4: Results
1.2 DSM-III-R classification of mental health disorders
1.3.6 Associated features 2
I n addition to the specific criteria listed above, the PTSD patient commonly presents with an extensive array of overlapping symptoms which may complicate the d iagnostic process. Symptoms of other disorders, such as anxiety and d epression, are common and in some instances may be severe enough to warrant multiple diagnoses on one or more of DSM- I I I-R Axes I , I I , or I I I (see sections 1 . 2 . 1 - 1 . 2 . 3 ) . Reviews o f studies examining the prevalence o f d isorders co occurring with PTSD have confirmed that, regardless of the nature of the trauma, PTSD is associated with high rates of other major psychological disorders ( Keane
& Wolfe, 1 990; McFarlane & Papay, 1 992; Roszell, McFall & Malas, 1 99 1 ) . The
most freq uently co-occurring diagnoses include major depression or manic d isorders, anxiety disorders, and substance abuse ( Behar, 1 987; Bresla u & D avis, 1 987a; Davidson , Kudler, Saunders, et aL , 1 990; Green, Lindy, Grace, et aL , 1 98 9 ; Helzer, Robins & McEvoy, 1 987; Hryvniak & Rosse, 1 989; Roszell, et aL , 1 99 1 ) . Somatic complaints (Axis I I I conditions) are also commonly reported in conjunction with PTSD d iagnoses (Centers for Disease Control, 1 988b; White &
Faustman, 1 989; Hryvniak & Rosse, 1 989; Shalev, Bleich & Ursano, 1 990; Solomon & Mikulincer, 1 987) .
High frequency of co-occurring diagnoses in PTSD populations presents researchers and clinicians with a number of difficulties relatin g to the assessment, treatment, and investigations of the disorder. Reports of comorbid diagnoses in Vietnam War veteran populations are considered in detail in section 2 . 4 1 , and results from analyses relating to co-occurring cond itions in the c urrent sample are presented i n section 4 . 9 .
1 .4 PTS D i n DSM-IV
When reviewing the D SM- I I I-R guidelines the DSM-IV PTS D sub-committee focused on fou r aspects of PTSD diagnosi s : definition of stressor in criterion A; placement of PTSD within the diagnostic classification; subtyping; and construct validity ( Davidson & Foa, 1 99 1 a) . The PTSD diagnostic criteria as d efined in DSM-IV (American Psychiatric Association, 1 9 94) are essentially u n a ltered from those in DSM- I I I-R with the exception of Criterion A, the stressor (see section
1 . 3 . 1 ) .
I n D SM-IV PTSD contin ues to be listed as an anxiety disorder and is d efined by four major criterio n ; the stressor, re-experiencing, avoidance and n u mbing, and symptoms of increased arousa l . Physiologic reactivity has been transferred from Criterion D to Criterion B. The remaining criteria are fundamentally u naltered . A sixth criterion ( F) has been added which states that "the distu rbance c a u ses clinically significant distress or impairment in social, occupational, or other important areas of functioning " (American Psychiatric Association, 1 994) . In addition to allowing a diagnosis of delayed onset PTSD, a distinction is also d rawn between acute and chronic forms of the disorder.
1 . 5 Chapter summary
This chapter has presented a particular model of PTSD as outlined by DSM- I I I- R . The general classification system o f the manual h a s been presented as wel l a s t h e specific criteria to be met for a PTSD diagnosis. To this point d iscussions h ave referred to PTSD in a general sense. The following chapter will focus specifically on combat-related PTSD .
