presence of a few PTSD symptoms after a trauma is common and does not signify the presence of disease, but the presence of the full syndrome itself is much less common and is associated with significant disability.

Substance abuse is defined as a maladaptive pattern of substance use (there are many types of abused substances, but alcohol abuse is the most common) that results in a failure to fulfill major social roles (such as work or family-care performance), that involves use of the substance despite physical hazards and in association with legal consequences, and that involves use despite deleterious social and interpersonal consequences.

Substance use disorders include substance abuse and substance dependence. Substance abuse is defined as a maladaptive pattern of substance use that results in a failure to fulfill major social roles (such as work or family-care performance), that involves use of the substance despite physical hazards and in association with legal consequences, and that involves use despite deleterious social and interpersonal consequences. Substance dependence involves persistent and sustained maladaptive desire for and/or preoccupation with the substance, manifesting physiologically as symptoms of withdrawal when the substance is not taken, or as tolerance—a need to imbibe markedly increased amounts of the substance in order to continue to feel the desired outcome. Psychological manifestations of substance use disorders dependence include taking the substance over longer periods than intended, making unsuccessful efforts to cut down, and/or continuing to use the substance despite knowledge of having a significant physical or psychological problem resulting from its use. There are many types of substances for which abuse and dependence can be diagnosed; in most societies nicotine dependence is the most common and hazardous substance use disorder, currently responsible for half a billion deaths a year worldwide (Ezzati and Lopez, 2003). The studies of Gulf War veterans were generally limited, however, to assessment of the use of alcohol and illegal drugs, and therefore, the committee restricts its comments to these substances.

The prevalence of those disorders among young and middle-aged adults in the general population has now been addressed in several large studies, including the National Survey of Drug Use and Health, the National Epidemiologic Survey on Alcohol and Related Conditions, and the US National Comorbidity Survey Replication, a nationally representative face-to-face household survey conducted from February 2001 to April 2003 (Kessler et al., 2005a,b). The most recent data show that the prevalence estimates for all anxiety disorders were 28.8% (lifetime) and 18.1% (in the last 12 months); for all mood disorders, 20.8% (lifetime) and 9.5% (in the last 12 months); and for all substance use disorders, 14.6% (lifetime) and 3.8% (in the last 12 months). It should be noted that there is substantial variation by gender, and also by age group, even within the limited age range covered. It is also well established that because of difficulties associated with recall, lifetime prevalences tend to provide underestimates of the likelihood that an individual has had a particular condition, and recall about whether the condition has occurred in the last 12 months is more accurate (Susser and Shrout, 2009).

The prevalence estimates for the general population are generally higher than those in deployed veterans exposed to combat and much higher than in the control nondeployed veteran populations. As noted above, this is partly explained by a healthy warrior outcome. Thus, both military screening and self-selection are likely to ensure that individuals enter the military with better mental and physical health than the general population.

Primary studies provided the basis of the committee’s findings on the relationship between deployment to the Gulf War and psychiatric outcomes (see Table 4-4). Primary studies were those in which veterans were categorized as deployed, not deployed, or deployed to a



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