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. Author manuscript; available in PMC: 2022 Sep 1.
Published in final edited form as: Psychol Trauma. 2020 Sep 3;13(6):665–672. doi: 10.1037/tra0000951

Longitudinal Change in Self-Reported Peritraumatic Dissociation During and After a Course of Posttraumatic Stress Disorder Treatment: Contributions of Symptom Severity and Time

Johanna Thompson-Hollands 1, Brian P Marx 1, Daniel J Lee 2, Denise M Sloan 3
PMCID: PMC8434818  NIHMSID: NIHMS1738571  PMID: 32881568

Abstract

Objective:

Peritraumatic dissociation, a dissociative reaction that occurs at the time of a traumatic event, has been established as a strong risk factor for posttraumatic stress disorder (PTSD). However, self-reported peritraumatic dissociation is typically assessed months or years after trauma exposure and may be influenced by current distress levels and other factors.

Method:

We examined the temporal stability of scores on the Peritraumatic Dissociative Experiences Questionnaire (PDEQ) among 126 treatment-seeking adults with PTSD during and after trauma-focused treatment. Participants reported dissociation during the same index event at baseline and 6, 12, 24, 36, and 60 weeks after the first treatment session.

Results:

There were substantial changes in PDEQ total scores over time, with > 40% of participants experiencing reliable change from baseline at least once during the study. Multilevel modeling revealed an overall decrease in PDEQ scores over time; scores on the Clinician-Administered PTSD Scale for DSM–5, Beck Depression Inventory-II, and PTSD Checklist for DSM–5 were each significantly associated with PDEQ scores.

Conclusions:

Our findings suggest the PDEQ does not provide temporally stable assessment of peritraumatic dissociation. Accordingly, it is crucial to control for current PTSD symptom levels when examining the degree to which peritraumatic dissociation confers risk for future symptom severity. Without such an accounting, our understanding of the relationship between PTSD and peritraumatic dissociation may be incorrect.

Keywords: peritraumatic dissociation, trauma, PTSD, PDEQ, dissociation

Peritraumatic dissociation (PD) encompasses a range of psychological reactions during overwhelming or threatening situations, including derealization, emotional numbness, and depersonalization (Marmar, Weiss, & Metzler, 1998). It is usually conceptualized as a temporarily protective response that insulates the individual from experiencing the full effect of psychological or physical pain associated with trauma exposure (Gershuny & Thayer, 1999; Moleman, Van der Hart, & Van der Kolk, 1992). However, the longer-term effects of having experienced PD are thought to be less salubrious, with the dissociative experiences interfering with or indicating deficiencies in cognitive integration and information processing with respect to the trauma (e.g., Brewin, 2001; Ehlers & Clark, 2000; Foa & Riggs, 1993).

Cross-sectional (e.g., McCanlies, Sarkisian, Andrew, Burchfiel, & Violanti, 2017) and prospective (e.g., Gandubert et al., 2016) studies have found a significant positive association between PD and posttraumatic stress disorder (PTSD) symptoms. Meta-analyses of risks and protective factors of PTSD indicate that PD is the strongest predictor of PTSD symptom severity (Breh & Seidler, 2007; Ozer, Best, Lipsey, & Weiss, 2003), regardless of trauma type. Yet not all studies have found a significant positive association between PD and PTSD (e.g., Marx & Sloan, 2005; Simeon, Greenberg, Knutelska, Schmeidler, & Hollander, 2003; Zoellner, Jaycox, Watlington, & Foa, 2003).

A significant concern regarding prior research on dissociation among trauma survivors is that these studies rely upon retrospective reporting (Candel & Merckelbach, 2004). Although PD is sometimes assessed shortly after the traumatic event itself (e.g., within 24 hr; Birmes et al., 2001), often the time between trauma exposure and PD assessment is much longer, on the order of several months or years (e.g., Johnson, Pike, & Chard, 2001; O’Toole, Marshall, Schureck, & Dobson, 1999). Lengthy intervals between the experience and when respondents are queried provide an opportunity for memory, attentional, and other cognitive biases to influence reporting and degrade recall. It is well established that recollections of traumatic experiences are unstable over time (e.g., Arnow et al., 1999; King et al., 2000; Krinsley, Gallagher, Weathers, Kutter, & Kaloupek, 2003; Roemer, Litz, Orsillo, Ehlich, & Friedman, 1998; Southwick, Morgan, Nicolaou, & Charney, 1997). This in turn raises concern that the numerous studies that have reported a strong association between having experienced PD and current levels of PTSD symptoms rest upon unreliable reports of PD, depending upon when each construct was assessed. Indeed, a study by van der Velden and Wittmann (2008) found that when PD is measured shortly after the trauma and then PTSD symptoms are measured several weeks or months later, over two thirds of studies do not find a connection between the two. However, most studies assess both PTSD symptoms and (recalled) PD concurrently and report positive associations.