•
2 :
Combat-related PTSD
Chapter contents
2.1 Chapter overview . . . 2 5
2 . 2 From shell shock to PTSD . . . 25
2 . 2 . 1 World War I to Korea . . . 25 2 .2.2 Vietnam and beyond . . . 28
2.3 The nature of combat-related ptsd . . . 3 1 2.3. 1 Prevalence of combat-related PTSD . . . 3 1 2.3. 2 Combat stressors . . . 33 2.3.3 Non-combat variables . . . 36
2.4 PTSD and the Vietnam War veteran . . . 39 2. 4. 1 Concurrent diagnoses . . . 39 2. 4. 2 Interpersonal functioning . . . • . . . 43
2. 4. 3 Combat veterans coping with stress . . . 47
2.5 H ypotheses . . . . . . . . 53
2.3 Chapter summary . . . . . 54
2 . 1 Chapter overview
As the character of successive wars has altered, so has the d iagnosis and treatment of psychiatric casualties. The first part of this chapter traces the evolution of the concept of combat-related PTSD , from early formulations of combat reactions d u ring the first and second World Wars, through to the Vietnam War and its aftermath .
The chapter proceeds to a consideration of the nature of combat-related PTSD ,
including prevalence a n d etiological factors. Particular attentio n is p a i d t o the role
of combat stressors in the development of the disorder. The third section of the
chapter reviews recent work with combat veterans with PTS D . The review
foc u ses on the areas of concurrent diagnoses, interpersona l functioning and
coping among PTSD veterans. Finally, hypotheses are presented which emerged
from the review and which form the basis of the data analyses in this study.
2 . 2 From shell shock to PTSD
2. 2. 1 World War I to Korea
As long as men have been asked to risk their lives in combat it i s l i kely that there h ave been many who were unable to cope with the task, or the conditions of b attle . While record ed descriptions of persistent, adverse combat reactions date back to before the American Civil War, systematic investigation s of their causes and consequences are of relatively recent origin (Foy, Carrol l & Donahue, 1 987; G lass, 1 969; Weber, 1 990) .
Prior to World War I military personnel displaying adverse combat reactions were.
believed to be lacking the military d iscipline found in normal soldiers ( Figley, 1 97 8 ; Parsons, 1 988) ' and were not regarded as legitimate casualties of war. Their failure to cope with the demands of combat was regarded as abnorma l , and as evidence of weakness, malingering, or coward ice ( G l ass, 1 969) .
D urin g World War I the term shell shock was used to describe the many
psych i atric casualties which were believed to be the result of protracted enemy
shelli n g . The explanation offered at the time was that the airblast of h ig h
explosives caused temporary or persistent neural damage. I t became evident that
shell shock was a psychological rather than a physical d isorder (Glass, 1 969) and
m ajor c ha nges in the treatment of combat stress reactions were initiated . As
soon a s possible after a psychiatric casualty occurred , treatment was begu n with
the clear expectation that the soldier would return to the unit as an active
combatant. To facilitate the speedy return to units, soldiers were treated as close
to the front and their units as possible. When applied to shell shock these
principles of immediacy, proximity, and expectancy, proved to be very effective
i n the rapid treatment and return of men to combat ( Kentsmith, 1 986) .
Following the First World War it became clear that a large n umber of veterans continued to suffer physical and emotional symptoms. These persistent postwar symptoms were defined as war neuroses and were regarded as an emotional d isorder, rather than an organic disturbance ( Brende & Parson, 1 98 5 ) . Although it was recognised that such symptoms were precipitated by combat, it was believed that they stemmed from predisposing character o r personality d efects
which resulted in the individ ual's inability to deal effectively with combat stress ( G lass, 1 969) .
With the onset of World War I I , emphasis was placed on a screening programme
to exclude from military service those with physical and mental disabilities.
Despite a psychiatric rejection rate of three to four times that of World War I , the
incidence of psychiatric disord ers in 1 943 was three times that of World War I
(G l ass, 1 969) . The primary terminology utilised d u ring the period,
psychoneurosis, reflected the belief that the casualties were the result of
personality defects which the screening programme had failed to detect.
