heart,” “soldier’s heart,” and “cardiac muscular exhaustion.” Many medical professionals and surgeons at the time believed that those conditions arose from the heavy packs that soldiers carried, insufficient time for new recruits to acclimatize to the military lifestyle, homesickness, and, as one army surgeon stated, poorly motivated soldiers who had unrealistic expectations of war (Jones, 2006). For much of the 20th century, psychologic conditions and impairments in military personnel were not accorded high medical priority because of the high fatality rates from disease, infection, and accidental injuries during war.

During World War I, shell shock and disordered action of the heart were commonly diagnosed in combat veterans (Jones, 2006). Symptoms of shell shock included tremors, tics, fatigue, memory loss, difficulty in sleeping, nightmares, and poor concentration—similar to many of the symptoms associated with PTSD. What is now known as delayed-onset PTSD was termed old-sergeant syndrome during the era of the world wars, when after prolonged combat, experienced soldiers were no longer able to cope with the constant threats of death or serious injury (Shephard, 2000). Stemming from the World War I definition of shell shock, other common diagnoses of soldiers during World War II included exhaustion, battle exhaustion, flying syndrome, war neurosis, cardiac neurosis, and psychoneurosis (Jones, 2006).

It was not until after the Vietnam War that research and methodical documentation of what was then termed combat fatigue began to accelerate in response to the many veterans suffering from chronic psychologic problems that resulted in social and occupational dysfunction (IOM, 2008a). The National Vietnam Veterans Readjustment Survey (NVVRS) was one of the first large-scale studies to examine PTSD and other combat-related psychologic issues in a veteran population (Kulka, 1990). The NVVRS helped to illuminate PTSD as a signature wound of the Vietnam War and resulted in greater recognition of PTSD as a mental health disorder. The findings contributed to the formal recognition of PTSD as a distinct disorder by the APA and later refining of the characteristic symptoms and diagnostic criteria.

DIAGNOSTIC CRITERIA FOR PTSD

Since 1980, PTSD has been the focus of much epidemiologic and clinical research, which in turn has led to modifications in the defining diagnostic criteria for PTSD. The current diagnostic criteria, taken from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), can be found in Box 2-1 (APA, 2000). The Department of Defense (DoD) and the Department of Veterans Affairs



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