Posttraumatic Stress Disorder 505
anxiety disorders, although the median delay in initial treatment contact was 12 years
(Wang, Berglund, et al., 2005; Wang, Lane, et al., 2005). With an increased utilization
of primary health and mental health services coupled with significant functional impair-
ment, PTSD is associated with higher health costs than the other anxiety disorders
(Marciniak et al., 2005; Walker et al., 2003). Tanielian and Jaycox (2008), for example,
concluded that the 2-year costs resulting from PTSD and major depression for the 1.6
million service members deployed since 2001 could range from $4.0 to $6.2 billion but
the provision of evidence-based treatment could reduce this cost by 27%. Clearly, the
elevated disability and economic burden caused by chronic PTSD makes this disorder a
serious societal health concern.
Clinician Guideline 12.9
Chronic PTSD is associated with some of the highest rates of disability, poor physical health,
and reduced social functioning among the anxiety disorders. The disorder takes a heavy
toll in human suffering and places a significant economic burden on the health care system.Comorbidity
Like the other anxiety disorders, PTSD is associated with a high comorbidity rate with
other Axis I disorders. In the NCS 88% of men with lifetime occurrence of PTSD and
79% of women had at least one other Axis I diagnosis (Kessler et al., 1995). Half of the
men with PTSD had a comorbid major depression or alcohol abuse/dependence, with
conduct disorder (43%), drug abuse/dependence (35%), simple phobia (31%), social pho-
bia (28%), and dysthymia (21%) also showing high rates of co- occurrence. For women
with PTSD, major depression (49%), simple phobia (29%), social phobia (28%), alcohol
abuse/dependence (28%), drug abuse/dependence (27%), dysthymia (23%), and agora-
phobia (22%) were common secondary diagnoses (see also Zlotnick et al., 2006, for
similar comorbidity rates). The temporal relationship among diagnoses is complex, with
many comorbid disorders occurring as a consequence of PTSD, and yet most people
with PTSD have at least one preexisting diagnostic disorder (Kessler et al., 1995). Even
higher comorbidity may be evident in clinical samples with PTSD. In their large out-
patient sample, Brown, Campbell, et al. (2001) reported that 98% of individuals with
an index diagnosis of PTSD had at least one comorbid disorder. The most common co-
occurring diagnoses were major depression (65%), panic disorder (55%), GAD (45%),
and social phobia (41%). Rates of substance abuse/dependence were not reported.
The relationship of major depression and PTSD to traumatic events is especially
important because both disorders are highly comorbid and they both can occur concur-
rently as distinct disorders in traumatized individuals (Blanchard, Buckley, Hickling, &
Taylor, 1998; Kilpatrick et al., 2003). Moreover, individuals with PTSD and comorbid
major depression are more distressed, more impaired on major role functions, more
likely to attempt suicide, and less likely to remit than individuals with PTSD alone
(Blanchard et al., 1998; Oquendo et al., 2003).
A high comorbidity rate is also evident between substance abuse/dependence disor-
ders and PTSD. A review of the relevant literature indicates that PTSD usually precedes