Longitudinal Analysis of the Relationship Between Symptoms and Quality
of Life in Veterans Treated for Posttraumatic Stress Disorder
Paula P. Schnurr
National Center for Post-Traumatic Stress Disorder, U.S.
Department of Veterans Affairs, and Dartmouth Medical School
Andrew F. Hayes
The Ohio State University
Carole A. Lunney
National Center for Post-Traumatic Stress Disorder,
U.S. Department of Veterans Affairs
Veterans Affairs Puget Sound Healthcare System
and University of Washington School of Medicine
New Orleans Veterans Affairs Medical Center
This study examined how change in posttraumatic stress disorder (PTSD) symptoms relates to change in
quality of life. The sample consisted of 325 male Vietnam veterans with chronic PTSD who participated
in a randomized trial of group psychotherapy. Latent growth modeling was used to test for synchronous
effects of PTSD symptom change on psychosocial and physical health-related quality of life within the
same time period and lagged effects of initial PTSD symptom change on later change in quality of life.
PTSD symptoms were associated with reduced quality of life before treatment. There were synchronous
effects of symptom change on change in quality of life but no significant lagged effects. Results indicate
the importance of measuring quality of life in future investigations of PTSD treatment.
Keywords: posttraumatic stress disorder, quality of life, military veterans, group psychotherapy
Individuals with posttraumatic stress disorder (PTSD) experi-
ence reduced quality of life (e.g., Magruder et al., 2004; Schonfeld
et al., 1997; Stein, Walker, Hazen, & Forde, 1997). For example,
a recent study found that 59% of PTSD patients had severe quality
of life impairment, which was comparable to 63% of patients with
major depression (Rapaport, Clary, Fayyad, & Endicott, 2005).
Furthermore, prospective cohort studies have found that initial
PTSD predicts poor life quality at subsequent follow-up intervals
(Holbrook, Hoyt, Stein, & Sieber, 2001; Michaels et al., 1999;
Zatzick, Jurkovich, Gentilello, Wisner, & Rivara, 2002). There
also is growing evidence that quality of life improves following
treatment for PTSD (e.g., Foa et al., 1999; Rapaport, Endicott, &
Clary, 2002; Tucker et al., 2001).
Including quality of life as an outcome in studies of PTSD
symptom-focused treatment reflects the assumption that reduced
quality of life is secondary to symptoms. However, the observation
of improvements in both symptoms and quality of life is only an
indirect reflection of the relationship between these domains. Fur-
thermore, such studies fail to capture lagged relationships. Time
may be needed in order for immediate improvement in symptoms
to affect quality of life. For example, a person whose avoidance
and irritability decrease following treatment may not show im-
provements in social functioning for months afterward because of
the time it takes to make and rebuild friendships. The effects of
PTSD symptom improvement on physical health might be delayed
given the complexity of factors hypothesized to underlie the rela-
tionship between PTSD and poor physical health (Schnurr &
We used latent growth modeling to fit a longitudinal model to
examine how change in PTSD symptoms relates to change in
quality of life. Data came from veterans with chronic PTSD who
took part in a randomized clinical trial of group psychotherapy
that compared trauma-focused and present-centered approaches
(Schnurr, Friedman, Lavori, & Hsieh, 2001). The year-long treat-
ment consisted of 30 weekly sessions to help patients reduce
symptoms, followed by 5 monthly sessions to help patients main-
tain their gains. Both conditions showed significant and compara-
Paula P. Schnurr, National Center for Post-Traumatic Stress Disorder,
U.S. Department of Veterans Affairs, and Department of Psychiatry, Dart-
mouth Medical School; Andrew F. Hayes, School of Communication, The
Ohio State University; Carole A. Lunney, National Center for Post-
Traumatic Stress Disorder, Department of Veterans Affairs; Miles McFall,
VA Puget Sound Healthcare System and Department of Psychiatry and
Behavioral Sciences, University of Washington School of Medicine; and
Madeline Uddo, New Orleans VA Medical Center.
This research was supported by a grant to Paula P. Schnurr from the U.S.
Veterans Affairs Cooperative Studies Program. A version of the paper was
presented in November 2005 as a poster at the annual meeting of the
International Society for Traumatic Stress Studies, Toronto, Canada. The
views expressed in this article are those of the authors and do not neces-
sarily represent the views of the National Center for Post-Traumatic Stress
Disorder or the U.S. Department of Veterans Affairs.
