1. Vojdani A, Thrasher JD. Cellular and humoral immune abnormalities in Gulf War veterans. Environ Health Perspect. 2004;112:840–6.[PMC free article][PubMed]
2. McKeown-Eyssen G, Baines C, Cole DE, Riley N, Tyndale RF, et al. Case-control study of genotypes in multiple chemical sensitivity: CYP2D6, NAT1, NAT2, PON1, PON2 and MTHFR. Int J Epidemiol. 2004;33:971–8.[PubMed]
3. Da Costa JM. On irritable heart: a clinical study of a form of functional cardiac disorder and its consequences. Am J Med Sci. 1871;61:17–52.
4. Myers ABR. On the Etiology and Prevalence of Diseases of the Heart among. Soldiers. London: John Churchill & Sons; 1870.
5. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders. 4th Edition. Washington, DC: American Psychiatric Press; 1994.
6. First MB, Spitzer RL, Gibbon M, et al. Structured Clinical Interview for DSM-IV. Washington, DC: American Psychiatric Press; 1997.
7. Lyons JA, Keane TM. Keane PTSD scale: MMPI and MMPI-2 update. J Traum Stress. 1992;5:111–7.
8. Davidson JRT, Book SW, Colket JT, Tupler LA, Roth S, David D, et al. Assessment of a new self-rating scale for post-traumatic stress disorder. Psychol Med. 1997;27:153–60.[PubMed]
9. Kubany ES, Leisen MB, Kaplan AS, Kelly MP. Validation of a brief measure of posttraumatic stress disorder: the Distressing Event Questionnaire (DEQ) Psychol Assess. 2000;12:197–209.[PubMed]
10. Weiss DS, Marmar CR. The Impact of Event Scale-Revised. In: Wilson J, Keane TM, editors. Assessing Psychological Trauma and PTSD. NY: Guilford; 1996. pp. 399–411.
11. Briere J. Psychometric review of the trauma symptom checklist-40. In: Stamm BH, editor. Measurement of Stress, Trauma, and Adaptation. Lutherville, MD: Sidran Press; 1996.
12. Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist (PCL) Behav Res Therap. 1996;34:669–73.[PubMed]
13. Norris FH, Perilla JL. The revised civilian Mississippi scale for PTSD: reliability, validity, and cross-language stability. J Traum Stress. 1996;9:285–98.[PubMed]
14. Foa E, Cashman L, Jaycox L, Perry K. The validation of a self-report measure of posttraumatic stress disorder: the posttraumatic diagnostic scale. Psychol Assess. 1997;9:445–51.
15. King LA, King DW, Leskin GA, Foy DW. The Los Angeles symptom checklist: a self-report measure of posttraumatic stress disorder. Psychol Assess. 1995;2:1–17.
16. Blake DD, Wheathers FW, Nagy LM, Kaloupeu DG, Klaumizer G, Charney DS, et al. A clinician rating scale for assessing current and lifetime PTSD: the CAPS. Behav Ther. 1990;13:187–8.
17. Bremmer JD, Vermetten E, Vythilingam M, Afzal N, Schmahl C, Elzinga B, et al. Neural correlates of the classic color and emotional Stroop in women-related posttraumatic stress disorder. Biol Psychiatry. 2004;55:612–20.[PubMed]
18. Bremmer JD, Soufer R, McCarthy G, Delaney R, Staib LH, Duncan JS, et al. Gender differences in cognitive and neural correlates of remembrance of emotional words. Psychopharmacol Bull. 2001;35:55–87.[PubMed]
19. Shin LM, Whalen PJ, Pitman RK, Bush G, Macklin ML, Lasko NB. An fMRI study of anterior cingulate function in posttraumatic stress disorder. Biol Psychiat. 2001;50:932–42.[PubMed]
20. Keane TM, Caddell JM, Taylor KL. Mississippi scale for combat-related posttraumatic stress disorder: three studies in reliability and validity. J Consult Clin Psychol. 1988;56:85–90.[PubMed]
21. Keane T, Wolf J, Taylor KL. Posttraumatic stress disorder: evidence for diagnostic validity and methods of psychological assessment. J Clin Psychol. 1987;43:32–43.[PubMed]
22. Kulka RA, Schlenger WE, Fairbank JA, Hough RL, Jordan CB, Marmar CR, et al. Trauma and the Vietnam war generation: Report of findings from the National Veterans Readjustment Study. NY: Brunner/Mazel; 1990.
23. Keane T, Fairbank J, Caddell J, Zimering R, Taylor K, Mora C. Clinical evaluation of a measure to assess combat exposure. Psychol Assess. 1989;1:53–5.
24. Spitzer RL, Williams JB. Structured Clinical Interviews for DSM-III-R- Non-Patient Version Modified for the Vietnam Veterans Readjustment Study. NY: New York State Psychiatric Institute, Biometrics Research; 1987.
