PTSD Combat Trauma and Stress Diagnosis and Treatment

After more than a decade at war in Iraq and Afghanistan, the rates of posttraumatic stress disorder in our military men and women have increased to as high as 30% in veterans returning from active duty. With this the Veteran’s Administration has seen a rise in substance abuse and the suicide rate. Eighteen to twenty-two veterans die by suicide in the United States every day (Reisman n.d., p.11). It is a complicated issue. Many veterans do not get diagnosed appropriately; there can be limited access to care and there is a stigma that prevents them from seeking out mental health services (Reisman n.d., p.11). This article is helpful in understanding PTSD combat trauma and stress diagnosis and treatment. Read more from Dr. Victoria Smithers on stress management here.

Today we will be discussing:

  1. PTSD Combat Trauma and Stress Diagnosis and Treatment
  2. The History of PTSD
  3. War Neurosis and Shell Shock
  4. Symptoms of Shell Shock
  5. Chronic Consequences of Combat War Neurosis|PTSD Stress and Trauma
  6. Post-Vietnam Syndrome
  7. How is PTSD Diagnosed?
  8. Two specifications for PTSD Stress Diagnosis
  9. How Common is PTSD in Veterans?
  10. PTSD Causes Severe Health Problems
  11. PTSD and Substance Abuse
  12. Neurobiology of Stress and Trauma| How Trauma Affects the Body
  13. Chronic or Severe Stress and PTSD
  14. Theological Perspective on Trauma
  15. Why Do We Suffer?
  16. Treatment for PTSD
  17. EMDR Therapy Improves PTSD Diagnosis
  18. Christian Counseling Adaptations for Treatment of PTSD
  19. Spiritually Integrated Cognitive Processing Therapy

The History of PTSD and Combat Stress Treatment

War neurosis is not new. In an interesting article in Dialogues in Clinical Neuroscience, Dr Marc Antoine Crocq details the history of posttraumatic stress disorder (PTSD). This condition was first described in literature from the battle of Marathon by Herodotus in 440 BC. In subsequent battles, physicians called it “battle dreams”, “cardiorespiratory neurosis” and “acute stuporous posttraumatic state”.

War Neurosis and Shell Shock Leads to Defining PTSD

There was a longstanding debate over organic versus emotional shock as cause of the condition. In World War I, the term “shell shock” was coined by Dr. Abram Kardiner. He wrote a book about his treatment of WWI veterans and the need to treat them immediately to prevent consolidation of the neurosis and its’ chronic intractable form. The term commonly used for soldiers’ mental disturbances caused by “fright and anxiety following an explosion of enemy shells and mines and seeing maimed or dead comrades. Read on for more about PTSD combat trauma and stress diagnosis and treatment.

Symptoms of Shell Shock Caused by Combat Trauma

  • states of sudden muteness
  • deafness
  • general tremor
  • inability to stand or walk
  • episodes of loss of consciousness
  • convulsions” (Crocq 2000, p. 47).

Chronic Consequences of Combat War Neurosis|PTSD Stress and Trauma

During World War II , American psychiatrists Grinker and Spiegel wrote a book further investigating war neurosis and distinguished acute and delayed reactions to combat. They used psychoanalysis and barbiturates to treat the condition.

Read on for more about PTSD combat trauma and stress diagnosis and treatment.

War psychiatry revealed chronic consequences of combat:

  • passive dependent states
  • psychosomatic states
  • guilt and depression
  • aggressive and hostile reactions
  • psychotic-like states.

Post-Vietnam Syndrome Leads to
Post-Traumatic Stress Disorder Category

In 1964 to 1973, the Vietnam War saw a huge increase in cases of war neurosis or what came to be called post-Vietnam syndrome. As many as 700,000 veterans required some form of psychological help after returning home from active duty in Vietnam. (Crocq 2000, pp.47-55) This is what led to the establishment of the posttraumatic stress disorder (PTSD) category in the DSMIII in 1980. Read on for more about PTSD combat trauma and stress diagnosis and treatment.

How is PTSD Diagnosed?

The diagnostic and statistical manual of mental disorders 5th edition, was updated in 2013 and the American Psychiatric Association revised the PTSD diagnostic criteria.