Unfortunately, despite evidence that traumatic memories are not necessarily reliable, the measurement of PD rarely has been subjected to strict scrutiny. Much of the literature has assumed that self-reports of PD would not change significantly from one assessment to the next, and individuals’ PD experiences are almost never assessed repeatedly within the same study. In one of the only existing efforts to examine the degree to which self-reported PD changes over time, Zoellner, Sacks, and Foa (2001) collected PD data from 30 women within 2 weeks of an assault and then again 12 weeks later. At baseline, all women were diagnosed with PTSD. Over the 12-week study, participants’ mean PD scores decreased by 63% (p < .001). A second study with a separate sample, reported in the same article, measured PD before and after PTSD treatment and also found significant changes in self-reported PD, although the pattern of change was distinct for women with chronic PTSD (average of 6 years) versus acute (average of 32 days; Zoellner et al., 2001). Although both of these studies indicated that self-reported PD is not stable over a 12-week period, both had relatively small samples and included assessments of PD at only two time points, and the analyses were limited to t tests rather than a more sophisticated examination of change.

In the only other study to include multiple assessments of self-reported PD over time, Marshall and Schell (2002) assessed 413 young adults within a few days of experiencing an incident of community violence and then reassessed them 3 and 12 months later. Cross-lagged panel analyses revealed that PD and PTSD severity scores had significant autoregressive effects at both follow-up points and were highly correlated (rs = .50–.54) at each time point. However, when baseline levels of these variables were accounted for, PD no longer predicted later PTSD symptoms, and vice versa. This study used a more sophisticated analytic approach than Zoellner and colleagues, although models were run separately for the 3-month and 12-month time points, resulting in some loss of information about the overall trajectory of change. The results established that cross-sectional correlations between PD scores and the PTSD Checklist-Civilian were strong over a 12-month naturalistic follow-up. However, the degree to which these constructs might change in tandem during PTSD treatment remains unknown.

The goal of this study was to examine the degree to which self-reported PD changes over the course of treatment for PTSD. If patients can reliably report on their past experience of PD, then PDEQ scores should be stable regardless of the passage of time or participation in trauma-focused treatment. Furthermore, we also sought to determine whether participants’ symptom levels (of self- or clinician-rated PTSD symptoms, as well as self-rated depression symptoms as a proxy for more general distress) were related to their report of PD. We expected that PDEQ scores would change significantly over time and would be significantly positively related to concurrently assessed PTSD and depression symptoms.

Method

Participants

As part of a larger treatment outcome study (see Sloan, Marx, Lee, & Resick, 2018 for parent study CONSORT diagram), we enrolled 126 treatment-seeking adults with PTSD. The sample was 52% male and had a mean age of 43.9 (SD = 14.6); most participants were White (54.8%) or African American (34.1%) and non-Hispanic (90.5%). To be eligible, participants were required to meet DSM–5 PTSD diagnostic criteria (American Psychiatric Association, 2013) and be stable on any psychiatric medication for at least 4 weeks. Exclusion criteria were high risk for suicide, active psychosis or mania, severe cognitive impairment, current substance dependence, or current participation in other PTSD-focused psychotherapy. Participants reported a wide range of most distressing trauma exposures, including sexual assault (28.8%), physical assault or threats (15.2%), combat (12%), and motor vehicle or other accidents (12%), and the mean length of time since trauma was 194.37 months (SD = 180.11, range = 2–672). The study was approved by institutional review boards at Boston University and VA Boston Health care System, Boston, MA, and was registered on ClinicalTrials.gov. All participants provided written informed consent.

Measures

Peritraumatic Dissociative Experiences Questionnaire (PDEQ).