25. Beals J, Manson SM, Shore JH, Friedman M, Ashcraft M, Fairbank JA, et al. The prevalence of posttraumatic stress disorder among American Indian Vietnam veterans: disparities and context. J Trauma Stress. 2002;15:89–97.[PubMed]
26. Monnelly EP, Ciraulo DA, Knapp C, Keane T. Low-dose risperidone as adjunctive therapy for irritable aggression in posttraumatic stress disorder. J Clin Psychopharmacol. 2003;23:193–6.[PubMed]
27. Barrett DH, Doebbeling CC, Schwartz DA, Voelker MD, Falter KH, Woolson RF, et al. Posttraumatic stress disorder and self-reported physical health status among US Military personnel serving during the Gulf War period: a population-based study. Psychosomatics. 2002;43:195–205.[PubMed]
28. Conrad KJ, Wright BD, McKnight P, McFall M, Fontana A, Rosenheck R. Comparing traditional and Rasch analyses of the Mississippi PTSD scale: revealing limitations of reverse-scored items. J Appl Meas. 2004;5:15–30.[PubMed]
29. Elhai JD, Frueh BC, Davis JL, Jacobs GA, Hamner MB. Clinical presentations in combat veterans diagnosed with posttraumatic stress disorder. J Clin Psychol. 2003;59:385–97.[PubMed]
30. Trent CR, Jr, Rushlau MG, Munley PH, Bloem W, Driesenga S. An ethnocultural study of posttraumatic stress disorder in African-American and white American Vietnam War veterans. Psychol Rep. 2000;87:585–9.[PubMed]
31. Beckham JC, Braxton LE, Kudler HS, Feldman ME, Lytle BL, Palmer S. Minnesota multiphasic personality inventory profiles of Vietnam combat veterans with posttraumatic stress disorder and their children. J Clin Psychol. 1997;53:847–52.[PubMed]
32. Betemps EJ, Smith RM, Baker DG, Rounds-Kugler BA. Measurement precision of the clinician administered PTSD scale (CAPS): a RASCH model analysis. J Appl Meas. 2003;4:59–69.[PubMed]
33. Engdahl B, Eberly R. Assessing PTSD among veterans exposed to war trauma 40–50 years ago. NCP Clinical Quarterly. 1994;4:13–14.
34. Hovens JE, Falger PR, Op den Velde W, Schouten EG, de Groen JH, Van Duijn H. Occurrence of current post traumatic stress disorder among Dutch World War II resistance veterans according to the SCID. J Anxiety Dis. 1992;6:147–57.
35. Chiappelli F, Prolo P, Cajulis E, Harper S, Sunga E, Concepcion E. Consciousness, emotional self-regulation, and the psychosomatic network: relevance to oral biology and medicine. In: Beauregard M, editor. Consciousness, Emotional Self-regulation and the Brain, Advances in Consciousness Research. John Benjamins Publishing Company; 2004a. pp. 253–74.
36. Chiappelli F, Abanomy A, Hodgson D, Mazey KA, Messadi DV, Mito RS, Nishimura I, Spigleman I. Clinical, experimental and translational psychoneuroimmunology research models in oral biology and medicine. In: Ader R, Falter D, Cohen R., editors. Psychoneuroimmunology, III. Academic Press; 2001. pp. 645–70.
37. Chiappelli F, Cajulis OS. Psychobiological views on ‘stress-related oral ulcers’ Quintess Intern. 2004;35:223–7.[PubMed]
38. Sterling P, Eyer J. Allostasis: a new paradigm to explain arousal pathology. In: Fisher S, Reason J, editors. Handbook of Life Stress, Cognition, and Health. NY: Wiley; 1988.
39. McEwen B, Wingfield JC. The concept of allostasis in biology and biomedicine. Hormones Behav. 2003;43:2–15.[PubMed]
40. Schulkin J. Allostasis: a neural behavioral perspective. Hormones Behav. 2003;43:21–7.[PubMed]
41. Foa E, Keane T, Friedman M. Effective Treatments for PTSD. NY: The Guilford Press; 2000.
42. Bradley R, Greene J, Russ E, Dutra L, Westen D. A multidimensional meta-analysis of psychotherapy for PTSD. Am J Pschiatr. 2005;162:214–27.[PubMed]
43. Pivac N, Kozaric-Kovacic D, Muck-Seler D. Olanzapine versus fluphenacine in an open trial in patients with psychotic combat-related post-traumatic stress disorder. Psychopharmacol. 2004;175:451–6.[PubMed]
44. Kozaric-Kovacic D, Kocijan-Hercigonja D, Grubisic-Ilic M. Posttraumatic stress disorder and depression in soldiers with combat experience. Croat Med J. 2001;42:165–70.[PubMed]
45. Kozaric-Kovacic D, Kocijan-Hercigonja D. Assessment of posttraumatic stress disorder and comorbidity. Mil Med. 2001;166:78–83.