Criterion A: stressor (one required)

The person was exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s):

  • Direct exposure – Witnessing the trauma Learning that a relative or close friend was exposed to a trauma
  • Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)

Criterion B: intrusion symptoms (one required)

The traumatic event is persistently re-experienced in the following way(s):

  • Unwanted upsetting memories
  • Nightmares
  • Flashbacks
  • Emotional distress after exposure to traumatic reminders
  • Physical reactivity after exposure to traumatic reminders

Criterion C: avoidance (one required)

Avoidance of trauma-related stimuli after the trauma, in the following way(s):

  • Trauma-related thoughts or feelings
  • Trauma-related external reminders

Criterion D: negative alterations in cognitions and mood (two required)

Negative thoughts or feelings that began or worsened after the trauma, in the following ways:

  • Overly negative thoughts and assumptions about oneself or the world
  • Exaggerated blame of self or others for causing the trauma Negative affect
  • Decreased interest in activities
  • Feeling isolated
  • Difficulty experiencing positive affect

Criterion E: alterations in arousal and reactivity

Trauma-related arousal and reactivity that began or worsened after the trauma, in the following way(s):

  • Irritability or aggression
  • Risky or destructive behavior
  • Hypervigilance
  • Heightened startle reaction
  • Difficulty concentrating
  • Difficulty sleeping

Criterion F: duration (required) Symptoms last for more than 1 month.

Criterion G: functional significance (required) Symptoms create distress or functional impairment (e.g., social, occupational).

Criterion H: exclusion (required) Symptoms are not due to medication, substance use, or other illness.

Read on for more about PTSD combat trauma and stress diagnosis and treatment.

Two specifications for PTSD Stress Diagnosis

  1. Dissociative Specification In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli: Depersonalization. Experience of being an outside observer of or detached from oneself (e.g., feeling as if “this is not happening to me” or one were in a dream). Derealization. Experience of unreality, distance, or distortion (e.g., “things are not real”).
  2. Delayed Specification. Full diagnostic criteria are not met until at least six months after the trauma(s), although onset of symptoms may occur immediately.

How Common is PTSD in Veterans?

In the National Comorbidity Survey Replication done in 2013 the lifetime incidence of PTSD in the US general population is 6.8% (3.6% men and 9.7% women). The numbers of veterans affected by PTSD varies by service era. While the lifetime prevalence of PTSD in Vietnam Veterans in an older 1988 study was 30.9% in men and 26.9% in women, a 1995 study of Gulf War veteran population found lifetime prevalence of PTSD was 10.1%. In a 2008 study, prevalence of PTSD among military previously deployed in Operation Enduring Freedom and Operation Iraqi Freedom (Afghanistan and Iraq) showed the prevalence of current PTSD was 13.8%. (Gradus n.d., p.2) The numbers also vary by race, deployed versus non-deployed, sex and branch of military. Read on for more about PTSD combat trauma and stress diagnosis and treatment.

The National Health Study for a New Generation of US Veterans is a health survey of 60,000 veterans done in 2014 comparing nondeployed and deployed veterans of Iraq and Afghanistan war. This study found 15.7% of deployed Veteran’s and 10.9% non-deployed screened positive for PTSD on a PTSD Checklist Civilian Version (PCL-C). Deployed Army veterans screened positive 18.6%, Marines 20.6%, Navy 12.3%, and Air Force 6.6%. Deployed males screened positive at 16.2% and women at 12.3% for PTSD. Deployed Hispanics screened positive for PTSD 19.7%, deployed whites 14.1%, and deployed African Americans 21.9%. (PTSD in Iraq and Afghanistan Veterans, pp. 1-5)

PTSD Causes Severe Health Problems:

(PTSD and DSM-5, p.1)

The growing number of suicide deaths in veterans has brought the crisis to the forefront and is the focus of ongoing research. A study found PTSD is associated with several physical health problems;

  • cardiovascular
  • respiratory
  • chronic pain
  • gastrointestinal disorders
  • cancer

PTSD was also found to be associated with mental health disorders:

  • depression
  • substance abuse disorder
  • anxiety

Even after adjusting for all these factors PTSD was found to be associated with:

  • suicide attempts
  • poor quality of life
  • short and long-term disability

(Physical and Mental Comorbidity 2007, p. 4).

