was formally recognized as a psychiatric diagnosis in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), published in 1980.

Characterized by symptoms of hyperarousal, numbing or avoidance, and re-experiencing of the traumatic event, PTSD may be evident shortly after exposure to a traumatic event or may take years for the veteran to have sufficient symptoms to meet the diagnostic criteria; once developed, the symptoms may persist for many years. PTSD, or symptoms associated with it, has been reported in veterans of World War II, the Korean War, the Vietnam War, the Gulf War, and OEF and OIF. The prevalence of PTSD in veterans increases as combat exposure increases, in some cases showing a dose-response relationship. PTSD is also highly comorbid with other psychiatric disorders, particularly major depression, general anxiety, and substance-use disorders. The presence of comorbid disorders increases the difficulty of diagnosing PTSD. PTSD is also associated with increased reporting of symptoms, medical conditions, and poor health in veterans. The DSM-IV requires that a diagnosis of PTSD include “clinically significant distress and/or impairment in social, occupational, and/or other important areas of functioning.” Veterans with PTSD report more disability and impaired functioning than those without PTSD.

Although military personnel may be exposed to identical stressors during their deployment to a war zone, their short-term and long-term responses to those stressors will vary. The variation is due to a host of individual risk factors and protective factors that influence the likelihood of long-term health effects after the exposures. The committee found that combat and being physically wounded were among the most significant risk factors for PTSD or other psychiatric disorders. Other important risk factors include childhood maltreatment, the presence of a pre-existing psychiatric disorder, poor social support on returning home, negative coping styles, being a member of a minority group, and lack of hardiness. Protective factors include better education, higher military rank, having a stable family life, and having a sense of control.


The committee reviewed numerous epidemiologic studies to arrive at conclusions about association. It weighed the strengths and limitations of all the epidemiologic studies and reached its conclusions by interpreting the data in the entire body of reviewed literature. It assigned each health outcome being considered to one of the five categories of association according to the specific criteria set forth above. The committee also considered health effects of PTSD. Its findings about the strength of the associations between deployment to a war zone, as a surrogate for deployment-related stress, and various health effects are summarized in Table S-1.


Table S-1 provides a summary of the committee’s conclusions for each health effect discussed in the report by category of association. No health effects were found for two categories of association, sufficient evidence of a causal relationship and limited/suggestive evidence of no association. Of all the long-term health effects reviewed, the strongest findings were on psychiatric disorders, including PTSD, anxiety, and depression. Alcohol abuse, suicide and accidental death in the early years after deployment, and marital and family conflict also appear to be adverse sequelae of deployment-related stress.

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