Correspondence concerning this article should be addressed to Paula P.
Schnurr, National Center for Post-Traumatic Stress Disorder (116D), U.S.
Veterans Affairs Medical Center, White River Junction, VT 05009. E-mail:
Journal of Consulting and Clinical Psychology
2006, Vol. 74, No. 4, 707–713
In the public domain
ble improvement in PTSD symptoms. Although treatment was not
associated with improved quality of life, there were marked intra-
individual changes on all of the measures used.
Figure 1 depicts our model, which is described in greater detail
below. The two treatment phases in the original study enabled us
to examine whether there were (a) synchronous effects of PTSD
symptom change on quality of life change within the same phase
and (b) lagged effects of PTSD symptom change during initial
weekly treatment on change in quality of life during subsequent
monthly treatment. We expected that higher PTSD severity would
be associated with poorer quality of life at baseline and that there
would be synchronous change during both phases. Prior evidence
did not provide a basis for hypothesizing that there also would be
lagged effects, although such effects are logically plausible. Qual-
ity of life includes psychosocial and physical elements (Gladis,
Gosch, Dishuk, & Crits-Christoph, 1999; Mendlowicz & Stein,
2000). We fitted a separate model for each domain because it was
possible that relationships between changes in symptoms and in
quality of life would differ across domains.
Participants were 325 male Vietnam veterans with PTSD in a random-
ized clinical trial of group therapy for PTSD (Schnurr et al., 2001, 2003).
They had to agree to terminate other PTSD treatment except for 12-step
programs and, if on psychoactive medication, be on a stable regimen for 2
months before the study. Exclusion criteria, based on the Diagnostic and
Statistical Manual of Mental Disorders (4th ed. [DSM–IV]; American
Psychiatric Association, 1994) were the following: current or lifetime
psychotic disorder, mania, or bipolar disorder; current major depression
with psychotic features; current alcohol or drug dependence; unwillingness
to refrain from substance abuse at treatment or work; significant cognitive
impairment; and severe cardiovascular disorder.
Thirty-five veterans from the original sample of 360 were excluded
because they did not participate in any follow-up assessments. These 35
men were comparable to the 325 included men on almost all measures,
including the primary PTSD outcome (Schnurr et al., 2003).
Participants’ average age was 50.69 years (SD ? 3.68). Two hundred
fifteen (66.2%) were White, 74 (22.8%) were Black, and 36 (11.0%) were
from other ethnic groups; 23 across all groups (7.1%) were Hispanic. Most
had graduated from high school (90.2%, n ? 290), and half (50.2%, n ?
163) were unemployed. The majority (70.8%, n ? 230) received Veterans
Affairs (VA) disability payments for a physical or mental problem; 60.6%
(n ? 197) were service-connected for PTSD.
toms. The Clinician-Administered PTSD Scale (CAPS; Weathers, Keane,
& Davidson, 2001) is a structured interview in which the frequency and
intensity of each of the 17 DSM-IV PTSD symptoms is rated on a 5-point
scale (ranging from 0–4). Scores are summed to create a total severity
measure. A change of ?10 points (roughly 0.5 SD) is defined as a
clinically significant change. The PTSD Checklist (PCL; Weathers, Litz,
Herman, Huska, & Keane, 1993) questionnaire contains the 17 DSM-IV
PTSD symptoms, rated on a 5-point scale ranging from 1 (not at all) to 5
(extremely). It has very good sensitivity and specificity for a diagnosis of
PTSD. The 12-item General Health Questionnaire (GHQ; Goldberg, 1992)
has good sensitivity and specificity as a measure of PTSD in a traumatized
sample (McFarlane, 1986). Symptoms are rated on a 4-point scale ranging
from 1 (much less than usual) to 4 (much more than usual). Higher scores
reflect higher symptom severity for each of these scales.
Quality of life.
Quality of life was measured with the Short-Form
Health Survey (SF-36; Ware & Sherbourne, 1992) and the Quality of Life
Inventory (QOLI; Frisch, 1994). Both instruments have excellent psycho-
metric properties (Frisch, 1994; Frisch et al., 2005; Gladis et al., 1999;
Three indicators were used to assess PTSD symp-
posttraumatic stress disorder; QoL ? quality of life.
Multivariate latent growth model with cross-domain estimation of change parameters. PTSD ?
