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* Posttraumatic Stress Disorder
Psychosomatics 43:195-205, June 2002
© 2002 The Academy of Psychosomatic Medicine

Posttraumatic Stress Disorder and Self-Reported Physical Health Status Among U.S. Military Personnel Serving During the Gulf War Period

A Population-Based Study

Drue H. Barrett, M.D., Caroline Carney Doebbeling, M.D., David A. Schwartz, M.D., Margaret D. Voelker, Ph.D., Kenneth H. Falter, Ph.D., Robert F. Woolson, Ph.D., and Bradley N. Doebbeling, M.D.

Received May 9, 2001; revised September 26, 2001; accepted October 1, 2001. From the Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA; Departments of Internal Medicine and Psychiatry, University of Iowa College of Medicine, Iowa City, IA; Duke University Medical Center and Veterans Affairs Medical Center, Durham, NC; Departments of Biostatistics and Epidemiology, University of Iowa College of Public Health, Iowa City, IA; and Iowa City Veterans Affairs Medical Center, Iowa City, IA. Address correspondence and reprint requests to Dr. Barrett, Centers for Disease Control and Prevention, Mail Stop E-19, 1600 Clifton Rd, Atlanta, GA 30333. E-mail dbarrett{at}cdc.gov


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The objective of this study was to investigate the relation between posttraumatic stress disorder (PTSD) and perceived physical health. Participants included 3,682 Gulf War veterans and control subjects of the same era who completed a telephone survey about their health status. PTSD was assessed using the PTSD Checklist–Military Version. Veterans screening positive for PTSD reported significantly more physical health symptoms and medical conditions than did veterans without PTSD. They were also more likely to rate their health status as fair or poor and to report lower levels of health-related quality of life. The results of this study are consistent with studies of other combat veterans and provide further support for an association between PTSD and adverse physical health outcomes. Stressful or traumatic life events, such as those encountered during a rapid military deployment and conflict, are associated with a variety of adverse health effects. These health effects may manifest themselves in both psychological and physical outcomes. Health care providers must be attentive to recognize and evaluate both of these dimensions.

Key Words: Stress • Military Personnel

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Posttraumatic stress disorder (PTSD) is an extreme response to a traumatic event that is characterized by persistent re-experiencing of the trauma through recurrent and intrusive recollections or dreams, persistent avoidance of stimuli associated with the trauma, numbing of general responsiveness, and persistent symptoms of increased arousal.1 PTSD is also associated with a general pattern of maladjustment and comorbidity, including difficulty with intimacy, social conflict, alcohol and drug abuse or dependence, depression, and generalized anxiety. 2–5

Research efforts are now examining the medical and somatic consequences of extreme stress, trauma, and PTSD. 6–8 Numerous studies have found a relation between high levels of combat exposure and increased reports of physical health symptoms. 9–11 Similarly, adverse physical health outcomes have been well described for non-combat-related trauma. For example, women who have experienced sexual abuse rate their health status more poorly, report more medical conditions, and use health care more often than women without such a history. 12–15

It may be likely that trauma-related PTSD leads to increased physical symptoms among combat veterans. For instance, Vietnam veterans diagnosed with PTSD are significantly more likely to report a variety of physical health symptoms, including cardiovascular, neurologic, gastrointestinal, and musculoskeletal complaints, than Vietnam veterans without PTSD. 16 PTSD has also been found to be associated with physician-diagnosed disorders in studies of Vietnam veterans17 and World War II and Korean veterans. 18

More recently, studies have documented an association between PTSD and physical health complaints among Gulf War veterans. Baker et al. 19 found that fatigue, nausea, muscle aches, dizziness, back pain, stomachache, and numbness were reported more often by Gulf War veterans with PTSD. Engel et al. 20 found a relation between PTSD and symptom reporting even after taking into account veteran-reported environmental exposures and comorbid medical conditions. Similar results were reported by Wagner et al., 21 who found that the degree of PTSD symptomatology immediately after the Gulf War was predictive of self-reported health problems 2 years later, even after controlling for the degree of combat exposure and initial level of health problems.