PTSD and Substance Abuse

A 2010 National Epidemiologic Survey on Alcohol and related conditions estimated the lifetime prevalence of PTSD as 6.4% and lifetime prevalence of substance use disorder as 35.3%. Among individuals with PTSD, 46.4% also met criteria for a substance use disorder in that study (McCauley 2012, p.4). The fact that PTSD and substance abuse co-occur makes the disorder more complex, more costly, increases physical problems, leads to higher suicide rates, increases legal problems, increases risk of violence, and worsens treatment adherence (McCauley 2012, p.2).

Read on for more about PTSD combat trauma and stress diagnosis and treatment.

Neurobiology of Stress and Trauma| How Trauma Affects the Body

Understanding how trauma affects the body is important. Trauma has neurologic and psychologic effects on the body. Following a trauma, the person can have an altered state of thinking and feeling.

There are physical changes that include:

  • dilated pupils
  • increase breathing
  • pulse
  • blood pressure

The psychological symptoms include:

  • distortion of time
  • fixation of attention
  • inability to see or hear what is going on around them
  • a distortion of sensory experiences
  • age regression

Traumatic memories are stored in the cortex on the right side of the brain.

This part of the brain is responsible for emotional, nonverbal, visual, and artistic processes. Trauma causes dissociation and keeps the left and right brain from talking to each other and so it may react too much or think there is alarm when there really isn’t. (Wright 2011, pp.190-201). Read on for more about PTSD combat trauma and stress diagnosis and treatment.

The thalamus relays information from the senses to the cortex where memories are stored.

The hypothalamus is involved in primary drives and motivation. It works with the pituitary gland during the stress response to release hormones. These hormones travel in blood to the adrenal gland and cause release of epinephrine; that increases heart rate and blood flow during stress.

The limbic system is made up of three parts:

  • hippocampus
  • amygdala
  • septum

The hippocampus takes information that has been determined important and stores it.

This procedure of processing and storing memories is called consolidation. The hippocampus deals specifically with unintentional, emotional, and episodic memories. The hippocampus is involved with formation of emotional bonds, attachments, and traumatic memories so it is directly involved in stress and trauma reactions.

The amygdala is connected to the hippocampus and is involved in emotion and emotional learning.

The amygdala is also found in the limbic system, below the cortex in the brain. Memories that have a high level of emotion attached, whether good or bad, are more likely to be stored as a memory. The basal ganglia are interlaced with the limbic system and is responsible for setting the body’s overall anxiety level. (Gingrich 2017, pp. 55-62)

Read on for more about PTSD combat trauma and stress diagnosis and treatment.

Chronic or Severe Stress and PTSD

Chronic or severe stress leads to another hormone pathway that releases cortisol. This or the reactivation of the stress response leads to the dysregulation of physiological, psychological, and behavioral responses to stress. This correlates with the inability to self-regulate emotions, thoughts and behaviors seen in PTSD (Gingrich, 2017 p.64). The understanding of how traumatic memories form and effect the body help us understand which therapies can be beneficial to lower anxiety and reduce harmful effects of the traumatic memories.

Trauma symptoms develop through experience, and so treatment must seek to facilitate neurological change through experience”

Gingrich 2017, p. 67

Theological Perspective on Trauma

The theology of suffering is a complicated issue and is the subject of many great sermons, theological dissertations, late night discussions and books. It seems that everyone experiencing trials and traumas gets to a point and asks “Why?”.

For Christians this can be particularly difficult and lead to further traumatization when church members or other Christians cast accusations their way like “God must be angry about how you are living your life.” or “God must be punishing you for something you have done.” This can alienate Christians from their church at critical times and lead to excessive guilt. Read on for more about PTSD combat trauma and stress diagnosis and treatment.

We must look to the Bible to understand the question “Why suffering?”.

Philip Yancey explains it quite well in his book Where Is God When It Hurts?. It all begins in Genesis, at “the Fall” of man, when Adam and Eve chose to eat of the Tree of Life. Evil, pain and suffering entered into Gods’ perfect creation. It is by God’s mercy that he provided us a way to restore that through his son Jesus Christ. Scripture clearly states that God cares about us and is aware of our suffering. Jesus experienced grief, fear, anguish, anger, and discontent so he understands our emotions. Trauma survivors often search for understanding and ask why when really they are feeling rejected, abandoned and betrayed by God (Thomas 2011, pp 467-469). The fact that he gave us Jesus and the Holy Spirit shows us that he has not abandoned us.

Find out how to have a relationship with God through Jesus Christ here.