46. Hamner MB, Frueh C, Ulmer HG, Arana GW. Psychotic features and illness severity in combat veterans with chronic posttraumatic stress disorder. Biol Psychiat. 1999;45:846–52.[PubMed]
47. Bisson JI, McFarlane AC, Rose S. Psychological debriefing. In: Foa E, et al., editors. Effective Treatments for PTSD. The Guilford Press; 2000. pp. 39–59.
48. Deahl M, Gillham A, Thomas J, Searle M, Srinivasan M. Psychological sequelae following the Gulf war: factors associated with subsequent morbidity and the effectiveness of psychological debriefing. Br J Psychiatry. 1994;165:60–5.[PubMed]
49. Turner S, Beidel D, Frueh B. Multicomponent behavioral treatment for chronic combat-related posttraumatic stress disorder: trauma management therapy. Behavioral Mod. 2005;29:39–69.[PubMed]
50. Sherman J. Effects of psychotherapeutic treatments for PTSD: a meta analysis of controlled clinical trials. J Trauma Stress. 1998;11:413–35.[PubMed]
51. Van Etten ML, Taylor S. Comparative efficacy of treatments for post-traumatic stress disorder: a meta analysis. Clin Psychol Psychother. 1998;5:126–44.
52. Hembree EA, Foa EB. Posttraumatic stress disorder: psychological factors and psychosocial interventions. J Clin Psychiatry. 2000;61S:33–9.[PubMed]
53. Davidson P, Parker K. Eye movement desensitization and reprocessing (EMDR): a meta analysis. J Consult Clin Psychol. 2001;69:305–16.[PubMed]
54. Foa E, Rothbaum B, Furr J. Augmenting exposure therapy with other CBT procedures. Psychiatr Ann. 2003;33:47–53.
55. Pitman R, Orr S, Altman B, Longpre R, Poire R, Macklin M, et al. Emotional processing and outcome of imaginal flooding therapy in Vietnam veterans with chronic posttraumatic stress disorder. Compr Psychiat. 1996;37:409–18.[PubMed]
56. Frueh BC, Turner SM, Beidel DC, Mirabella RF, Janes WJ. Trauma management therapy: a preliminary evaluation of a multicomponent behavioral treatment for chronic combat-related PTSD. Behav Res Ther. 1996;34:533–43.[PubMed]
57. Boudewyns G, Hyer L. Physiological response to combat memories and preliminary treatment outcome in Vietnam veterans: PTSD patients treated with direct therapeutic exposure. Behav Ther. 1990;21:63–87.
58. Cooper N, Clum G. Imaginal flooding as a supplementary treatment for PTSD in combat veterans: a controlled study. Beh Ther. 1989;3:381–91.
59. Hamner M, Robert S, Frueh B. Treatment resistant posttraumatic stress disorder: strategies for intervention. CNS Spectr. 2004;9:740–52.[PubMed]
60. Stein DJ, Zungu-Dirwayi N, van Der Linden GJ, Seedat S. Pharmacotherapy for posttraumatic stress disorder. Cochrane Database Syst Rev. 2000;4:CD002795.[PubMed]
61. Brady K, Pearlstein T, Asnis G, Baker D, Rothbaum B, Sikes C, et al. Double-blind placebo-controlled study of the efficacy and safety of sertraline treatment of posttraumatic stress disorder. J Am Med Assoc. 2000;283:1837–44.[PubMed]
62. Davidson J, Landburg P, Pearlstein T, Weisler R, Sikes C, Farfel G. Double-blind comparison of sertraline and placebo in patients with posttraumatic stress disorder (PTSD). Abstracts of the American College of Neuropsychopharmacology 36th Annual Meeting; San Juan, Puerto Rico. 1997.
63. Davidson J, Malik M, Sutherland S. Response characteristics to antidepressants and placebo in post-traumatic stress disorder. Int Clin Psychopharmacol. 1996;12:291–6.[PubMed]
64. Chung M, Min K, Jun Y, Kim S, Kim W, Jun E. Efficacy and tolerability of mirtazapine and sertraline in Korean veterans with posttraumatic stress disorder: a randomized open label trial. Hum Psychopharmacol. 2004;19:489–94.[PubMed]
65. Chiappelli F, Prolo P, Negoatis N, Lee A, Milkus V, Bedair D, et al. Tools and methods for evidence-based research in dental practice: preparing the future. J Evid Based Dent Pract. 2004b;4:16–23.