Some Gulf War veterans have expressed concern about a "Gulf War syndrome," characterized by reporting of a variety of unexplained health complaints. The most commonly reported symptoms have included headache, joint pain, fatigue, and memory and concentration problems. 22–24 Wolfe et al. 25 explored the relation between psychiatric status and Gulf War veterans' health problems and found that PTSD and bipolar disorder were significant predictors of health symptoms. However, the investigators cautioned that 67%–73% of Gulf War veterans reporting increased health symptoms were not diagnosed with PTSD or bipolar disorder, suggesting that psychiatric status does not fully explain Gulf War veterans' health complaints.

In addition to a growing body of literature showing that PTSD is associated with adverse health outcomes, PTSD has been found to be associated with decreased functional status and poorer health-related quality of life among female veterans referred for outpatient mental health services. 26 Seventy-seven percent of the women in this study reported traumatic events associated with sexual assault, domestic violence, accidents and natural disasters, and physical assault or criminal victimization.

The purpose of this study was to further examine the relation between PTSD and perceived physical health and health-related quality of life using a stratified, random sample of men and women who served in the military during the time of the Gulf War, from August 2, 1990 through July 31, 1991.


  METHODS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Subjects
Subjects were participants in a population-based survey of self-reported illness and health status among Gulf War veterans, conducted by investigators at the University of Iowa in collaboration with the Iowa Department of Public Health and the Centers for Disease Control and Prevention. The purpose of the survey was to assess the current prevalence of symptoms and illnesses among Gulf War military personnel and to compare this with the prevalence of these conditions among comparable military personnel who were not deployed to the Persian Gulf. The methods used for selecting, locating, and interviewing subjects are described in detail elsewhere. 2728

Briefly, a cohort of study subjects was defined from records of military personnel who served during the Gulf War. Two criteria were used to define eligibility for inclusion in the cohort: 1) listing of Iowa as the home of record on the individual's original military record at enlistment, and 2) service in a regular military or activated National Guard or reserve unit some time during Gulf War military operations (from August 2, 1990 through July 31, 1991). On the basis of these criteria, the Defense Manpower Data Center, operated by the Department of Defense, provided demographic and military information for 28,968 military personnel potentially eligible for inclusion in the study. Each individual was classified into one of four study domains based on deployment and military status: 1) deployed to the Persian Gulf theater in a regular military unit, 2) deployed to the Persian Gulf theater in a National Guard or reserve unit, 3) served during the time of the Gulf War in a regular military unit but not deployed to the Persian Gulf theater, and 4) served during the time of the Gulf War in an activated National Guard or reserve unit but not deployed to the Persian Gulf theater. Within each study domain, the population was further stratified by age (<=25 or >25 years old on August 2, 1990), sex, race (white or black/other), rank (officer or enlisted), and branch of service (Army, Navy/Coast Guard, Air Force, or Marines). A total of 4,886 eligible study subjects were independently selected from each of the four study domains with proportional allocation for the stratification variables. These individuals were then surveyed through a structured telephone survey conducted between September 1995 and May 1996 to assess the prevalence of self-reported health concerns and exposures. A total of 3,695 persons, or 76% of the eligible study subjects (91% of those contacted), completed a telephone interview.

We excluded 13 telephone-survey participants (1%) because of missing information on one or more of the variables of interest, leaving 3,682 subjects for our analyses. Approximately half (51%) of the sample was deployed to the Persian Gulf, 53% served in a regular military unit during the time of the Gulf War, and 89% were enlisted. More than half of the participants (56%) were in an Army unit; the remainder were evenly distributed among the remaining branches (Air Force 14%, Marines 14%, Navy or Coast Guard 16%). Proportionate to the sampled population of military personnel, most were male (91%) and of white race (96%). About half of the sample (49%) was >25 years of age at the beginning of the conflict (August 2, 1990).