The PDEQ (Marmar, Weiss, & Metzler, 1997) is the most commonly used measure of PD and was used in the previously mentioned work of Zoellner et al. (2001) and Marshall and Schell (2002). It is a self-report measure consisting of 10 items, each scored on a range from 1 (not at all true) to 5 (extremely true); the total score of 10–50 is a sum of the individual item ratings. The PDEQ has shown good test–retest reliability (Marshall, Orlando, Jaycox, Foy, & Belzberg, 2002). Example items include “What was happening seemed unreal to me, like I was in a dream or watching a movie or play” and “My sense of time changed—things seemed to be happening in slow motion.” Cronbach’s alpha for the scale at baseline was .88.

Clinician-Administered PTSD Scale for DSM–5 (CAPS-5).

The CAPS-5 (Weathers, Blake, et al., 2013) is a structured diagnostic interview that assesses PTSD diagnostic status and symptom severity. The CAPS-5 has demonstrated strong interrater reliability, test–retest reliability, and validity (Weathers et al., 2018). In this study, assessors who were unaware of the treatment condition of participants and had at least a master’s degree in psychology administered the CAPS-5. Interrater reliability was good (κ = .85).

PTSD Checklist for DSM–5 (PCL-5).

The PCL-5 (Weathers, Litz, et al., 2013) is a 20-item self-report questionnaire assessing each of the DSM–5 PTSD symptoms over the past month. Total scores range from 0–80, with higher scores indicating greater symptom severity. The PCL-5 is psychometrically sound (Bovin et al., 2016) and has good temporal stability (Keane et al., 2014).

Beck Depression Inventory-II (BDI-II).

The BDI-II (Beck, Steer, & Brown, 1996) is a self-report questionnaire assessing depression symptoms over the past 2 weeks. Total scores range from 0–63, with higher scores indicating greater severity. The BDI-II is widely used and has good psychometric properties (Beck et al., 1996).

Procedure

Participants were recruited from the community via local announcements (Craigslist, flyers) and provider referrals and completed a baseline assessment. They were then randomized 1:1 to receive one of two treatments: cognitive processing therapy (CPT; Resick, Monson, & Chard, 2016), a 12-session intervention focusing on reevaluating maladaptive trauma-related thoughts (including written trauma accounts), or written exposure therapy (WET; Sloan & Marx, 2019), a five-session intervention focused on writing detailed descriptions of the traumatic event in response to specific prompts. Participants in both conditions met with a clinician for each session and completed follow-up assessments at 6, 12, 24, 36, and 60 weeks after the first treatment session. For further study design details, see Sloan, Marx, and Resick (2016). As has been reported previously, WET was found to be noninferior to CPT regarding change in PTSD symptom severity through both 36 (Sloan et al., 2018) and 60 weeks (Thompson-Hollands, Marx, Lee, Resick, & Sloan, 2018).

Data Analysis

First, we calculated overall averages of PDEQ scores across the sample and then calculated within-individual change scores. The reliable change index (Jacobson & Truax, 1991), a psychometric criterion of whether a change in an individual’s score is statistically significant, was calculated for the PDEQ. Following the formula described by Jacobson and Traux, using the baseline standard deviation from our sample (10.39) and published test–retest reliability for the PDEQ (.85; Marshall et al., 2002), reliable change was identified as instances of change ± 12 points from the baseline PDEQ total score. We quantified changes in PDEQ total scores over time using standardized mean gain scores (ESsg; Lipsey & Wilson, 2001). ESsg is a standardized effect size that can be interpreted like Cohen’s d but includes a correction for the association between two measurement occasions. Accordingly, this effect size is ideal for examining intraindividual change in repeated-measure designs.

Next, multilevel modeling (MLM; Raudenbush & Bryk, 2002) was conducted in R (R Core Team, 2017). We included all participants in the analyses, regardless of whether they dropped out of treatment, and all assessment time points through 60 weeks. Models consisted of time points nested within persons, and PDEQ scores were the dependent variable. Linear time was entered as number of weeks, centered at the baseline assessment. CAPS-5, PCL-5, and BDI-II scores were grand mean centered at each assessment point; there were no additional covariates entered. A model also was run examining the possible effect of treatment condition (CPT vs. WET) on PDEQ scores; treatment condition was not significantly predictive of either baseline PDEQ scores or change over time, so this was omitted from all models. All analyses were conducted using restricted maximum likelihood, except for deviance calculations which were conducted using maximum likelihood.

