PTSD: National Center for PTSD

Findings from the National Vietnam Veterans' Readjustment Study

Jennifer L. Price, PhD

Introduction

The National Vietnam Veterans' Readjustment Study (NVVRS) was conducted in response to a congressional mandate in 1983 for an investigation of Posttraumatic Stress Disorder (PTSD) and other postwar psychological problems among Vietnam Veterans (Kulka et al., 1990a, Kulka et al., 1990b). The purpose of the NVVRS was to obtain accurate prevalence rates of postwar psychological problems in order to serve the needs of the nation's Veterans. The NVVRS used a multimethod assessment approach (e.g., self-report, clinical interview) to study representative national samples of Vietnam Veterans and their peers. Participants were grouped according to their involvement in the Vietnam war, including Vietnam theater Veterans (i.e., men and women who served on active duty in Vietnam, Laos, or Cambodia), Vietnam era Veterans (i.e., men and women who served on active duty during the Vietnam era but not in the Vietnam theater), and non-Veterans or civilian counterparts (i.e., men and women who did not serve in the military during the Vietnam era).

What were the major findings of the NVVRS?

The most important overall conclusion of the NVVRS was that across over 100 life-adjustment indices, the majority of Vietnam Veterans appeared to have successfully readjusted to postwar life, and the majority were at the time of the study experiencing few symptoms of psychological disorders. However, the NVVRS also revealed that a substantial minority of Vietnam theater Veterans were suffering from a variety of psychological problems and experiencing a wide range of life-adjustment problems (e.g., marital problems, work difficulties). Unfortunately, only a small number of these Veterans actually sought treatment from mental health providers.

What is the prevalence of PTSD?

PTSD was assessed using a multimethod approach, including three primary indicators: the Mississippi Combat-Related PTSD Scale, the Minnesota Multiphasic Personality Inventory-PTSD Scale, and the Structured Clinical Interview for DSM-III-R PTSD module. Seven secondary indicators were also used. According to the results gathered using these assessment tools, an estimated 15.2% of male and 8.5% of female Vietnam theater Veterans met criteria for current PTSD (Schlenger et al., 1992; see Table 1). Those with high levels of war-zone exposure had significantly higher rates, with 35.8% of men and 17.5% of women meeting criteria for current PTSD. Rates of PTSD were consistently higher for Vietnam theater Veterans than for Vietnam era Veterans and civilians. The NVVRS estimated prevalence of lifetime PTSD among Vietnam theater Veterans was even higher, with similar rates between male and female Veterans (see Table 1). As opposed to full PTSD, Weiss et al. (1992) found that a substantial number of Vietnam Veterans had current partial PTSD, with even higher prevalence rates for lifetime partial PTSD (see Table 1). Overall, the NVVRS found that at the time of the study approximately 830,000 male and female Vietnam theater Veterans (26%) had symptoms and related functional impairment associated with PTSD.

Table 1
Rates of PTSD and Partial PTSD for Vietnam Theater Veterans

In a reanalysis of the NVVRS data, along with analysis of the data from the Matsunaga Vietnam Veterans Project, Schnurr, Lunney, Sengupta, and Waelde (2003) found that, contrary to the initial analysis of the NVVRS data, a large majority of Vietnam Veterans struggled with chronic PTSD symptoms, with four out of five reporting recent symptoms when interviewed 20-25 years after Vietnam.

What other psychological disorders are common among Vietnam Veterans?

Vietnam Veterans also struggle with a number of psychological disorders other than PTSD. The most commonly reported disorders vary slightly between male and female Veterans. However, depression, anxiety, and alcohol problems are typically the most prevalent across groups (see Table 2).

Table 2
Most-Prevalent Disorders Among Vietnam Theater Veterans

Almost all of these disorders were more common among Vietnam theater Veterans than among their civilian counterparts, but initial investigation revealed few differences between Vietnam theater Veterans and Vietnam era Veterans. Jordan et al. (1991) found that Vietnam theater Veterans with high levels of war-zone exposure were significantly more likely than those with low exposure to develop the psychological disorders listed above.

What other problems did Vietnam Veterans report?

In addition to the psychological disorders listed above, a substantial minority of Vietnam theater Veterans also reported readjustment problems such as occupational instability, marital conflicts, and family problems. Moreover, Veterans with PTSD were more likely to report marital, parental, and other family adjustment problems (including violence) than Veterans without PTSD (Jordan et al., 1992). Veterans who experienced the highest level of war exposure also reported the highest frequency of physical health problems. Veterans with a current diagnosis of PTSD or a lifetime diagnosis of substance abuse tended to report poorer physical health as well.

What are the risk factors for Vietnam Veterans?

As indicated above, the NVVRS data revealed that higher levels of war-zone exposure tended to contribute to a higher degree of symptoms. Results showed that Veterans with one psychological or readjustment problem tended to have multiple difficulties. In addition, race/ethnicity appeared to be an important risk factor, as African-American and Hispanic Vietnam Veterans tended to report more mental health and life adjustment problems. For PTSD in particular, Hispanic male Veterans had the highest prevalence rate. However, Ruef, Litz, and Schlenger (2000) found that when the data were reanalyzed, several variables influenced this relationship. This suggests that ethnicity may not have been the primary differentiating factor.

A number of other researchers have also reanalyzed the data from the NVVRS in order to further identify prewar and war-zone stressor risk factors as well as postwar resilience and recovery factors. The following summaries provide important information about some of the most prominent findings.

King, King, Gudanowski, and Vreven (1995) examined war-zone variables and their relationships to PTSD symptoms. Exposure to the malevolent environment was strongly associated with PTSD symptom severity. Other war-zone stressors such as perceived threat and atrocities/abusive violence were also linked directly to PTSD severity.