Assessment Instruments
Posttraumatic Stress Disorder. PTSD was assessed by use of the PTSD Checklist–Military Version (PCL-M). 29 This instrument includes 17 items regarding symptoms of PTSD as defined by DSM-III-R. 30 Subjects were asked about symptoms experienced in the month before the interview. Re-experienced symptoms were specific to military experiences. The subjects were asked to rate the degree to which they were bothered by each symptom (not at all, a little bit, moderately, quite a bit, or extremely). Thus, for each item, a severity score was assigned ranging from 1 (symptom did not occur) to 5 (symptom was extremely bothersome). The severity scores for each item were then summed, and a total PTSD severity score ranging from 17 to 85 was calculated. A previously established cutoff score of 50 or more was used to categorize PTSD. This cutoff score has been established for optimal sensitivity and specificity by using a receiver-operator characteristic curve in relation to a structured psychiatric interview for the diagnosis of PTSD as the gold standard. 29

Physical Health Symptoms. Subjects were asked about 37 physical health symptoms that may have occurred in the year before the interview. The symptom list was developed for this study and included original questions and questions from the Brief Symptom Inventory31 and the Chronic Fatigue Syndrome Questionnaire. 32 The symptoms were grouped into seven areas: 1) constitutional symptoms (tender or painful lymph nodes under arms or in neck; a feeling of bodily discomfort after exertion; trouble swallowing; any tendency to bruise or bleed easily; swelling of both feet or both ankles; hot or cold spells; fever, sweats at night, or shaking chills; mouth sores; inflammation or redness of eyes; unexpected hair loss; sore throat or irritation); 2) neurologic symptoms (feeling weak in parts of the body; numbness or tingling in parts of the body; loss of hearing or ringing in the ears; tremors or shaking; double vision not correctable by glasses; seizures or convulsions; any headaches; faintness, lightheadedness, or dizziness); 3) cardiovascular symptoms (heart palpitations, pounding, or racing sensations; pains in the heart or chest); 4) gastrointestinal symptoms (unrelated to pregnancy or menstruation, including nausea or upset stomach; reflux, heartburn, or indigestion; vomiting; frequent diarrhea; abdominal pain; constipation); 5) genitourinary symptoms (frequent or painful urination); 6) dermatologic symptoms (skin redness or skin rash; dryness or scaling of skin; blisters, open sores, or skin ulcers; eruptions of hives or welts on skin; persistent sensations of itching skin; wounds that are slow to heal); and 7) musculoskeletal symptoms (pain or aches in more than one joint; back pain; joint stiffness; muscle tension, aches, soreness, or stiffness).

Medical Conditions. Subjects were also presented with a list of 57 medical conditions and were asked to indicate whether the medical condition was present in the year before the interview. In addition, subjects were given the opportunity to list other health conditions not included on the list. These conditions were grouped into 12 major diagnostic categories based on the International Classification of Diseases, 9th Revision, Clinical Modification, 33 coding for the following: 1) infectious or parasitic diseases (tuberculosis, malaria, human immunodeficiency virus infection or acquired immunodeficiency syndrome, leishmaniasis, chronic mononucleosis, chronic candidiasis, or chronic yeast disease); 2) neoplasms (aplastic anemia, leukemia, lymphoma, skin cancer, any other cancer); 3) endocrine disorders (thyroid disorder, diabetes, other endocrine disorder); 4) mental disorders (depression, anxiety disorders, other psychiatric disorders excluding PTSD); 5) nervous system or sensory organ disorders (repeated seizures, convulsions, or blackouts; recurrent headaches; migraines; neuralgia or neuritis; amnesia or severe memory loss; sleep apnea or narcolepsy; chronic ear infection); 6) circulatory system diseases (high blood pressure, coronary heart disease, tachycardia or rapid heartbeat, cerebrovascular accident); 7) respiratory system disorders (asthma, bronchitis, pneumonia, other lung conditions, chronic sinusitis, rhinitis, allergies); 8) digestive system diseases (ulcer disease, gastritis, enteritis, colitis, hepatitis or yellow jaundice, cirrhosis of the liver, other liver disease, frequent diarrhea); 9) genitourinary system disorders (renal disease, frequent bladder infections, genital organ disease); 10) skin disorders (tumor, cyst, or growth of skin; eczema or psoriasis; dermatitis; any disease of the hair or scalp, including hair loss); 11) musculoskeletal system disorders (arthritis or rheumatism, fibromyalgia or fibrositis, lumbago, any disease of the muscles or tendons); and 12) symptoms, signs, and ill-defined conditions (chronic fatigue syndrome, multiple chemical sensitivity or environmental illness). All medical conditions were assessed by subject self-report; no physical examinations were conducted.

