Risk Factors in a General

Bonnie

j

for PTSD and Other Sample of Vietnam

L. Green, Ph.D., Mary Goldine C. Gleser,

C. Grace, M.Ed., M.S., Jacob Ph.D., and Anthony Leonard,

This study examined the contribution of premilitary, military, and postmilitary risk factors to posttraumatic stress disorder (PTSD) and other postwar diagnoses in a sample of Vietnam veterans. PTSD was explained primarily by war stressors, including threat to life and

exposure

to grotesque

death,

but premilitary

and post-

military factors also contributed to the likelihood of a current diagnosis of PTSD. Panic disorder was also highly predicted by war experiences, whereas prewar f unctioning played a stronger role in several non-PTSD diagnoses. The study supported the notion that PTSD is specifically linked to intense stressors. Mechanisms f or interactions among risk factors are discussed. (Am J Psychiatry 1990; 147:729-733)

A

number of studies over the past several years have examined the predictors of the diagnosis of posttraumatic stress disorder (PTSD) in Vietnam veterans; the focus has been on aspects of soldiers’ war experiences. For the most part, these studies have shown that combat experience and exposure to abusive violence or atrocities predict chronic symptoms of PTSD (1, 2).

A few studies

have

examined

factors

other

than

war

stressors that also put veterans at higher risk for PTSD. Foy et al. (3) found that combat exposure and adjustment during military service predicted PTSD symptoms in a small group of treatment-seeking veterans, whereas an index of premilitary adjustment did not. Later, Foy and Card (4) replicated the major features of that study in a national nonclinical sample and found essentially the same results, although in both cases the premilitary adjustment variable was added last to the regression equation. Other investigators,

too,

have

found

war

stressors

to be the primary

minants of symptoms of PTSD, although pects of prewar functioning may also

Received

1989;

April

accepted

26,

1988;

Dec.

21,

Center, Department of Medicine. Address Psychiatry, University

revisions

1989.

From

received

Aug.

deter-

various contribute

1 and

the Traumatic

Nov.

Stress

Am

J

in part © 1990

Psychiatry

asto

22,

Study

of Psychiatry, University of Cincinnati College reprint requests to Dr. Green, Department of of Cincinnati College of Medicine, Cincinnati,

OH 45267-0539. Supported Copyright

by NIMH American

1 47:6,

grant MH-36791 to Dr. Psychiatric Association.

June

1990

Diagnoses Veterans

Green.

D. Lindy, B.A.

M.D.,

current mental status (5). Postwar factors that have been examined and shown to predict postwar adjustment are negative life events (6) and social supports (7). None of these investigators has included diagnoses other than PTSD when examining these risk factors, to explore diagnostic overlap and the discriminant validity of the PTSD diagnosis. We proposed a model of the factors that contribute to posttraumatic adjustment following a traumatic event (8). In addition to the effect of the nature of the stressful experience, the processing of the event was seen to be affected by aspects of the person experiencing the event (including premorbid functioning, the specific meaning of the event to the person, etc.). Aspects of the recovery environment, such as the support network, the societal attitude toward the event, and subsequent negative life events, were also hypothesized to add to the prediction of current adjustment. These categories of variables correspond loosely to the premilitary, military (combat), and postmilitary factors used by other investigators (1). Following this model in the present study, we exammed the relative contribution of prewar, war stressor, and postwar environmental factors to long-term postservice adjustment in a group of Vietnam veterans. In addition to PTSD we included other major diagnoses so that their predictability could be compared to the predictability of PTSD. It is the first study of which we are aware that has included risk factors not only for PTSD but for other diagnoses as well in a wide-ranging sample of veterans, most of whom were not seeking treatment.

METHOD

Subjects who served in Vietnam between 1965 and 1972 were systematically recruited from a variety of sources. Of the 200 male participants, one-third came from clinical referral sources, including area Veterans Outreach Centers, Veterans Administration (VA) hospitals, and the Disabled American Veterans. The subjects who were not seeking treatment (two-thirds of the sample) were recruited from industry, police and fire departments, and the National Guard, were referred by other subjects, or were recruited from news-

729

POSTWAR

TABLE

DIAGNOSES

OF

1. Intercorrelations

VIETNAM

VETERANS

Among Risk Factors for 200

Veterans of the Vietnam

War Postwar

W ar Stressor Risk

Preservice

Grotesque Death

Special Assignment

Support Homecoming

0.03 -0.08

0.08 -0.01 -0.01

0.12 0.08 0.01

at

Current Social Support

Life

Events

factors

Adolescent Educational Age when

Axis

Unit Patrol

Drafted

Factor

Factor

friendships level serving in Vietnam

-0.04 -0.12 -0.01

I diagnosis

Antisocial

personality

0.17a

0.11

0.12

0.17a

0.06

0.08

0.07

0.23a

0.12

o.16a

o.21

o.19

0.02

-0.07

-0.07

0.11

-0.07

-0.06

0.30a

-0.12

-0.11

0.11 0.22a

disor-

der diagnosis War stressor Drafted Unit patrol Grotesque death Special assignment

-0.05

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

o.2oa

0.26a

-0.2S’ -0.13

-0.12

0.06

ap