66. Rose S, Bisson J, Wessely S. A systematic review of single-session psychological interventions (‘debriefing’) following trauma. Psychother Psychosom. 2003;72:171–5.[PubMed]
67. Wessely S, Rose S, Bisson J. Brief psychological interventions (‘debriefing’) for trauma-related symptoms and the prevention of post traumatic stress disorder. Cochrane Database Syst Rev. 2001;3:CD000560.[PubMed]
68. Suzanna RO, Jonathan BI, Simon WE. Psychological debriefing for preventing post traumatic stress disorder (PTSD) Cochrane Database Syst Rev. 2002;2:CD000560.[PubMed]
69. Albucher RC, Liberzon I. Psychopharmacological treatment in PTSD: a critical review. J Psychiatr Res. 2002;36:355–67.[PubMed]
70. Levine EG, Eckhardt J, Targ E. Change in post-traumatic stress symptoms following psychosocial treatment for breast cancer. Psychooncol. 2005 Jan 13 [Epub] [PubMed]
71. McPherson F, Schwenka MA. Use of complementary and alternative therapies among active duty soldiers, military retirees, and family members at a military hospital. Mil Med. 2004;169:354–7.[PubMed]
72. Westermeyer J, Canive J, Thuras P, Chesness D, Thompson J. Perceived barriers to VA mental health care among Upper Midwest American Indian veterans: description and associations. Med Care. 2002;40S:I62–71.[PubMed]
73. Sommers E, Porter K, DeGurski S. Providers of complementary and alternative health services in Boston respond to September 11. Am J Public Health. 2002;92:1597–8.[
John Dale has completed 20 years of military service, in Iraq – the last time in 2006 amid some of the fiercest fighting of the war – and Sierra Leone and Northern Ireland. His plan was to leave the army and join the police or fire service.
But today, aged 40, the former sergeant major and father of three children is homeless, living in a tent in the garden of the Margate house belonging to the brother of his wife, Kerry.
He had been released from prison in April, after being found not guilty of the attempted murder of Kerry. The charge, he says, came about after he lied to police so that they would lock him up, so that his family, who had watched helplessly as he fell apart, would not have to "babysit" him any more.
Dale's life began to unravel two years ago, when his regiment, the 1st Battalion, the Light Infantry, was preparing to return to Iraq on what would have been his fourth tour. He never made it. The nightmares and flashbacks he increasingly suffered but had tried to suppress, became impossible to ignore. He saw dead children everywhere. He couldn't see a way out and tried to kill himself.
He says he can pinpoint the root of his problems back to an incident in Basra in the first month of the Iraq invasion, seven years ago. "We were told to hit and clear an enemy building," says Dale. "The tanks opened up on the building and we went in, firing, throwing grenades in every room. We thought there was no one firing back because of the weight of fire. But when we got in there, it wasn't an enemy building, it was just a normal family. There were about seven of them in total. Dead children lying all over the floor." It was 27 March, 2003, his 33rd birthday.
As platoon sergeant he had to clear the casualties: "I really struggled hard with it. We were always told that we had to go in gently, not to injure any civilians. Me and the corporal got together afterwards and we knew what we'd done was wrong. But you tried not to talk about it."
Three years later his first marriage broke down and he drank heavily. By the time of his third tour, amid nightly mortar attacks, his mental health had deteriorated. The army sent out a psychiatrist, whom, he later discovered, said he had probable post-traumatic stress disorder (PTSD). Dale says he only learned of the early diagnosis this year when the notes were disclosed during a tribunal over his war pension. He plans to sue the army, he says, for not undertaking his treatment sooner.
"Have you ever seen the advert where a guy kills a kid in a car accident and he sees the kid everywhere, in the park, in his home? That's what 2003 did to me. I would watch soldiers die in Afghanistan and it would all come back. You go out to get drunk to try and stop it but it just gets worse. Every time I have a birthday, I can't celebrate it. I put the cards in a drawer. How can I celebrate a birthday when I … " His words hang in the air.
Two years later, haunted by what had happened, Dale tried to kill himself "three or four times" and was sectioned. He was formally diagnosed with PTSD by a military specialist in September 2008, and medically discharged the following September.
But things came to a head in November 2009, when he shoved Kerry aside after a row over money. She called the police; he says he told them he tried to kill her. Now he says he lied to police because he wanted to be locked up. Prison reminded him of Iraq and gave him flashbacks. He did not get treatment for PTSD there. On 4 April this year a jury found him not guilty and he was released.
Dale and Kerry, whom he married two months ago, had relied on his pension to cover the rent on their Dover home. But when he was remanded in custody his war pension was stopped. Kerry fell behind with the rent and was evicted.
In May, he sought treatment with Talking 2 Minds, a psychotherapy group run by a former SAS officer. "I've not had one nightmare or flashback since. I'm homeless, I'm living in a tent. I might not have the luxuries some people have but at least I've got my head back and my life back." He says the military "are teaching to kill without emotion", adding: "They give you resettlement to get a job. But something should be done to reprogram you."