PTSD: just how common is it?

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by Chris Frueh, PhD on April 1, 2010 · 5 comments

in research,stigma,trauma

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.

Prevalence rates

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.

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PTSD: the pitfalls of stigma and stereotypes
April 9, 2010 at 5:00 pm

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Isaac Nahakuelua April 21, 2010 at 5:48 am

Chris,
Yes, adaptable when recognized and effective with practice.
I believe so far, that the trivializing of human suffering and experience by “qualified” medical personnel gives the majority a reference point to tolerate a uniquely evolved human state of mind as a kind of excepted normality; albeit trusting the “experts” in knowing what is right. And so the human animal will adapt to it’s social environment in the way nature has built us to adapt.
Knowing who we really are, or what really is from a medicalized stand-point is extremely subjective; particularly in western medicine versus asian medicine and all the other beliefs in the middle.
National leaders set a certain standard for living by shaping their people the best way they can through rewards/punishments/modeling untill a habitual normality pervades through the hearts and minds. Untill someone comes in and changes things–that is what we really are.

B. Christopher Frueh April 16, 2010 at 5:34 pm

Isaac,

Thank you for your insightful comment. You raise a very good point, which I think might be summarized another way: there is a distinction between a “disorder” and a reaction to a profound experience. As a combat veteran you have directly experienced the intensity and power of war, which results in a range of thoughts, emotions, and biological changes for most warriors. If would strike me as unusual if such an experience did not affect you in powerful ways. As for your question, I would not suggest any reaction is “wrong” per se, but would ask you in return is it adaptive and effective for you?

Perhaps another question we might ponder in the course of this discussion is: Have we “medicalized” human suffering and experience in some way that perhaps trivializes it or distorts perception of who we really are?

Thank you for your comment and more, for your service to country.

Isaac Nahakuelua April 16, 2010 at 4:39 am

I agree with your assertion that many veterans do not have combat PTSD. It is much more profitable to be making 5 -7 k a month as a “crazy-vet” rather than participating in the gauntlet of the undisciplined citizen for 1.5 – 4k a month. Many veterans do fake certain symptoms to get the benefits.
However though, there are many combat veterans out there whom saw another side of life—a side that many people are aware of, but have not had that experience burn into their soul. Those combat veterans who saw the other-side of life have endured a kind of unique stress that can only be acquired from war. Some of these veterans crave this kind of stress and want more of a particular scenario to complement a Neuro-physiological need that can only be induced by a high-stress producing stimuli such as a war environment.
Once the veteran is out from the war environment and in the abnormal world of the undisciplined citizen; then the veteran may cause certain events to happen in exchange for that quick fix of dopamine and serotonin levals proportionate to those levals while in combat.
Is the veteran wrong for doing this, or is the veteran subjected by nature’s gift of human-adaptation?

Airborne Infantry soldier (6 yrs)
Afghanistan, March 2004-2005

Lisa Richardson April 10, 2010 at 5:07 am

Dr Frueh writes compassionately (and boldly) about combat related PTSD, and the brave men and women who struggle with this incredibly destructive disorder. For those who use the support services and those who provide them, they will know how socio-politically charged the issues of PTSD assessment and treatment are. Within the combat-related PTSD research arena, good science is not always popular science and emotion can run high. Regardless, Dr Frueh’s message is an important one; namely, be grateful for the sacrifice and support the sufferers by listening without judgement or assumption, and encouraging those who need help, to get help. As ANZAC Day nears, and Australian troops are increasingly brought home from the Middle East, his blogs are a timely reminder of how much we owe to so few and how important family and friends, as well as the wider community, are to those who have experienced trauma.

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