You have to look further at the bible to understand more about whether life trials are Gods wrath, are due to a fallen world or they serve some other purpose. C.S. Lewis once wrote:

God whispers to us in our pleasures, speaks in our conscience, but shouts in our pains, it is His megaphone to rouse a deaf world

(Yancey 1990, p.68).

I would agree that suffering often is what is necessary to get our attention and turn our focus to God. I know the Bible says God created us in His image for the purpose of bringing glory to Him. If you had spent as much time in an Intensive Care Unit as I have you will agree a life threatening illness makes you forget your differences, leads you to comfort strangers and often brings you to your knees before God.

Read on for more about PTSD combat trauma and stress diagnosis and treatment.

Why Do We Suffer?

The story in John 9:3 of the blind man is the clearest message to me, directly from Jesus to the disciples, that explains the question of why we suffer:

Neither this man nor his parents sinned , but this happened so that the work of God might be displayed in his life.

John 9:3

Romans 5:3-5 also supports the role of our trials and suffering in shaping our souls:

We also rejoice in our sufferings, because we know that suffering produces perseverance; perseverance, character; and character, hope. And hope does not disappoint us, because God has poured out his love into our hearts by the Holy Spirit.

(Common English Bible,2011, John 9:3 and Romans 5:3-5)

Treatment for PTSD

Current treatment recommendations for posttraumatic stress disorder are outlined in the 2017 treatment guidelines published by the Veterans Health Administration and Department of Defense and the American Psychological Association. These include trauma focused psychotherapies that have a large evidence base. Both guidelines strongly recommend:

  • Prolonged exposure (PE)
  • Cognitive Processing Therapy (CPT)
  • Trauma-focused Cognitive Behavioral Therapy (CBT). (Watkins 2018, p.1)

Trauma focused therapies target memories of the traumatic event or thoughts and feelings about the event. Other non-trauma-focused therapies address symptoms through relaxation and interpersonal therapy and have not been as effective.

Read on for more about PTSD combat trauma and stress diagnosis and treatment.

The VA went through extensive research, designed a working group of many specialties and a focus group of patients as they designed the treatment guidelines. The VA included eye movement desensitization therapy (EMDR) and APA also recommended brief eclectic psychotherapy and narrative exposure therapy (VA/DoD Clinical Practice Guideline for The Management of Posttraumatic Stress Disorder and Acute Stress Disorder 2017, p.46).

The dropout rate in all the exposure therapies was low at 18% and was similar across PE, CPT, and CBT in studies. In the VA guidelines of 2017, they did not find that any one of the PE, CPT or CBT therapies had a clear benefit or outperformed the others. (Watkins 2018, p.10)

EMDR Therapy Improves PTSD Diagnosis

A recent meta-analysis published in 2018 found EMDR therapy improved PTSD diagnosis, reduced PTSD symptoms, and reduced other trauma related symptoms (Wilson 2018, p. 923) Another meta-analysis done in 2018 found that EMDR was better than CBT in reducing post traumatic stress symptoms and anxiety symptoms (Khan 2018, p. 1)

Research has shown that patients prefer PE,CPT and CBT over other therapies like psychodynamic psychotherapy and EMDR (Watkins 2018. P.10). It is also clear that patients prefer psychotherapy over medication. The VA guidelines clearly state that psychotherapy is more effective than pharmacotherapy in treating PTSD in Veterans.

When psychotherapy fails clinicians may consider use of serotonin reuptake inhibitors like Sertraline or Paroxetine (VA/DoD Clinical Practice Guideline for The Management of Posttraumatic Stress Disorder and Acute Stress Disorder 2017, p. 51). Yet in a 15 year longitudinal study of Iraq and Afghanistan veterans who initiated psychotherapy for PTSD in the Veterans Health system only 20% ever received any sessions of PE or CPT (Maguen 2019, p. 112). This emphasizes the need to educate providers in the VA and the community about effective psychotherapy treatments for PTSD. Read on for more about PTSD combat trauma and stress diagnosis and treatment.

National Suicide Prevention Lifeline
No matter what problems you are dealing with, we want to help you find a reason to keep living. By calling 1-800-273-TALK (8255) you’ll be connected to a skilled, trained counselor at a crisis center in your area, anytime 24/7. National Suicide Prevention Lifeline

Christian Counseling Adaptations for Treatment of PTSD

Thomas outlines a Christian approach to processing trauma in Counseling Techniques in the Trauma Focused strategies chapter. This includes processing the trauma by using a cognitive behavioral therapy approach.

