From Hollywood movies and media reports dating back to the late 1970s, you may have formed the impression that posttraumatic stress disorder (PTSD) is rampant among men and women who have been deployed to war zones.
Remember Bruce Dern’s character in Coming Home? Or characters in The Deer Hunter, Rambo: First Blood, or more recently Jarhead and In the Valley of Elah? All of us can probably conjure up an image of the archetypal dysfunctional combat veteran: emotionally volatile, paranoid, socially isolated, angry, violent, drug-dependent and plagued by vivid flashbacks to brutal combat experiences.
Yet, how true to life is this image? It may come as a surprise to you, but this question is harder to answer than you might think.
In studies of U.S. military veterans, the prevalence of combat-related PTSD ranges from about two to 17 percent. This is a wide range. Here are some reasons why there’s such considerable variability in rates of prevalence:
- scientific and technical differences in sampling strategies;
- measurement strategies (e.g., use of structured psychiatric interviews versus self-report measures);
- inclusion and measurement of the Diagnostic and Statistical Manual’s “clinically significant impairment” criterion;
- latency of assessment and potential for recall bias;
- various features of the combat experience itself
Prevalence rates are also likely affected by issues related to a range of sociopolitical and cultural factors. For example, PTSD rates in the U.S. military are often a bit higher than they are for other Western nations. Media reports, societal expectations and even various system incentives (e.g., disability payments) or disincentives (e.g., stigma) can influence symptom reports and affect perceptions of combat and emotional problems. The same is often true for many reported physical symptoms as well.
Is it possible to narrow the range of PTSD prevalence with any precision? Despite a significant body of scientific literature on PTSD, a lack of clarity remains regarding the prevalence of the disorder among military personnel and veterans. In 2007, a debate in Science demonstrated an interesting variety of perspectives that experts in the field hold. This debate followed Bruce Dohrenwend and colleagues’ excellent re–evaluation of PTSD prevalence among Vietnam veterans from data collected in the late 1980s by the National Vietnam Veterans Readjustment Survey. Data from this one study have been interpreted to indicate a 15.2%, 9.1% and 5.4% prevalence of PTSD among Vietnam veterans.
More recently, an article last year by David Dobbs in Scientific American and highlighted in numerous print, radio and television stories and blogs further reinforced the fact that PTSD prevalence remains hotly debated. This is partly because the stakes are large: major decisions about VA funding, research allocations, veteran disability payments and even society’s perspective on war itself may hinge on the answer to this question.
My own interpretation of the scientific literature is that the best prevalence estimates are in the five to nine percent range. This is undoubtedly a meaningful percentage, but it also means that, by any estimate, the vast majority of combat veterans DO NOT have PTSD.
What’s the bottom line?
Regardless of the “true” prevalence of combat-related PTSD, the disorder as we currently define it is present in a substantial number of veterans and is associated with severe impairment in daily functioning, the presence of other psychiatric disorders, other medical problems and reduced quality of life. Thus, it represents a significant and costly illness to veterans, their families and our society as a whole. Certainly we need more research to help us better understand the prevalence, course, phenomenology, protective factors, effective treatments and costs associated with combat-related PTSD.
The bottom line is that veterans with PTSD or any other difficulties readjusting to civilian life need and deserve compassion, understanding and the very best healthcare and mental health services that we as a society can provide. We owe them that much, don’t you think?
A national expert on PTSD research, Dr. Frueh is the director of Clinical Research at The Menninger Clinic and a professor at the University of Hawaii at Hilo.