was felt in the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), published in 1952 by the American Psychiatric Association (APA).

After the Vietnam War, research demonstrated that many veterans, particularly those exposed to severe war-related trauma, and other traumatized populations such as Holocaust survivors, suffered from chronic psychologic problems that often resulted in social and occupational dysfunction. The strength of the evidence led to the formal recognition of PTSD as a psychiatric diagnosis in the third edition of DSM (DSM-III), published in 1980. Because the DSM-III provided a formal operational definition of PTSD, it presented a platform for large-scale studies of PTSD in Vietnam veterans and veterans of later wars.

In the sections below, the committee discusses the diagnosis and clinical features of PTSD; its prevalence in military populations; the course of the disorder; the comorbidity of PTSD with other psychiatric disorders and associated disability of people who have PTSD; risk and protective factors for PTSD; and finally the neurobiology of PTSD.

DIAGNOSIS AND CLINICAL FEATURES

People who are exposed to traumatic events react to them in different ways; some experience temporary distress, and others will go on to develop PTSD or other psychiatric disorders, such as major depression. The criteria for PTSD are listed in the fourth edition of the DSM (DSM-IV-TR) (Box 5-1) and require that the person have experienced, witnessed, or been confronted with an event that involves actual or threatened death, serious injury, or a threat to the physical integrity of self or others and that the person have responded with intense fear, helplessness, or horror. Symptoms must persist for a month or more and include three symptom clusters:

  • Re-experiencing—intrusive recollections of a traumatic event, such as flashbacks or nightmares.

  • Avoidance/numbing—efforts to avoid reminders of the event and numbing of emotions.

  • Hyperarousal—manifested by, for example, difficulty in sleeping or jumpiness.

Finally, the person must have clinically significant distress or functional impairment resulting from the symptoms (APA 2000).

Two terms are used to describe PTSD in this report: lifetime and current. In lifetime PTSD, the person has met the criteria for a diagnosis of PTSD at some point and may or may not be symptomatic at the time of the assessment. The meaning of current PTSD varies by study; it can mean that the person met the criteria for PTSD at the time of the assessment, within the preceding month, within the preceding 3 months, 6 months, even 12 months. The committee used the terminology and timeframe for PTSD as given in each study. Lifetime and current PTSD may or may not be related to combat or deployment experiences; when PTSD has been related to combat or deployment experiences, the committee has included this information in its discussion.

PTSD should be assessed on the basis of a thorough diagnostic interview; structured or semistructured interviews, such as the Clinician-Administered PTSD Scale, the Structured Clinical Interview for DSM-IV (SCID), the Diagnostic Interview Schedule for DSM-IV (DIS-IV), and the Composite International Diagnostic Interview (CIDI) are examples of diagnostic



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