and assault, poor living conditions, and exposure to environmental and chemical stressors. Some stressors are specific to reserve and National Guard troops, peacekeepers, and women.

STRESSORS DURING COMBAT

Exposure to combat has been described as one of the most intense stressors that a person can experience (Grinker and Spiegel 1945), and for many people who experience combat, it is the most traumatic experience of their life (Kulka et al. 1990). Combat may encompass many threatening situations. Among those reported most frequently by all U.S. combat veterans are killing or attempting to kill the enemy; being shot at by others; exposure to dead and wounded comrades, enemy combatants, and civilians; and being injured.

Deployment stressors in the Persian Gulf War included being in the vicinity of a Scud missile explosion, contact with prisoners of war or dead animals, direct combat duty, witnessing the death of a person, forced sexual relations or a sexual assault, being exposed to dismembered bodies or maimed soldiers, coming under small-arms fire, having artillery close by, and having a combat-related injury (Kang et al. 2000; Unwin et al. 1999). Hobfoll et al. (1991) noted that military personnel in the Gulf War were at greatest risk for stress when their work was hazardous and they anticipated exposure to chemical warfare; the risk increased with more time spent in the field and more exposure to the dead and wounded. Another stressor was the feeling that they were deserting their families at a time of need.

Sutker et al. (1993) asked 215 Gulf War veterans about their perception of injury and death, preparedness for deployment and combat, unit cohesiveness, harshness of the physical environment, perceived level of national support for the war, and stress attributable to nonmilitary events. Respondents were also asked to describe the three most stressful events they had experienced during their deployment. The stressful events cited most frequently were hardships associated with separation of home and family (18%), fear of Scud missile and other military attacks (15%), and discomfort with the physical environment (13%). Other stressors included loss of control, uncertainty, and fear of the unknown (8%); lack of leadership (7%); protracted delays in returning home after cessation of hostilities (5%); inadequacy of supplies and equipment (5%); prolonged truck transport through the desert (4%); lack of information (4%); and financial difficulties (3%).

In one of the few studies to determine not only stressful exposures but the level of stress experienced by the veterans, Stretch et al. (1996a) conducted a survey of 1524 veterans deployed to the Persian Gulf during Operation Desert Shield and Operation Desert Storm. The veterans, about half of whom were reservists, were asked to indicate what stressors they had experienced and how stressful each was. Of the stressors associated with combat exposures, 80% of the veterans indicated that threats of Scud missile, terrorist, or chemical attacks were stressful; 59-69% of the veterans rated the stress as moderate or greater. Such events as being in danger of being killed or wounded or being fired on by the enemy were stressors for almost half the veterans. Almost 83% of the veterans reported lack of contact with their families to be stressful; 68% of those surveyed found it to be moderately stressful or worse. In a study of Pennsylvania and Hawaii active-duty and reserve or National Guard soldiers who had been deployed to the Gulf War (Stretch et al. 1996b), the stressors that were most closely associated with PTSD were those related to combat, such as exposure to the killing or wounding of American soldiers by friendly fire, having a buddy killed or wounded in action, and exposure to dead or dying people. Other significant stressors for PTSD included concern about exposure to oil-well fires in Kuwait,



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