SCHNURR, HAYES, LUNNEY, MCFALL, AND UDDO
McHorney, Ware, Rogers, Raczek, & Lu, 1992). The SF-36 has been
recommended as the best all-purpose instrument for assessing quality of
life in those with anxiety disorders (Mendlowicz & Stein, 2000). SF-36
scores range from 0 to 100, with higher scores reflecting better outcomes.
Four of its eight scales reflect mental/emotional/social functioning and
well-being; the other four scales reflect physical functioning and health
perceptions. On the QOLI, each of 16 aspects of life (e.g., work, friend-
ship) is rated in terms of satisfaction (?3 ? very dissatisfied to 3 ? very
satisfied) and importance (0 ? not at all important to 2 ? extremely
important). For items with non-zero importance ratings, each satisfaction
rating is weighted by its importance value and then averaged to form a
composite that ranges from ?6 (most negative) to 6 (most positive).
As indicated above, our analyses separately examined psychosocial and
physical domains. There were three indicators of psychosocial quality of
life: the QOLI and the SF-36 Social Functioning and Role—Emotional
scales. We selected these SF-36 scales because their content explicitly
addresses psychosocial functioning; Mental Health and Fatigue were ex-
cluded to avoid the observation of spurious relationships with the PTSD
measures. The 4 physical health scales from the SF-36 were used as
indicators of physical health-related quality of life: Physical Functioning,
Role—Physical, Bodily Pain, and General Health.
Written informed consent was obtained from each participant after the
study procedures had been explained, prior to data collection and the
initiation of treatment. Across 10 VA Medical Centers, participants were
randomly assigned to either trauma-focused group therapy (TFGT; Foy,
Glynn, Ruzek, Riney, & Gusman, 1997) or present-centered group therapy
(PCGT). In TFGT, exposure is conducted in a group context that includes
psychoeducation, cognitive restructuring, relapse prevention, and coping
skills training. PCGT includes nonspecific and supportive kinds of inter-
ventions in order to control for the nonspecific benefits of the group
experience. It does not include exposure or the other elements of TFGT.
Each treatment group consisted of 6 participants. Two master’s- or
doctoral-level clinicians conducted treatment using a manualized protocol.
Weekly group therapy was provided for 30 weeks, followed by monthly
group booster sessions for 5 months. Assessments were performed at
baseline, 7 months (the end of weekly sessions), and 12 months (the end of
monthly sessions). Assessments were done by a master’s- or doctoral-level
clinician blind to group assignment.
We estimated separate structural equation models for the two quality of
life domains, each with two components: (a) a multivariate latent growth
measurement model estimating baseline and change in PTSD symptoms
and quality of life during the study and (b) a structural component linking
the baseline and change estimates from the latent growth models (e.g.,
MacCallum, Kim, Malarkey, & Kiecolt-Glaser, 1997; Willet & Sayer,
1994). The model is shown in Figure 1.1We used a two-step approach, first
estimating a good-fitting measurement model, then estimating the struc-
tural component. Parameter estimates were derived through maximum
likelihood using M-plus (Muthe ´n & Muthe ´n, 1998).2
The measurement component of the model was estimated separately for
PTSD symptoms and for the two quality of life domains to estimate change
in PTSD symptoms and quality of life over time, with change treated as a
random effect. Underneath the latent growth model is a factor analytic
model of PTSD symptoms and quality of life, with each construct mea-
sured with the same indicators measured over time (three for PTSD and
psychosocial quality of life; four for physical health-related quality of life).
Each participant’s change estimates represented his average monthly
change in latent symptoms or quality of life (a) between baseline and 7
months and (b) between 7 and 12 months.3Changes over time are indexed
relative to the baseline factor mean (constrained to zero). Positive values
indicate an increase and negative values indicate a decrease in symptoms
or quality of life.
The structural model was used to examine (a) synchronous effects of
PTSD on quality of life, that is, whether change in PTSD symptoms
predicted change in psychosocial or physical health-related quality of life
during the same treatment phase and (b) lagged effects, that is, whether
change in symptoms during initial weekly treatment predicted change in
quality of life during subsequent monthly treatment.4We also assessed
whether change in quality of life depended on baseline symptoms. The
structural parameters were estimated as fixed effects.