Results

Mean PDEQ scores were 27.66 (SD = 10.39) at baseline and 25.95 (SD = 12.75) at 60 weeks. The sample demonstrated wide heterogeneity in the amount of change in PDEQ scores from baseline to 60 weeks, as shown in Figure 1. Table 1 displays the number and percentage of participants at each time point who showed reliable change from their baseline PDEQ score. Collapsing across all follow-up time points, 23 participants (19.8%) experienced a reliable increase in PDEQ scores relative to baseline, and 30 participants (25.9%) experienced a reliable decrease in PDEQ scores relative to baseline. A very small number of participants (four, 3.4%) reported both a reliable increase and a reliable decrease in scores, at different time points. A slight majority of participants (57.8%) did not experience any reliable change in PDEQ scores following the baseline.

Figure 1.

Figure 1.

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Distribution of change in Peritraumatic Dissociative Experiences Questionnaire (PDEQ) total score from baseline to week-60 assessment.

Table 1.

Reliable Change in PDEQ Scores From Baseline at Each Assessment Point

Time point Reliable decrease in PDEQ Reliable increase in PDEQ
6 weeks 12 (10.6%) 15 (13.3%)
12 weeks 16 (14.4%) 7 (5.4%)
24 weeks 13 (13.0%) 10 (10.0%)
36 weeks 15 (15.2%) 2 (2.0%)
60 weeks 13 (12.5%) 11 (10.6%)
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Note. PDEQ = Peritraumatic Dissociative Experiences Questionnaire.

Standardized mean gain scores quantifying PDEQ score change over time are presented in Table 2. The point of greatest change was observed at the 36-week time point (ESsg = −.24), reflecting a small-magnitude decrease. Notably, on average, PDEQ scores evidenced a gradual decrease over time, with a small-magnitude rebound between 36 and 60 weeks (see Figure 2). Total PDEQ scores were significantly correlated with total CAPS-5 scores at every time point (rs = .24–.48, all ps < .05).

Table 2.

Effect Sizes for PDEQ Change Over Time

Sequential Cumulative
Session M SD ESsg SEsg 95% CI ESsg SEsg 95% CI
Baseline 27.66 10.39 — — — — — —
6 weeks 27.68 11.07 0.04 0.09 [−0.14, 0.22] 0.04 0.09 [−0.14, 0.22]
12 weeks 25.91 11.77 −0.18 0.17 [−0.51, 0.15] −0.13 0.13 [−0.38, 0.12]
24 weeks 25.75 11.67 −0.03 0.07 [−0.17, 0.11] −0.13 0.13 [−0.38, 0.12]
36 weeks 24.21 11.54 −0.10 0.10 [−0.30, 0.10] −0.24 0.21 [−0.65, 0.17]
60 weeks 25.95 12.75 0.08 0.09 [−0.10, 0.26] −0.11 0.12 [−0.35, 0.13]
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Note. CI = confidence interval; ESsg = standardized mean gain score; SEsg = standard error of the standardized mean gain score.

Figure 2.

Figure 2.

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Cumulative PDEQ standardized mean gain scores.

For the primary MLM analyses, we first tested an initial model of change in PDEQ scores over time; this model included fixed effects of the intercept and linear time, as well as random effects for the intercept and slope. As shown in Table 3 (Model 1), all fixed effects were significant, indicating that there were significant decreases in PDEQ scores over the course of the study.

Table 3.

Parameter Estimates for Models of PDEQ Scores Over Time

Model 1 Model 2 Model 3 Model 4
Fixed effects Estimate SE Estimate SE Estimate SE Estimate SE
Intercept 28.04*** 0.90 28.02*** 0.86 27.36*** 0.79 27.32*** 0.81
Time −0.14** 0.04 −0.14*** 0.04 −0.04** 0.01 −0.04** 0.01
CAPS-5 total score Not included 0.12*** 0.03 Not included Not included
PCL-5 total score Not included Not included 0.15*** 0.02 Not included
BDI-II total score Not included Not included Not included 0.18*** 0.03
Deviance 4,563.94 4,548.74 4,525.50 4,536.46
AIC 4,581 4,573 4,551 4,561
BIC 4,608 4,605 4,582 4,592
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Note. SE = standard error; CAPS-5 = Clinician-Administered PTSD Scale for DSM–5; PCL-5 = PTSD Checklist for DSM–5; BDI-II = Beck Depression Inventory-II; AIC = Akaike information criterion; BIC = Bayesian information criterion.