King, King, Foy, and Gudanowski (1996) found that prewar risk factors differed for women and men. For women, instability within the family of origin had the largest influence on PTSD; an early trauma history had a direct link as well. For men, family instability, childhood antisocial behavior, and a younger age at entry to the war predicted total PTSD; an early trauma history was also directly associated with PTSD. An early trauma history interacted with the war-zone stressor level to increase PTSD symptoms for male Veterans exposed to high levels of combat.

King, King, Fairbank, Keane, and Adams (1998) examined postwar factors and found that social support, hardiness, and additional negative life events following Vietnam affected men's and women's resilience and recovery. Social support played the largest role as a protective factor against development of PTSD.

King, King, Foy, Keane, and Fairbank (1999) combined prewar, during war, and postwar variables to determine which are most important. For women, PTSD was directly affected by (1) the prewar risk factor of an early trauma history; (2) the war-zone stressors of atrocities, abusive violence, and perceived threat; and (3) the postwar resilience-recovery variables of additional stressful life events, hardiness, and functional social support. For men, PTSD was directly affected by these same variables plus the prewar risk factor of age at entry to the war, the malevolent environment war-zone stressor, and the postwar resilience-recovery variable of structural social support.

Schnurr, Lunney, and Sengupta (2004) also conducted a reanalysis using a sample from the NVVRS and a sample from the Hawaiian Vietnam Veterans Project, which was modeled on the NVVRS. This reanalysis focused on determining which variables predict the initial development of PTSD and which variables predict the maintenance of PTSD symptoms over the longer term (see Table 3).

Table 3
Risk Factors Associated with PTSD in Vietnam Veterans

*Peritraumatic dissociation is immediate dissociation at the time of the traumatic event.

Schnurr, Lunney, and Sengupta (2004) also found evidence for several variables acting as protective factors against the development and maintenance of PTSD (see Table 4).

Table 4
Protective Factors Associated with PTSD in Vietnam Veterans

Conclusions

The NVVRS sample is arguably the most representative group of Vietnam Veterans to be studied to date. Thus, the results are critically important in understanding the effect of the Vietnam War on Veterans. Such an understanding is important in developing and applying mental health treatments to those who continue to suffer from PTSD or other psychological/readjustment problems. Using the NVVRS data, recent researchers have confirmed that premilitary, during military, and postmilitary variables all have strong influences on who develops PTSD, and these variables likely also influence who maintains PTSD. An important message for Veterans already exposed to combat violence is that social support plays a critical role in reducing PTSD symptoms and increasing one's level of functioning.

References

1. Jordan, B. K., Marmar, C. R., Fairbank, J. A., Schlenger, W. E., Kulka, R. A., Hough, R. L., et al. (1992). Problems in families of male Vietnam Veterans with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 60, 916-926.
2. Jordan, B. K., Schlenger, W. E., Hough, R. L., Kulka, R. A., Weiss, D. S., Fairbank, J. A., et al. (1991). Lifetime and current prevalence of specific psychiatric disorders among Vietnam Veterans and controls. Archives of General Psychiatry, 48, 207-215.
3. King, D. W., King, L. A., Fairbank, J. A., Keane, T. M., & Adams, G. (1998). Resilience-recovery factors in posttraumatic stress disorder among female and male Vietnam Veterans: Hardiness, postwar social support, and additional stressful life events. Journal of Personality and Social Psychology, 74, 420-434.
4. King, D. W., King, L. A., Foy, D. W., & Gudanowski, D. M. (1996). Prewar factors in combat-related posttraumatic stress disorder: Structural equation modeling with a national sample of female and male Vietnam Veterans. Journal of Consulting and Clinical Psychology, 64, 520-531.
5. King, D. W., King, L. A., Foy, D. W., Keane, T. M., & Fairbank, J. A. (1999). Posttraumatic stress disorder in a national sample of female and male Vietnam Veterans: Risk factors, war-zone stressors, and resilience-recovery variables. Journal of Abnormal Psychology, 108, 164-170.
6. King, D. W., King, L. A., Gudanowski, D. M., & Vreven, D. L. (1995). Alternative representations of war zone stressors: Relationships to posttraumatic stress disorder in male and female Vietnam Veterans. Journal of Abnormal Psychology, 104, 184-196.
7. Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., et al. (1990a). The National Vietnam Veterans Readjustment Study: Tables of findings and technical appendices. New York: Brunner/Mazel.
8. Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., et al. (1990b). Trauma and the Vietnam War generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel.
9. Ruef, A. M., Litz, B. T., Schlenger, W. E. (2000). Hispanic ethnicity and risk for combat-related posttraumatic stress disorder. Cultural Diversity and Ethnic Minority Psychology, 6(3), 235-251.
10. Schlenger, W. E., Kulka, R. A., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., et al. (1992). The prevalence of post-traumatic stress disorder in the Vietnam generation: A multimethod, multisource assessment of psychiatric disorder. Journal of Traumatic Stress, 5, 333-363.
11. Schnurr, P. P., Lunney, C. A., & Sengupta, A. (2004). Risk factors for the development versus maintenance of posttraumatic stress disorder. Journal of Traumatic Stress, 17, 85-95.
12. Schnurr, P. P., Lunney, C. A., Sengupta, A., & Waelde, L. C. (2003). A descriptive analysis of PTSD chronicity in Vietnam Veterans. Journal of Traumatic Stress, 16, 545-553.
13. Weiss, D. S., Marmar, C. R., Schlenger, W. E., Fairbank, J. A., Jordan, B. K., Hough, R. L., et al. (1992). The prevalence of lifetime and partial post-traumatic stress disorder in Vietnam theater Veterans. Journal of Traumatic Stress, 5, 365-376.

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