The author identified a distinct subgroup of posttraumatic stress disorder patients that merits further study. A group of middle-aged and elderly war veterans presented with depressive illness that included preoccupation with guilt related to specific acts of omission or commission during combat. These men initially seemed unscathed by their wartime experiences, and they had made successful adaptations to civilian life. In each case, a contemporary traumatic event activated the disorder. These patients had mastered their war traumas effectively using defense mechanisms that result in repression rather than in the more usual and more primitive splitting. Their guilt persisted unconsciously and later returned as sorrow, concern, and feelings of responsibility for particular acts.

There is a brief, comprehensive bibliography on combat-related posttraumatic stress disorders.