**

p < .01.

***

p < .001.

Next, we tested a model with CAPS-5 total scores as a time-varying covariate, keeping the remainder of the variables unchanged (Table 3, Model 2). CAPS-5 scores significantly contributed to the prediction of PDEQ scores (p < .001) such that for every 1-point increase in CAPS-5 scores from the sample mean on a given occasion, PDEQ scores at that occasion rose by 0.12 points. The slope remained significant in Model 2, indicating that PDEQ scores decreased over and above what is explained by concurrent clinician-rated PTSD symptoms. Overall, Model 2 showed improved fit compared with Model 1.

Next, we tested a model with PCL-5 total scores as a time-varying covariate instead of CAPS-5 total scores (Table 3, Model 3). PCL-5 scores significantly contributed to the prediction of PDEQ scores (p < .0001) such that for every 1-point increase in PCL-5 scores from the sample mean on a given occasion, PDEQ scores at that occasion rose by 0.15 points. The slope remained significant in Model 3, indicating that PDEQ scores decreased over and above what is explained by concurrent self-reported PTSD symptoms. Model 3 showed improved fit compared with Model 2.

We next tested a model that included BDI-II total scores as a time-varying covariate (Table 3, Model 4). BDI-II scores significantly contributed to the prediction of PDEQ scores (p < .0001) such that for every 1-point increase in BDI-II scores from the sample mean on a given occasion, PDEQ scores at that occasion rose by 0.18 points. The slope remained significant in Model 4, indicating that PDEQ scores decreased over and above what is explained by concurrent self-reported depression symptoms. Model 4 did not show superior fit compared with Model 3, indicating that the model using PCL-5 scores was the best fitting.

Discussion

Results of this study make clear that for a substantial minority of individuals, scores on the PDEQ change over the course of PTSD treatment. Although the literature on PD has largely assumed that this is a phenomenon about which individuals can accurately and consistently report, our knowledge of the nature of traumatic memories suggests this assumption should be approached with caution. Even when people are asked to report more objective details regarding their traumatic experiences, inconsistency is common (e.g., Arnow et al., 1999; King et al., 2000; Krinsley et al., 2003; Roemer et al., 1998). For example, Southwick and colleagues (1997) assessed a sample of National Guard soldiers 1 month after their return from deployment in the Gulf War and again 2 years later. On both occasions, the soldiers completed a questionnaire regarding whether they experienced a variety of situations during deployment (e.g., seeing others killed or wounded, being stationed close to enemy lines), and 88% changed their responses to at least one item between the two assessments. Levels of PTSD symptoms have been related variably to increased reporting of traumatic experiences (e.g., Roemer et al., 1998; Wessely et al., 2003). Given the landscape of inconsistent trauma exposure reporting, it is perhaps unsurprising that reports of the details of a traumatic experience (i.e., the extent of PD) also would shift over time. Although the overall mean change in PDEQ scores from baseline to 60 weeks was small in the present study, a substantial minority of study participants (>40%) reported reliable changes over the course of the study. That reliable changes were seen across a large subgroup suggests that PDEQ scores at any one time point should not be automatically considered to be reliable and valid. Such a finding decreases confidence in much of the PD literature. Clinically, our results may suggest that PD would be better assessed in an interview format, where clinicians can probe responses and attempt to clarify the extent of disorientation. However, dissociation will likely remain an experience that is difficult to describe “objectively” as it by nature involves confusion and an altered perception of self/other/time.

We also found that self-reported PTSD symptoms account for a significant component of PDEQ scores at any one time. One potential explanation is that as individuals begin to improve over the course of PTSD treatment, they may retrospectively view their traumatic experiences as less overwhelming and consequently report that less dissociation occurred. Another possibility is that responding on the PDEQ is influenced in part by current symptom severity and distress, which decreases over the course of treatment. The reason that PCL-5 scores, rather than CAPS-5 or BDI-II scores, provided the best model fit in terms of predicting the PDEQ changes may be that both trauma symptomatology and distress are at play. Self-report measurements of PTSD symptoms allow individuals to select higher (or lower) scores for each individual item than might be rated by a clinician; those respondents who were feeling especially distressed at a given time might therefore have rated themselves very highly on both the PCL-5 and the PDEQ, but this “distress effect” would have been somewhat blunted when looking at CAPS-5 scores. Finally, treatment itself may change the structure and organization of the traumatic memory, including recollected PD. As patients are asked to reflect deeply on their traumatic experience in ways that they may have been avoiding prior to treatment, this could cause the memory itself to become clearer and better organized.