  • The first phase emphasizes safety and symptom stabilization. Exposure therapy or prolonged exposure therapy is used to desensitize clients from anxiety. The exposure is paired with relaxation techniques like mindfulness, breathing and meditation.
  • The second phase deals with processing of traumatic memories and therapist can use BASK model to explore behaviors, affect, sensation and knowledge associated with the memory. Grounding techniques can be used to help keep them in the present as they process traumatic memories. Painful emotions especially guilt must be acknowledged and worked through. Use of prayer, Scripture and spiritual practices can be integrated with these therapies as many trauma survivors wrestle with spiritual questions.
  • The final phase is consolidation and resolution and here client works on developing new coping mechanisms and establishing new healthy relationships (Thomas 2018, pp. 467-485).

Gingrich & Gingrich, in Treating Trauma in Christian counseling define combat trauma and discusses the psychological sequela of combat stress I have already reviewed above. They also address moral injury or a fracture in moral or spiritual framework that occurs after witnessing or perpetrating human suffering, injustice, or death. Symptoms like anger, demoralization, poor self -care, shame and guilt may occur. They often experience grief over the many losses. Read on for more about PTSD combat trauma and stress diagnosis and treatment.

All of this can challenge a veterans’ faith or spiritual beliefs.

42% of OIF/OEF veterans reported they lost touch with their spirituality or having difficulty in their spiritual life. 32% of those in that study wanted to have spiritual counseling during reintegration. The Veterans Affairs endorses PE, CPT, CBT and EMDR therapies as I have discussed. They have formed a research and integration center with emphasis on using chaplains in PTSD treatment (Gingrich 2017, pp. 368-370).

Following a moral injury, a Veteran is often unable to forgive themselves.

The individual may question his faith or lose belief in a God who would let something so horrible happen. Moral injury often occurs regarding military and war related experiences so can occur with PTSD. Building Spiritual Strength is an 8- session group therapy that can be led by a chaplain and addresses concerns with their relationship with a Higher Power and challenges with forgiveness, including self forgiveness (Moral Injury, VA).

Spiritually Integrated Cognitive Processing Therapy for PTSD

A specific Spiritually Integrated Cognitive Processing Therapy was developed by a clinical psychologist, a military psychologist, a psychiatrist, and a VA chaplain. This approach uses spiritual and psychological resources in the treatment of PTSD and moral injury. It is an adaptation of the evidence-based treatment Cognitive Processing Therapy. Knowing only 20- 30% of those who are affected seek treatment for PTSD, Moral injury may decrease the effectiveness of current treatments and be a barrier to recovery.

Active duty soldiers and veterans report high rates of spirituality and religiosity and many rely on their faith to cope

Pearce 2018, p.2

Spirituality must be incorporated in treatment of PTSD

Spiritually Integrated- CPT targets inaccurate or maladaptive beliefs that result in guilt, shame and self- blame that prevent trauma recovery. This process uses cognitive restructuring and behavioral exercises to change how the individual thinks about the trauma. They can process emotions, contextualize the event, and integrate the experience in a positive way. SICPT uses the client’s spiritual beliefs and values to challenge maladaptive thinking and uses spiritual tools to resolve moral injury through compassion, grace, repentance, confession, forgiveness, atonement, restitution and making amends (Pearce 2018, pp. 3-7). Read on for more about PTSD combat trauma and stress diagnosis and treatment.

Prayer and Scripture can be utilized in PE, CPT, CBT and EMDR therapies.

After patient’s intake assessment, the therapist must establish that the client desires integration of Christian components into therapy. The therapist can open and close the session in prayer and play Christian worship music at key points in the session. Psychoeducation can include the theology of suffering, review who God is and His promises to his people in the Bible. Clients can meditate on scripture and worship music can be played during relaxation exercises. Gods’ promises and “I am” statements can be used to foster positive self-talk and adjust thinking to God’s truths. Church services can be a supportive community and provide social support to improve social skills.

Inviting God into every moment of life helps orient your thinking towards God. A Prayer journal can help process painful memories and deal with fear, anxiety, guilt, and anger.

If you or a loved one is battling with combat related PTSD and moral injury please reach out to your Pastor, the Veteran’s administration, a local counselor, a trusted friend or primary care doctor. There is help for you! God loves you and will never leave you!