Health-Related Quality of Life. The Medical Outcomes Study Short Form-36 (SF-36) 34 was used to assess functional status and health-related quality of life. The SF-36 is a general health instrument that assesses major domains of health status, including physical, social, and role functioning; mental health; and general health perceptions. Eight previously validated subscales were calculated, measuring Physical Functioning, role limitations due to physical health problems (Physical Role), Bodily Pain, Social Functioning, general Mental Health, role limitations due to emotional problems (Emotional Role), Vitality (energy/fatigue), and General Health perceptions. Physical and Mental Health Summary scales were also calculated. Scores ranged from 0 to 100, with lower scores reflecting impaired functioning or quality of life.

Data Analysis
We calculated the prevalence of subjects screening positive for PTSD on the PCL-M by demographic and military characteristics, including Gulf War deployment status (deployed, not deployed), military status (regular military, National Guard or reserve), age (<=25 years, >25 years), sex, race (white, other), rank (enlisted, officer), and branch of service (Army, Air Force, Marines, Navy or Coast Guard). In addition, because smoking has been associated with trauma exposure and PTSD and influences health status, we calculated the prevalence of PTSD by smoking status (never smoked, former smoker, current smoker). Subjects who indicated that they had smoked <=100 cigarettes in their lives were categorized as never smokers. We used multivariable logistic regression analysis to determine the associations between the demographic, military, and smoking variables and PTSD status. Both crude odds ratios and 95% confidence intervals, and odds ratios and confidence intervals adjusted for each of the other demographic, military, and smoking variables, are presented.

We conducted linear regression analyses to compare the mean number of physical symptoms and medical conditions and the mean SF-36 scores by PTSD status. In addition to reporting unadjusted means and standard errors (SEs), we calculated the mean differences and SEs adjusted for the demographic, military, and smoking variables. We also calculated the weighted prevalence of subjects reporting any one of the items constituting each symptom and condition category by PTSD status. In addition, we computed Spearman correlation coefficients to assess the association between the number of physical health symptoms reported and the severity of PTSD symptoms (total PCL-M score). The same approach was used to assess the association between the number of medical conditions reported and PTSD severity.

Validation of PTSD Measure. Because our study used a screening measure to assess PTSD rather than a structured interview to diagnose PTSD, we did not attempt to ensure that criterion A (exposure to a traumatic event that involved actual or threatened death or serious injury and that resulted in intense fear, helplessness, or horror) 1 was satisfied. Gulf War veterans were questioned about a variety of exposures, including nine items relating to combat experiences (Table 1). To validate the PTSD classification, we created a dichotomized summary combat variable. Gulf War–deployed subjects who reported three or more of the nine combat-related exposures and reported that they were present during the time of either the ground or air conflict (from January 16, 1991 through February 28, 1991) were classified as having participated in combat. These criteria were chosen to provide a conservative estimate of combat exposure. In addition, the cutoff of three combat-related exposures was found to discriminate best between men and women who were hypothesized to have differential rates of combat exposure. We calculated the prevalence of PTSD by combat-exposure status and compared the mean number of combat-related exposures reported among subjects with and without PTSD. These analyses were restricted to Gulf War–deployed subjects because these data were not collected on nondeployed subjects.