A primary limitation of our study is the long mean delay between participants’ trauma experience and the first PDEQ administration. However, because our focus was not on what peritraumatic dissociation does or does not predict (e.g., PTSD symptoms or diagnostic status, functional impairment), but rather on whether and how PDEQ scores change in the context of PTSD treatment and follow-up, and how that might impact our understanding of what the PDEQ is measuring, the time since the traumatic event is not a substantial study limitation. Nonetheless, the broad range of time since trauma in our sample (2 months to 56 years) means that we may be capturing many different patterns of change. We strongly encourage the examination of longitudinal PDEQ scores among samples with a more homogeneous time since trauma.

Additional possible limitations include our sample’s mix of trauma types. Previous PDEQ research also has included samples with mixed trauma types (e.g., Hetzel-Riggin & Meads, 2016), and the majority of individuals who meet criteria for PTSD have experienced multiple Criterion A events (Kilpatrick et al., 2013), making this a highly relevant sample for understanding the course of PD reporting among a typical clinical population. Nevertheless, it is possible that individuals with a single, discrete trauma will show different patterns than those with less complex trauma histories.

Conclusion

Given the role of peritraumatic dissociation in various theories of trauma processing and/or PTSD development, it is critical that both measures for assessing this variable be valid and reliable—that is, we must be accurate regarding what we are actually measuring versus what we believe we are measuring. The PDEQ has been purported to measure the actual psychological and sensory experience of an individual at the time of a trauma; it has been implied, by the developers and by researchers who have subsequently used the scale, that scores on the measure are time invariant. We are not suggesting that PDEQ scores specifically, or assessments of peritraumatic reactions more generally, are not important to our understanding of trauma and recovery (Bovin & Marx, 2011). Instead, we suggest that, based on the cumulative findings as well as on theoretical critiques of the peritraumatic dissociation literature, researchers invest effort into more basic studies of this phenomenon. Importantly, much previous research has neglected to consider the current psychological state of the respondent (i.e., symptomatology, mood) and situational factors (i.e., treatment context, passage of time) when drawing conclusions regarding the association between the PDEQ and other measures. “Peritraumatic dissociation” as measured by the PDEQ has been treated as an objective, invariant measurement about the traumatic experience rather than as a subjective report that may be related to the “true” level of peritraumatic dissociation but is also highly influenced by the individual’s current symptoms and potentially cognitive variables. Tracking individuals’ PDEQ scores over time, beginning as close to the trauma as possible and including measures of other variables that could conceivably impact recall or reporting of dissociative experiences, will be critical.

The large number of studies that have found an association between PDEQ scores and PTSD indicate that this measure is detecting something significant regarding the etiology or maintenance of the disorder. However, deficits of previous research designs mean conclusions about the role of PD have outpaced what we can responsibly claim to understand. The fact that individuals’ PDEQ scores vary over time is meaningful and not a source of error in terms of our understanding of trauma, but only if we are willing to reevaluate what the measure may be telling us about patients’ experience.

Clinical Impact Statement.

The extent to which people report that they dissociated during a traumatic event changes as they undergo treatment for their posttraumatic stress disorder (PTSD) and is related to the severity of their self-reported PTSD symptoms, suggesting that such reports should be interpreted with caution.

Acknowledgments

This project was supported by Grant R01 MH095737 from the National Institute of Mental Health awarded to Denise M. Sloan. Johanna Thompson-Hollands was supported by the Department of Veterans Affairs (Clinical Sciences Research and Development Service Award IK2 CX001589). Daniel J. Lee was supported by National Institute of Mental Health Award T32MH019836. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. government. This study was reviewed and approved by the institutional review boards of VA Boston Healthcare System and Boston University. The data that support the findings of this study are available from Johanna Thompson-Hollands upon reasonable request.

Contributor Information

Daniel J. Lee, National Center for PTSD at VA Boston Healthcare System, Boston, Massachusetts

Denise M. Sloan, National Center for PTSD at VA Boston Healthcare System, Boston, Massachusetts, and Boston University School of Medicine

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