As a result of a 1 944 U nited States commission on war-stress a new terminology exhaustion, was officially e stablished. While this new diagnostic category reflected the important role fatigue was perceived to h ave in the development of stress symptoms, the traumatic effects of battle continued to be minimised i n explanations o f persistent, long-term psychological problems (Weber, 1 990) . An i nteraction between predisposing and precipitating events in the psychic life and e nvironment of the individual conti nued to be viewed as the primary cause of combat stress reactions (Weber, 1 990) .
The Korean War saw a significantly reduced rate of psychiatric evacuations ( 6 % compared with 23% in World War I ) which was in part attrib uted t o the nine month rotation period employed, and the immediate pragmatic approach for dealing with combat stress (Figley, 1 978) . In Korea, and later in Vietnam, the principles of i mmediacy, proximity, and expectancy, were again employed and
expanded . As a consequence 8 5 % to 90% of combat exhaustion c ases were returned to active d uty (Mareth and Booker, 1 98 5 ) . The success of this p o licy led to the view that situational stressors of the combatant were the primary factors leading to a psychiatric casualty (Goodwin , 1 980) .
With a g rowing emphasis on the situational and social determinants of combat adjustment, a distinction emerged between exhaustion and combat exhaustion,
thus avoiding confusion with the notion of physical fatigue and its implication for the cause of psychiatric breakdown . Later the term combat fatigue was adopted by Navy and marine personnel and then accepted into general usage (Glass, 1 969) .
2. 2. 2 Vietnam and beyond
With the onset of the Vietnam War, military psychiatrists relied primarily o n
preventative measures to minimise psychiatric casu a lties . This policy appeared
to be relatively successfu l , with remarkably low rates of psychiatric casualty i n
Vietnam compared t o previous wars (Brende & Parsons, 1 985; Glass, 1 969;
Kentsmith, 1 986) . Factors which are thought to have contributed to the low
psychiatric casualty rate include; the policy of limiting the tour of d uty to 1 2 or
1 3 months, the provision of periods of rest and recreation ( R & R ) , the return o f
combatants t o battle as soon as possible and an emphasis on maintaining troop
morale ( Brende & Parsons, 1 98 5 ; Kentsmith, 1 986) .
The appa rently low psychiatric attrition rate in Vietnam may be misleading, however, as the true rate is likely to have been higher than official reports
indicate ( Brende & Parsons, 1 98 5 ; Figley, 1 97 8 ; Weber, 1 990) . Diagnoses of combat exha,-:!stion did not include character and behavioral d isorders, soldiers with a history of pre-military service adj u stment problems, or those treated by unit medics and rapidly returned to combat ( Boman, 1 98 2 ) . The potential masking effect of substance abuse, and violence toward comrades has also been noted (Boman, 1 98 2 ; Brende & Parson , 1 98 5 ) . These u nconventional forms of psychopathology (d rug abuse, fragging, insubordination) reached l evels never before attained by U n ited States military personnel (Glass, 1 96 9 ) , yet were not regarded as evidence of psychiatric casualties of combat.
Not only was the incidence of reported p sychiatric casualty lower for the
Vietnam War than for earlier conflicts, but the pattern of reporting also differed .
For World War I I and the Korean War the incidence of psychiatric casualty
increased with the intensity of battle . With Vietnam there was a sudden
unexpected rise in the i ncidence of combat-related psychiatric d isorders towards
the end of the war as the conflict was windi ng down (Goodwin, 1 980) . More
surprising was the increase over a decade l ater in the number of veterans who
turned to the Veterans Administration (VA) Hospital system for a ssistance
(Taylor, 1 989) . This pattern could not be accounted for by the prevailing
concept of combat exhaustion, and d id not support the belief that the lower
i ncidence of combat psychiatric casualty was d ue to the preventative and
treatment measures implemented by the military psychiatrists.