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TABLE 1.



For all variables, frequency distributions were obtained using SAS35 and reported as the actual number of subjects surveyed. Prevalence estimates and all other statistical analyses were performed using SUDAAN36 to account for the complex sampling design. Alpha was set at 0.05, and all P values are two-tailed.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Of the 3,682 subjects in our sample, 53 met the screening criteria for current PTSD as measured by the PCL-M (weighted prevalence 1.09%; SE 0.20). PCL-M scores ranged from 17 to 81 (median score 18). The mean PCL-M score was 58.7 (standard error [SE] 2.68) for those screening positive for PTSD and was 19.7 (SE 0.24) for those screening negative.

The association between PTSD status and demographic and military characteristics is reported in Table 2. Subjects who were deployed to the Persian Gulf theater of operations were twice as likely to screen positive for PTSD as those who were not; however, this result was not statistically significant in the adjusted analyses. In comparison with Army personnel, those in the Marines, Air Force, or Navy or Coast Guard were significantly less likely to report symptoms of PTSD. Marine and Air Force personnel were least likely to screen positive for PTSD. Current smoking status was also significantly associated with PTSD status. Current smokers were almost four times more likely to screen positive for PTSD than never smokers.


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TABLE 2.



Physical Symptoms and Medical Conditions. Subjects who screened positive for PTSD reported a significantly higher number of symptoms and medical conditions than those without PTSD (Table 3). Those screening positive for PTSD reported a mean of 19.83 symptoms, compared with a mean of 3.64 symptoms among persons without PTSD. A mean of 10.18 medical conditions were reported by subjects with PTSD, compared with a mean of 1.73 medical conditions reported by those without PTSD. This pattern remained when the analysis was stratified by deployment status.


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TABLE 3.



The number of physical symptoms reported was positively correlated with PTSD severity (r = 0.60, P = 0.001). A similar positive relation was found between the number of medical conditions reported and PTSD severity (r = 0.50, P = 0.0001).

The prevalence of at least one symptom in each of the physical health symptom categories was significantly higher among persons screening positive for PTSD (Figure 1). More than 90% of the subjects screening positive for PTSD reported at least one symptom from the constitutional, neurologic, gastrointestinal, dermatologic, and musculoskeletal categories. Among persons with and without criteria for apparent PTSD, the cardiovascular and genitourinary symptom categories were reported the least frequently; however, these were the categories with the smallest number of individual symptoms.



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FIGURE 1.

Note: The prevalence reflects the proportion of subjects who reported any of the symptoms defining that category. Asterisks indicate that there was a significant difference in the prevalence among those with PTSD compared to those without PTSD, after adjusting for deployment status, age, sex, race, rank, branch, military status, and smoking status. Prevalence estimates account for the complex sampling design.


With the exception of endocrine disorders and neoplasms, persons screening positive for PTSD were also significantly more likely to report one or more medical conditions from each of the medical condition categories (Figure 2). The most frequently reported medical condition categories among persons screening positive for PTSD were the mental disorders and nervous system and sensory organ disorders. More than 90% of persons positive for PTSD reported at least one condition within each of these categories. Among persons without PTSD, the most frequently reported conditions were respiratory system and dermatologic disorders.



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FIGURE 2.

Note: The prevalence reflects the proportion of subjects who reported any of the medical conditions defining that category. Asterisks indicate that there was a significant difference in the prevalence among those with PTSD compared to those without PTSD, after adjusting for deployment status, age, sex, race, rank, branch, military status, and smoking status. Prevalence estimates account for the complex sampling design.