In exploratory analyses, we tested the possibility of causal paths from
change in quality of life to symptom change by reversing the direction of
the paths in the structural model. That is, PTSD symptoms were treated as
the outcome, and paths went from baseline quality of life and the two
quality of life change estimates to the two PTSD symptom change esti-
mates. These analyses were the same as the primary analyses in all other
Information about the latent growth measurement model is
presented in Table 1. All three measurement models fit well
according to conventional cutoff criteria (Hu & Bentler, 1999).
Except for baseline psychosocial quality of life, reliabilities
reached traditionally acceptable levels, although reliability was
slightly lower for the psychosocial domain than for the physical
The observed means and factor loadings at each time period are
presented in Table 2. The observed means show that the sample
had significant PTSD and poor psychosocial and health-related
quality of life according to definitions or norms for the individual
measures. For example, on the CAPS, scores of 40–59 are con-
sidered “PTSD” and scores of 60–79 are considered “severe
PTSD” (Weathers et al., 2001). On the SF-36, scores for the
current sample fell between 1 and 2 SDs below norms for the U.S.
general population, which range from 70.1 to 83.0 on the four
1Not depicted in Figure 1 are the error correlations between each
indicator over time to account for associations between the same indicator
not attributable to change in the latent variable over time. Model fit was
always improved by freely estimating these covariances rather than fixing
them to zero. Residuals in the estimation of the quality of life change
parameters are also not shown in Figure 1 but are represented as d1 and d2
in Figure 2.
2Full information maximum likelihood (FIML) was used to handle
missing data, which was assumed to be missing at random. When listwise
deletion was used, there were no qualitative changes to the results.
3To interpret these estimates as desired and to identify the model,
several constraints had to be imposed: (a) factor loadings for each indicator
were constrained to be constant over time, making the scores on the latent
variables comparable over time; (b) intercepts of the model estimating each
indicator were constrained to be constant over time; (c) factor intercepts
were fixed to zero; (d) the factor loading for the first indicator was fixed to
1 at each time point; (e) factor variances were fixed at 1; and (f) the
baseline factor mean was constrained to zero.
4We fit an additional structural model that included age, therapy type,
ethnicity (White vs. non-White) and education as additional predictors of
change in quality of life. Because none of these variables significantly
predicted quality of life change and none of the structural coefficients
linking change to change were qualitatively affected by including these
predictors, we do not discuss this more complicated model.
SYMPTOMS AND QUALITY OF LIFE IN VETERANS WITH PTSD
physical health subscales and from 83.1 to 83.6 on the two psy-
chosocial health subscales we used (QualityMetric Incorporated,
The coefficients for mean latent monthly change indicate a
statistically significant average reduction in PTSD from baseline to
the end of weekly treatment but no significant change during
monthly treatment (Table 1). The intraindividual change was sub-
stantial, for example, on the CAPS, 38.2% of the sample had
clinically significant improvement and 18.6% had clinically sig-
nificant worsening from 0 to 7 months. There was no average
change in either quality of life domain during either phase; how-
ever, the statistically significant variances reflect meaningful in-
dividual differences comparable to those observed on the CAPS.
For example, on the QOLI, 24.5% of the sample improved and
20.7% worsened from 0 to 7 months by ?0.50 SD. During the
same time, 16.5% to 25.8% improved and 19.6%–26.4% worsened
by ?0.50 SD on the SF-36 subscales.
In Figure 2 we graphically display the structural model and
structural parameter estimates for psychosocial and physical qual-
ity of life domains. Although the figure displays only the structural
model, it is important to keep in mind that the structural model and
the measurement model are combined at this stage of the analysis
into a single omnibus model. The overall models fit the data well
by traditionally accepted standards, CFI ? .97, RMSEA ? 0.06,
?2(121) ? 248.16, p ? .001, for psychosocial quality of life, and
CFI ? .98, RMSEA ? 0.04, ?2(176) ? 272.42, p ? .001, for
physical health-related quality of life.
At baseline, higher PTSD symptom severity was associated with
poorer psychosocial quality of life (Figure 2). There were synchro-
nous effects of PTSD symptom change from 0 to 7 months and
from 7 to 12 months. Improvement in symptoms was associated
with an improvement in quality of life. The lagged effect of PTSD
symptom change was not statistically significant, that is, symptom
change from 0 to 7 months did not predict quality of life change
from 7 to 12 months. Baseline PTSD symptoms significantly
predicted change in psychosocial quality of life from 0 to 7
months, but not from 7 to 12 months. Participants with higher
PTSD symptom severity at baseline improved in psychosocial
quality of life during weekly treatment more so than those with
relatively fewer PTSD symptoms. Overall, the model explained
77% and 49% of the variance in change in psychosocial quality of
life from 0 to 7 months and from 7 to 12 months, respectively.