It is also likely that many veterans who sought help in VA hospitals fol lo wing the Vietnam War were misdiagnosed . Straker ( 1 976) reported , for example, that
7 7 % of Vietnam veterans admitted to VA hospitals received the wrong d iagnosis of schizophrenia. Many others, estimated as high as 60% (Brende & Parsons, 1 98 5 ) , were ad mitted for substance abuse problems. The inadequacy of the existing DSM- I I diagnostic categories and the problem of misdiagnosis was eventually remed ied in 1 980 with the introduction of the d iagnostic category of PTSD in D SM-l i i . Similarities had been noted between the symptoms found in combat veterans and those of civilian survivors of mass disasters and the d isord er was assigned the comprehensive diagnostic label PTSD ( Ke ntsmith,
1 98 6) . The diagnostic criteria for the disorder are presented in section 1 . 3 .
PTSD has continued to be utilised as the primary diagnostic c ategory for
p sychiatric casualties of war, and most recently attention has turned to veterans
of the Falklands and Persian Gulf conflicts . Although early reports suggested that
there were few psychiatric casualties among the British veterans of the Fal klands
( Price, 1 984) , reports of cases of delayed onset PTSD indicate that the rate may
in fact be higher (Jones & Lovett, 1 987) . It is also appare nt that a significant
proportion of Persian Gulf War veterans are likely to be affected by PTSD ( Litz
et a I . , 1 99 3 ; M illar, Martin & Jay, 1 99 1 ) .
Since the formulation of the diagnostic category of PTSD there has been a proliferatio n of research concerned with the disorder. The large body of literature on combat-related PTSD continues to increase, and covers an expansive range of issues, including diagnosis, etio logy, treatment, assessment, psychosocial effects, and mediating factors . Several of these issues will be addressed in d etail
in the following sections which consider factors contributing to the d evelopment of PTSD and specific outcomes of PTSD .
2 . 3 The nature o f combat-related PTSD 2. 3. 1 Prevalence of combat-related PTSD
Few researchers would contradict the view that the battlefield is a stressful environment. Despite the early recognition of combat stress reactions, systematic research into psychological disorders arising from combat has expanded significantly in response to the aftermath of the Vietnam War. Literature regarding the epidemiology and etiology of combat-related PTSD and the postwar adjustment of Vietnam War veterans will be reviewed in the remainder of this chapter.
Although PTSD was not a diagnostic entity u ntil several years after the end of
the Vietnam War, soldiers who participated in that conflict have been shown to
be at risk of developing PTSD. It is difficult to accurately determine the number
of veterans with the d isorder as prevalence rates vary according to sampling
methods and assessment instruments used . Community surveys of Vietnam
veterans h ave reported current PTSD prevalence rates of between 1 2% and 1 9 %
( C ard , 1 987; Centers for Disease Control, 1 988a; Gold berg , True, Eisen et a L ,
1 990; G reen, Grace, Lindy et a L , 1 990a; Lon g , Chamberlain & Vincent, 1 992;
Kulka, Schlenger, Fairbank et aL , 1 990) . The Vietnam Experience Study reported
that about 1 5 % of Vietnam veterans experienced combat-related PTSD at some
time d uring or after military service, and 2% had the disorder during the month
epidemio logical study of Vietnam veterans, Kulka et a l . estimated the current PTSD prevalence rate at 1 5 % and the l ifetime rate at 3 1 % ( Kulka, Schlenger, Fairb a n k et a I . , 1 990) . In a co-twin control study, Eisen et al. ( 1 99 1 ) found that 1 7 % of Vietnam veterans had current PTSD, the same rate reported by Green and her colleagues (Green et aI . , 1 990a ) . In a national cohort of Vietnam veteran s , C ard ( 1 987) reported that 1 9 % of the veterans had PTSD. In a New Zealand community survey of Vietnam veterans 1 2 % of the sample had the disord e r ( Long et aI . , 1 992) .