Health-Related Quality of Life. Among persons screening positive for PTSD, only 42% (n = 24) rated their current general health status as excellent, very good, or good. In contrast, 94% (n = 3,314) of persons without PTSD rated their health in the good to excellent range. Persons screening positive for PTSD reported significantly lower levels of functioning and quality of life on each of the subscales of the SF-36 (Table 4). The largest adjusted mean differences between the groups were found on the Emotional Role and Physical Role subscales.


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TABLE 4.



Validation of PTSD Measure. Overall, 27% (n = 566) of the Gulf War-deployed subjects were classified as combat participants. The prevalence of PTSD was significantly higher among Gulf War-deployed subjects categorized as combat participants than among those who did not participate in combat (adjusted odds ratio 2.3; 95% confidence interval 1.2–4.7). The prevalence of PTSD was 3.4% among combat participants and 1.4% among combat nonparticipants. Subjects with PTSD reported an average of 3.03 combat-related exposures (SE 0.32), versus an average of 1.79 combat-related exposures (SE 0.04) reported by subjects without PTSD.


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
This study found a significant positive relation between PTSD and multiple indices of self-reported physical health among military personnel who served during the time of the Gulf War. Not unexpectedly, these health complaints were accompanied by lower ratings of overall health status and health-related quality of life. Decrements in health-related quality of life were seen across all domains measured, indicating that people with PTSD experience lower physical, social, and mental health functioning. The current results confirm the relation between PTSD and increased reporting of physical health symptoms found previously among Vietnam veterans16 and in studies of Gulf War veterans. 19–21,25

The magnitude of the differences in the health-related functional status measures is particularly noteworthy. Veterans with PTSD scored lower on every subscale of the SF-36, with the largest differences evident on the Emotional Role and Physical Role subscales. These subjects reported that they were experiencing functional impairment in the physical, mental, and social dimensions of health. The degree of decrement in functional status was similar to that found among patients with both serious medical and psychiatric diseases. 37

The mechanisms by which stressful life events produce psychological and physiologic responses likely involve a complex interaction of the peripheral and central nervous systems, as well as secretions of hormones from the pituitary and adrenal glands. Along with increased rates of stress, persons with PTSD have increased cardiovascular reactivity, autonomic hyperarousal, disrupted sleep patterns, and other physiologic changes. 6 These physiologic changes, combined with the psychological and behavioral correlates of PTSD (e.g., depression, hostility, increased substance use, and poor coping skills), place people with PTSD at particularly high risk for adverse medical outcomes.

Schnurr et al. 38 suggested that an individual's reaction to trauma is important for predicting outcome. Our finding of an association between PTSD and an increased rate of smoking may be important in understanding the relation between PTSD and health. Compared with never smokers, current smokers were four times more likely and former smokers were two times more likely to meet the criteria for PTSD. This association between smoking and PTSD has been found previously among U.S. veterans of the Vietnam War39 and among Israeli veterans of the 1982 Lebanon War. 40 Among combat veterans with PTSD, heavy smoking is associated with increases in past-year and lifetime health complaints, negative health behaviors, and total PTSD symptoms. 41 Smoking and other adverse health behaviors, such as alcohol and drug use, may explain some of the increased physical symptoms reported by veterans with PTSD.

Epidemiologic research has also established a relation between depression and cigarette smoking, with an increased prevalence of smoking and a decreased likelihood of successful quitting associated with increased depression scores. 42,43 The possible interaction between PTSD, other comorbid psychiatric conditions, substance abuse, and physical health status merits further study.

Several methodologic issues should be considered when interpreting this study's results. Data for this study were collected within the context of a larger study, the objective of which was to assess the prevalence of self-reported symptoms and illnesses among military personnel deployed to the Gulf War. Thus, the study was designed to assess a variety of medical and psychiatric outcomes thought to be relevant to the health concerns of Gulf War veterans using a method that would ensure the greatest response rate. This involved using a broad health assessment approach and a telephone survey method. We have no objective measures of health status, and our finding of an association between PTSD and self-reported adverse health outcomes may reflect an increased tendency of veterans with PTSD to overreport symptoms.