The results for physical health–related quality of life were
highly similar to the results for psychosocial quality of life (Figure
Latent Growth Measurement Model Results
quality of life
Latent variable reliabilities
Mean latent monthly change
Baseline to 7 months
7 to 12 months
Baseline to 7 months
7 to 12 months
Goodness of fit
Note. N ? 325. PTSD ? posttraumatic stress disorder; QoL ? quality of
life; CFI ? comparative fit index; RMSEA ? root mean square error of
approximation. Reliability for each construct was estimated as (?j?j)2/[(?j
?j)2??j(1 ? ?j
* p ? .05.*** p ? .001.
2)], where ?jis the standardized factor loading for indica-
Latent Variable Indicator Means, Standard Deviations, and Factor Loadings
Observed means Factor loadings
Baseline7 months12 monthsBaseline 7 months12 months
Psychosocial quality of life
Physical quality of life
Checklist; QOLI ? Quality of Life Inventory. Numbers in parentheses beside observed means are standard deviations. Numbers in parentheses beside factor
loadings are unstandardized factor loadings. Factor loadings are from the measurement model constraining factor loadings to be invariant over time.
PTSD ? posttraumatic stress disorder; CAPS ? Clinician-Administered PTSD Scale. GHQ ? General Health Questionnaire; PCL ? PTSD
SCHNURR, HAYES, LUNNEY, MCFALL, AND UDDO
2). Higher PTSD symptom severity was associated with poorer
quality of life at baseline. There were synchronous effects of PTSD
symptom change during both treatment phases; symptom improve-
ment was associated with improvement in quality of life. The
lagged effect of symptom change on health-related quality of life
was not statistically significant. Baseline PTSD symptoms did not
predict change in the physical health domain during either phase.
The magnitude of the relationship between PTSD symptoms and
health-related quality of life was weaker than in the psychosocial
domain. Overall, the model explained 19% of the variance in
change in physical health–related quality of life from 0 to 7 months
and 13% of the variance in change from 7 to 12 months.
In the analyses performed to examine causal paths from quality
of life to symptoms, the reversed model for psychosocial quality
of life fit slightly worse than the original model, CFI ? .96,
RMSEA ? 0.06, ?2(121) ? 260.81, p ? .001. As in the original
model, only the synchronous effects were significant. Baseline
quality of life did not predict change in PTSD symptoms during
either phase. For physical health-related quality of life, the fit of
the reversed model was similar to the fit of the original model,
CFI ? .98, RMSEA ? 0.04, ?2(176) ? 270.21, p ? .001. The only
notable difference was a significant lagged effect from quality of
life change from 0 to 7 months to PTSD symptom change from 7
to 12 months (standardized path coefficient ? ?.20, p ? .05).
To our knowledge, this is the first study to directly examine how
change in PTSD symptoms relates to change in quality of life
among individuals with PTSD. Higher PTSD severity was associ-
ated with poorer psychosocial and physical health–related quality
of life at the beginning of treatment, a finding that is consistent
with results of cross-sectional studies (e.g., Magruder et al., 2004;
Rapaport et al., 2005). Although there were no overall improve-
ments in quality of life among participants in the original treatment
study (Schnurr et al., 2003), we found that there was a significant
7 to 12
0 to 7
7 to 12
0 to 7
PTSD SYMPTOMS QUALITY OF LIFE
baseline and change in posttraumatic stress disorder (PTSD) symptoms. Results for psychosocial quality of life
(QoL) are presented to the left of the slash, with physical health-related QoL results presented to the right.
Numbers beside bidirectional arrows are correlations, and unidirectional arrows are standardized path coeffi-
cients. *p ? .05; **p ? .01; ***p ? .001.
Structural model estimating change in psychosocial and physical health-related quality of life from
SYMPTOMS AND QUALITY OF LIFE IN VETERANS WITH PTSD
amount of change within individual participants and that this
change was related to PTSD symptom change. Our study builds on
prior longitudinal investigations (e.g., Holbrook et al., 2001;
Zatzick et al., 2002) by explicitly assessing how change in PTSD
symptoms is related to change in quality of life. These relation-
ships occurred synchronously, that is, during the same period of
time. Initial symptom change was unrelated to later changes in
quality of life.