If you are a veteran with a service dog, join us for stress reduction, relaxation and help with bonding with your dog. Visit us at Counting Stars Ranch for more details.

National Suicide Prevention Lifeline
No matter what problems you are dealing with, we want to help you find a reason to keep living. By calling 1-800-273-TALK (8255) you’ll be connected to a skilled, trained counselor at a crisis center in your area, anytime 24/7. National Suicide Prevention Lifeline

Find out how to have a relationship with God through Jesus Christ here.

Common English Bible (2011)

References

Crocq,M. (2000, March). From shell shock and war neurosis to posttraumatic stress

disorder: a history of psychotraumatology. Dialogues Clin Neurosci, 2(1). https: www.ncbi.nlm.nihgov/pmc/articles/PMC3181586/

Gingrich, H & Gingrich, F.C. (2017), Treating Trauma In Christian Counseling. Downers Gove, IL: Inter Varsity Press

Gradus, J.L. (n.d.). Epidemiology of PTSD. VA. Retrieved from https://www.ptsd.va.gov/professional/treat/essentials/epidemiology.asp

Commented [SV1]:

Hurley, E.C. (2018), Effective Treatment of Veterans With PTSD: Comparison Between Intensive Daily and Weekly EMDR Approaches. Frontiers In Psychology. Retrieved from https://www.frontiersin.org/articles/10.3389/fpsyg.2018.01458/full

Khan, A.M. (2018) Cognitive Behavioral Therapy versus Eye Movement Desensitization and Reprocessing in Patients with Post-traumatic Stress Disorder. Cureus.10(9), Retrieved from https://pubmed.ncbi.nlm.nih.gov/30416901/

Lee, C.W. and Cuijpers. P. (2013). A meta-analysis of the contribution of eye movements in processing emotional memories. Journal of Behavior Therapy and Experimental Psychiatry, 44(2). Pp. 231-239.

Maguen, S. (2019) Factors Associated with completing evidence-based psychotherapy for PTSD among veterans in a national healthcare system. Psychiatry Research, 274

McCauley, J.L. (2012, September 1). Posttraumatic stress disorder and co-occuring substance use disorders: advances in assessment and treatment. Clin Psychol, 19(3). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 38111127/

Commented [SV2]:

NIMH. (n.d.). Post-traumatic stress disorder. NIMH. Retrieved from https://www.nimh.nih,gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml

Pearce, M., Haynes, K. Rivera, N, Koenig, H.G. (2018, February 20). Spiritually Cognitive processing Therapy: A New Treatment for Post-traumatic Stress

Disorder That Targets Moral Injury. Global Adv Health Med, 7:2164956118759939

Reisman, M. (n.d.). PTSD Treatment for Veterans: What’s Working, What’s New, and What’s Next, Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5047000/

Theory. EMDR Institute, Retrieved from https://www.emdr.com/theory/

Thomas, J.C. (2018). Counseling Techniques. Grand Rapids, Michigan: Zondervan

US Department of Veterans Affairs. (n.d.). PTSD in Iraq and Afghanistan Veterans.VA. Retrieved from https://www.publichealth.va.gov/epidemiology/studies/new- generation/ptsd.asp

US Department of Veterans Affairs. (n.d.) PTSD and DSM-5. VA. Retrieved from https://www.ptsd.va.gov/professional/treat/essentials/dsm5_ptsd.asp

Commented [SV3]:

Integrated

US Department of Veterans Affairs. (n.d.) Moral Injury. VA. Retrieved from https://www.ptsd.va.gov/professional/treat/occurin/moral_injury.asp

US Department of Veterans Affairs/ DOD. Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder; Revised June 2017.

Wilson, G. (2018). The Use of Eye-Movement Desensitization Reprocessing Therapy in Treating Post-traumatic Stress Disorder- A Systematic Narrative Review. Frontiers in Psychology. 6:9:923. Retrieved from https://pubmed.ncbi.nlm.nih.gov/29928250/

Wright, H.N. (2011). The Complete Guide to Crisis & Trauma Counseling. Grand Rapids, Michigan: Bethany House

Yancey, P. (1990). Where Is God When It Hurts. Grand Rapids, Michigan: Zondervan

PTSD combat and stress diagnosis and treatment, stress, anxiety

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