measure of the presence or absence of physical (somatic) symptoms because it does not include medically explained symptoms, only medically unexplained symptoms. Unfortunately, prevalences of somatic symptoms were not measured in these studies, and the rate of somatization disorder does not provide a basis for estimating prevalences of somatic symptoms.

Approximately 10 years after the Gulf War, Toomey et al. (2007) used clinical interviews to estimate the current prevalence of mental disorders that had onset during the Gulf War. They studied a subset of deployed (n = 1061, participation rate = 53%) vs nondeployed (n = 1128, participation rate = 39%) veterans who had been interviewed in the National Health Survey of Gulf War Veterans and their Families (Kang et al., 2000). The interviews were carried out between 1998 and 2001. Gulf War-onset mental disorders were more prevalent in deployed (18.1%) versus nondeployed veterans (8.9%). with increased rates of PTSD as measured by the CAPS in Gulf War veterans (6.2% vs 1.1%; OR 5.78, 95% CI 2.62-12.74). Elevations in anxiety disorders, other than PTSD, as measured by the CIDI were elevated almost fourfold (OR 3.79, 95% CI 1.8-7.99) as was MDD (7.1% vs 4.1%; OR 1.81, 95% CI 1.03-3.19). Approximately 10 years after the war, era-onset major depression continued to be more prevalent among deployed (3.2%) versus nondeployed veterans (0.8%), as were rates of PTSD (1.8% vs 0.6%), although both decreased over time and for PTSD, the difference was no longer significant at 10 years. Somatoform disorders were rare in both groups (1.0% in deployed vs 0.3% in nondeployed), and the difference was not significant in this category overall. There was a significant difference in pain disorder (0.9% vs 0.01%) that represents the presence of one unexplained pain symptom. There was no significant difference in rates of somatization disorder between deployed and nondeployed veterans. Independent predictors of war-era onset mental disorders included female gender, higher levels of combat exposure, and the presence of prewar mental disorders.

Six years after the Gulf War, Al-Turkait and Ohaeri (2008) conducted a cross-sectional study in a stratified random sample of 200 Kuwaiti military men who had served in the Gulf War, using both self-administered questionnaires and a validated interview, the CAPS. Subjects were divided into four groups of 50 men each: retired from the military before the war, active duty but not in combat, active duty and in combat, and prisoners of war (POWs). The overall prevalence of PTSD as determined by the CAPS was 31.7%. The rate was highest for the most highly exposed group, POWs (48%), 22% for those with frontline combat exposure, 32% for those who were active-duty but had not been exposed to combat, and 24% for the retired control group. Higher rates of PTSD were associated with higher rates of depression and anxiety and lower self-esteem. Although this study included comparison groups and diagnostic interviews, the timeframe for prevalence is not reported, which limits its usefulness.

Secondary Studies

The committee identified five secondary studies (Axelrod et al., 2005; Black et al., 2006; Kang et al., 2005, 2009; Rona et al., 2007). Two of these studies focused on women veterans (Kang et al., 2005; Rona et al., 2007) and are discussed in the section on female veterans at the end of this chapter. Secondary studies also focused on borderline personality traits and the possibility that there may be an interaction between these traits and PTSD after deployment.

Axelrod et al. (2005) assessed 94 Operation Desert Storm veterans from the Connecticut National Guard study at several points following their return from the gulf for PTSD symptoms, combat exposure, and personality traits. The study asked retrospectively about pre- and postwar traits associated with borderline personality disorder, a chronic condition characterized by mood instability and difficulty with relationships. They reported that the presence of prewar borderline



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