More evidence is needed before firm conclusions about the
absence of lagged effects can be drawn. Perhaps the minimal
impact of treatment or the small average change in either symp-
toms or quality of life in the original study impaired our ability to
detect such effects. However, we believe that this is an insufficient
explanation given the marked intraindividual change and the sub-
stantial synchronous relationships we observed. Although lagged
effects should be explored in a study with greater average treat-
ment effects, it also would be useful to examine how PTSD
symptom change relates to specific elements of quality of life (e.g.,
social, occupational), which might vary in response to the reduc-
tion in symptoms.
Results were consistent across psychosocial and physical do-
mains of quality of life but were much stronger for the psycho-
social domain. This may be due to the overall poor physical health
of our sample, but additional factors may be relevant. It is easy to
understand how reductions in nightmares, intrusive thoughts, and
hypervigilance could affect life satisfaction or functioning. It is
perhaps more difficult to understand how reducing PTSD symp-
toms could affect physical health, despite evidence that PTSD is
associated with poor health (see Schnurr & Green, 2004). The
discussion of mechanisms by which PTSD might affect health is
beyond the scope of this article; biological, psychological, and
behavioral factors are likely to be involved (Schnurr & Green,
2004). Nevertheless, our results extend current knowledge by
showing how changes in PTSD symptoms are related to changes in
physical health–related quality of life.
Our primary focus was unidirectional given the literature, which
has emphasized the effect of PTSD symptoms on quality of life. In
exploratory analyses to examine the effect of change in quality of
life on symptom change, we observed findings similar to the
primary results, although we also found a lagged effect of initial
change in physical health–related quality of life on subsequent
change in PTSD. It is likely that symptoms and quality of life
interact mutually over time over time, with life events such as
divorce and job loss worsening symptoms and symptom resolution
leading to improved social and occupational functioning. An ideal
context in which to address this issue would be a treatment study
in which there were clinically meaningful treatment effects, ob-
jective and subjective quality of life measures, and more frequent
measurement intervals to capture the dynamic interplay between
symptoms and quality of life.
Caution in generalizing our findings to other PTSD samples is
warranted. Our sample consisted of middle-aged male veterans
with chronic PTSD. Two thirds were White, and 70% were re-
ceiving disability compensation. Prior to generalizing our findings
to all PTSD patients, it would be useful to apply our methods to
data from a more diverse and less impaired sample that showed
greater average improvements in PTSD symptoms and quality of
Despite these limitations, our statistical approach is worth not-
ing. The advantages of latent growth models to assess change as
compared with difference score analysis are well known, the most
important being more reliable measurement of change (e.g., Dun-
can, Duncan, Strycker, Li, & Alpert, 1999; MacCallum et al.,
1997). Using multiple indicators of symptoms and quality of life in
a latent variable measurement model allowed us to further improve
reliability. Unlike studies that have examined whether treating
PTSD symptoms improves quality of life, our approach allowed us
to examine both synchronous and lagged effects and to quantify
the magnitude of these effects in the context of optimal measure-
Our observation of the relationship between change in PTSD
and change in quality of life complements evidence that success-
fully treating PTSD results in improved quality of life (e.g., Foa et
al., 1999; Rapaport et al., 2002; Tucker et al., 2001). In their
thoughtful discussion of quality of life and clinical significance,
Gladis et al. (1999) provocatively asked, “Should clinicians and
their patients feel that the job is not done (or not done well) if
symptoms are alleviated but other areas of the patient’s life are not
fully satisfying?” (p. 328). The robust associations we observed
between change in symptoms and change in quality of life suggest
that interventions targeting quality of life would be unnecessary.
However, it is important to remember that our data indicate rela-
tive relationships and not the absolute level of symptoms or quality
of life attained. Also, we did not attempt to improve quality of life.
Perhaps couples therapy or work therapy could lead to further
improvements in these domains beyond that attained through res-
olution of PTSD symptoms. Future studies should examine
whether treatments designed to enhance quality of life could
confer additional benefit to patients beyond the benefit resulting
from PTSD treatment.
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Received August 12, 2005
Revision received April 3, 2006
Accepted April 11, 2006 ?
SYMPTOMS AND QUALITY OF LIFE IN VETERANS WITH PTSD