 614–618. doi: 10.1097/YCO.0b013e3282f0ffd9 CrossRefGoogle ScholarPubMed
Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., & Dunbar, G. C. (1998). The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59, 22–33. Retrieved from: http://www.psychiatrist.com/jcp/article/pages/1998/v59s20/v59s2005.aspx Google ScholarPubMed
Simpson, T. L., Lehavot, K., & Petrakis, I. L. (2017). No wrong doors: findings from a critical review of behavioral randomized clinical trials for individuals with co-occurring alcohol/drug problems and posttraumatic stress disorder. Alcoholism: Clininical and Experimental Research, 41, 681–702. doi: 10.1111/acer.13325 CrossRefGoogle ScholarPubMed
Sobell, L. C., & Sobell, M. B. (1992). Timeline follow-back: a technique for assessing self-reported alcohol consumption. In Litten, R. Z. & Allen, J. P. (eds), Measuring Alcohol Consumption: Psychosocial and Biochemical Methods (pp. 41–73). Totowa, NJ: Humana Press. doi: 10.1007/978-1-4612-0357-5_3 CrossRefGoogle Scholar
Souza, T., & Spates, C. R. (2008). Treatment of PTSD and substance abuse comorbidity. Behavior Analyst Today, 9, 11–26. doi: 10.1037/h0100643 CrossRefGoogle Scholar
Stewart, S. H., Pihl, R. O., Conrod, P. J., & Dongier, M. (1998). Functional associations among trauma, PTSD, and substance-related disorders. Addictive Behaviors, 23, 797–812. doi: 10.1016/S0306-4603(98)00070-7 CrossRefGoogle ScholarPubMed
Toll, B. A., Cooney, N. L., McKee, S. A., & O’Malley, S. S. (2006). Correspondence between Interactive Voice Response (IVR) and Timeline Followback (TLFB) reports of drinking behavior. Addictive Behaviors, 31, 726–731. doi: 10.1016/j.addbeh.2005.05.044 CrossRefGoogle ScholarPubMed
van Dam, D., Vedel, E., Ehring, T., & Emmelkamp, P. M. G. (2012). Psychological treatments for concurrent posttraumatic stress disorder and substance use disorder: a systematic review. Clinical Psychology Review, 32, 202–214. doi: 10.1016/j.cpr.2012.01.004 CrossRefGoogle ScholarPubMed
van Minnen, A., Harned, M. S., Zoellner, L., & Mills, K. (2012). Examining potential contraindications for prolonged exposure therapy for PTSD. European Journal of Psychotraumatology, 3, 18805. doi: 10.3402/ejpt.v3i0.18805 CrossRefGoogle ScholarPubMed
van Minnen, A., Hendriks, L., & Olff, M. (2010). When do trauma experts choose exposure therapy for PTSD patients? A controlled study of therapist and patient factors. Behaviour Research and Therapy, 48, 312–320. doi: 10.1016/j.brat.2009.12.003 CrossRefGoogle ScholarPubMed
Weathers, F., Litz, B., Herman, D., Huska, J., & Keane, T. (1993). The PTSD Checklist (PCL): Reliability, Validity, and Diagnostic Utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX, October 1993.Google Scholar
Wilkins, K. C., Lang, A. J., & Norman, S. B. (2011). Synthesis of the psychometric properties of the PTSD checklist (PCL) military, civilian, and specific versions. Depression and Anxiety, 28, 596–606. doi: 10.1002/da.20837 CrossRefGoogle ScholarPubMed
Wisco, B. E., Marx, B. P., Wolf, E. J., Miller, M. W., Southwick, S. M., & Pietrzak, R. H. (2014). Posttraumatic stress disorder in the US Veteran population: results from the National Health and Resilience in Veterans study. Journal of Clinical Psychiatry, 75, 1338–1346. doi: 10.4088/JCP.14m09328 CrossRefGoogle ScholarPubMed
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