personality traits was associated with the development of some features of PTSD after combat exposure, and that PTSD symptoms at 1 month were associated with increases in endorsement of borderline personality traits at 6 months postwar.

In 2005, a third survey of the National Health Survey of Gulf War Era Veterans and Their Families population was conducted by Kang and colleagues (2009). This survey used self-administered questionnaires, rather than validated diagnostic interviews on a much larger sample of deployed (n = 6111) versus era veterans (n = 3859), although the overall response rate was low (34%). The study reported elevations in all mental disorders among those deployed to the Persian Gulf when compared to era veterans. In contrast to the previous report, which found no persistent significant differences in rates of PTSD, this study reported persistent two to threefold elevations in the rates of PTSD (in the past 4 weeks) in deployed versus nondeployed veterans based on the PCL-C (15.2% vs 4.6%; OR 2.98, 95% CI 2.54-3.50) as well as persistent elevations in major depression (in the past 4 weeks) (14.9% vs 5.8%; OR 2.34, 95% CI 2.03-2.70). Rates of functional impairment and reports of physical symptoms were also elevated about twofold in those deployed to the Gulf War when compared with the nondeployed. The authors did not report on whether PTSD or the presence of mental disorders was associated with the presence or magnitude of physical symptoms or disability.

Summary and Conclusion

The Committee draws four main conclusions on the relationship between deployment to the Gulf War and mental disorders.

First, combat exposure in the Gulf War was causally related to PTSD. Although the available evidence from Gulf War studies is somewhat limited, it is, however, sufficient to support the conclusion that the causal relationship of combat exposure to PTSD shown for other wars also pertains to combat exposure and the development PTSD in the Gulf War. In addition, the Gulf War studies suggest that future research should evaluate whether, in some instances, deployment to a war zone, without combat experience, could be a cause of PTSD.

Second, there is sufficient evidence of an association between deployment to the Gulf War and several other psychiatric disorders. These include generalized anxiety disorder, depression, and substance abuse, particularly alcohol abuse. For these disorders, the available evidence is not sufficient to establish whether or not the association is due to a causal relationship between the deployment and the psychiatric outcome.

Third, the associations between Gulf War deployment and psychiatric disorders were still evident 10 years after deployment (Fiedler et al., 2006; Kang et al., 2009; Toomey et al., 2007). For many of the psychiatric disorders that were measured in long-term follow-up studies, their prevalence even 10 years after the war was more than twofold higher in veterans who had been deployed compared with nondeployed veterans.

Fourth, from several lines of evidence, it can be inferred that the high prevalence of medically unexplained disability in Gulf War veterans cannot be reliably ascribed to any known psychiatric causes or disorders. It is not possible to attribute the high prevalence of medically unexplained disability in Gulf War veterans to somatoform disorder, based on available evidence. For example, a comparison of disabled Gulf War veterans with disabled veterans from other wars did not support such an attribution (Ismail et al., 2002), although veterans with known diseases or serious medical conditions were excluded from the disabled groups in this study. The majority of disabled Gulf War veterans did not have a diagnosable psychiatric disorder. Moreover, the prevalence of psychiatric disorder among disabled Gulf War veterans was similar



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