Because PTSD was one of many assessed health outcomes, we chose to use a brief PTSD screen rather than a more lengthy, structured diagnostic approach. However, the PCL-M has proved to be a useful measure for assessing PTSD in clinical and research settings in which it is not feasible to administer a structured interview. Among Gulf War veterans, the results of the PCL-M were highly correlated with scores on the Mississippi PTSD Scale (r = 0.85). 29

In using the PCL-M to assess PTSD, it is important to note that the cutoff score of 50 was established with Vietnam combat veterans. Among these veterans, this cutoff score yielded a sensitivity of 0.82 and a specificity of 0.83 in comparison with PTSD diagnosis made with the Structured Clinical Interview for DSM. 29 More recent research with Vietnam veterans undergoing treatment for PTSD has confirmed that the recommended cutoff of 50 is the optimal cutoff score. 44 Further research is needed to determine whether 50 is the optimal cutoff score for veterans of the Gulf War.

To assess the validity of our measure of PTSD, we compared the prevalence of PTSD among Gulf War veterans classified as combat participants and nonparticipants. We also examined the mean number of combat-related exposures reported by Gulf War veterans with and without PTSD. These analyses indicated that combat exposure was associated with PTSD status, thus suggesting that our PTSD measure was correctly classifying subjects with military trauma.

Another limitation of our study is the low number of subjects who screened positive for PTSD (16 in the nondeployed group and 37 in the deployed group). The prevalence of current PTSD found in this study (1.09%) is somewhat lower than the rate of PTSD found among Gulf War veterans when PTSD was diagnosed using a structured clinical interview (5.4%–7.2%) 25 and is lower than rates of PTSD found in national samples (7.8%). 45 Although higher rates of PTSD (18%–46%) have been found in studies of specific Gulf War veterans, such as veterans who reported handling dead bodies46 or those involved in war-zone graves-registration duties, 47 most Gulf War veterans have not been diagnosed with PTSD. 27

The sample of veterans who participated in the Iowa Gulf War study may not be representative of all U.S. military personnel. The participants, all of whom listed Iowa as their home of record at the time of enlistment, were predominantly white men. Although the gender distribution of participants in this study was similar to that of military personnel deployed during the Gulf War, the extent to which these findings may be generalized to other military populations, racial minorities, women, or survivors of other types of traumatic events may be limited.

Despite these potential limitations, this study adds to the body of knowledge regarding PTSD and physical health outcomes and confirms the findings of previous studies. Using a well-validated and widely used measure, the SF-36, we demonstrated that in addition to increased reports of physical health symptoms and medical conditions, veterans with PTSD experience significant decrements in their functional status and health-related quality of life.

In summary, the results of this study are consistent with studies of other combat veterans and provide further support for an association between PTSD and self-reported adverse physical health outcomes. Stressful or traumatic life events, such as those encountered during a rapid military deployment and conflict, are associated with a variety of adverse health effects. These health effects may manifest themselves in both psychological and physical outcomes. Health care providers must be attentive to recognize and evaluate both of these dimensions.


  ACKNOWLEDGMENTS

 
Use of trade names is for identification only and does not constitute endorsement by the Public Health Service or the U.S. Department of Health and Human Services. This study was supported by a cooperative agreement (U50/CCU711513) with the Iowa Department of Public Health from the National Centers for Environmental Health, Centers for Disease Control and Prevention. Drs. Doebbeling, Woolson, and Schwartz are partially supported by Department of Defense grant no. DAMD17-97-1-7355. Dr. Voelker is partially supported by National Institute of Mental Health training grant no. 5T32 MH15158-23.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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