The prevalence rates reported for community samples are l ower than the rates reported for veterans with high combat exposure and lower than rates reported for clinical samples of veteran s . These rates range from 2 5 % to 70% for veteran s exposed to high levels of combat ( Ku l ka et a I . , 1 990; Oei et a I . , 1 990) and between 30% and 68% for clinical sam
p
les of veterans ( Blake, Keane, Wine et aI . , 1 989; Breslau & Davis, 1 987b; Foy et aI . , 1 987; G reen et aI . , 1 990a) .While there is a n extensive literature on PTSD for clinical samples of military popul ations there has been little research examining the prevalence of PTSD in the general population ( McCaffery, Hickling & M arrazo, 1 989) . One of the earliest U S surveys of PTSD in the general population estimated the PTSD lifetime prevalence rate to be 1 % (Helzer, Robins, & McEvoy, 1 987) . Other community studies h ave reported PTSD lifetime prevalence rates of 2 . 6 % (Shore, Tatum & Vollmer, 1 986) ' 1 . 3 % (Davidson, Hughes, Blazer & George, 1 99 1 ) , and 2 . 9 % for males' and 3 . 3 % for females (Shore, Vollmer & Tatum, 1 989) . In a recent st!Jdy, Norris ( 1 992) examined a sample of 1 000 adults and found that 69% h ad been
exposed to a traumatic event d u ring their lifetime. The PTSD prevalence rate for the s a mple was 5 . 1 % and lifetime frequencies ranged from 4.4% for sexual assault to 30. 2 % for tragic death .
These studies demonstrate that PTSD prevalence rates are higher among combat veteran samples than non-combat samples (Goldberg, True, Eisen et aI . , 1 9 90; Kulka et aL , 1 990; Dei et a L , 1 990) , and higher than estimates of the prevalence of PTSD , in the general populati o n .
2. 3. 2 Combat stressors
For a PTSD diagnosis, DSM-I I I- R d i agnostic criteria requires the existence of a
precipitatin g traumatic event. Researchers report that the primary factor in the
development of combat-related PTS D is combat stress (Green et aI . , 1 990a;
Cord ray, Pol k & Britton, 1 992; Foy et aL, 1 984; Foy & Card, 1 987; Penk et aL ,
1 98 1 ) . I n particular, the duration and intensity of combat exposure appears to
be most consistently associated with PTSD symptoms (Green et aL, 1 990a;
Cordray et a L , 1 992; Foy et aL , 1 984; Foy & Card, 1 98 7 ; Penk et aL , 1 98 1 ;
Boman, 1 98 2 ; Boulanger & Kadushin, 1 986; Buydens-Branchey, Noumair &
Branc hey, 1 990; Frye & Stockton 1 982) .
Other aspects of military service, closely related to combat exposure have also been associated with the development of PTSD. Soldiers at greater risk of developing the disorder include those who were engaged on special assignment d uties, such as reconnaissance behind enemy lines (Green et a L , 1 989) , those in tactical m i litary occupational specialties, such as infantrymen and artillery
crewmen ( Centers for Disease Contro l , 1 988a; Vincent, Chamberlain & Lon g , 1 994a ) , those w h o assisted with casualty treatment ( O ' Brien & H ughes, 1 9 9 1 ) and those who had friends killed or missing in action ( Chemtob, Bauer, Neller et a L , 1 9 90; O ' Brien & Hughes, 1 99 1 ) .
Levels of PTSD h ave also been associated with having been physically wounded ( Buydens-Branchey et a L , 1 990) , i ncluding the number of times wounded, and being wou nded shortly after return from R & R ( Chemtob et aL , 1 990) . The degree of officer support for soldiers suffering initia l combat stress reactions (Solomon, Mikulincer & Hobfo l l , 1 986) ' authority pro blems, lack of service promotion, and disciplinary actions (Worthington, 1 97 7 ) , have also been associated with the post-military adjustment of combat vetera n s .
The most common a pproach to understanding w a r stressors has b e e n to utilise
measures of combat which are specified as objectively as possible ( Fontana,