PTSD in Women Who Served as Nurses in Vietnam

This chapter reviews nurses’ traumatic events and stressful war-time experiences. Onset of war-related PTSD and its persistence many years after nurses’ service were elevated among those who had pre-Vietnam vulnerabilities, particularly pre-war psychiatric disorders. The rate of war-related PTSD onset among nurses was higher than that among male veterans with low probable combat exposure; and the odds of its persistence were nearly four times higher among nurses than among male veterans with moderate probable combat exposure. Likely sources of war-related stress among the nurses included their service in the operating room, their personal risk of enemy attack, and of sexual harassment and attack by fellow American soldiers. Nevertheless, the large majority of nurses reported a strong positive effect of military service on their lives.

Controversies About Rates of Post-Traumatic Stress Disorder in U.S. Vietnam Veterans

This chapter reexamines past estimates that 30.9% of veterans had developed PTSD during their lifetimes and that 15.2% were currently suffering from PTSD. The 1988 National Vietnam Veterans Readjustment Study (NVVRS) of a representative sample of 1,200 male veterans also found a strong dose–response relationship: as retrospective reports of combat exposure increased, PTSD occurrence increased. Skeptics have argued that these results are inflated by recall bias and other flaws. This chapter uses military records to construct a new exposure measure and to cross-check exposure reports in rigorous diagnoses of a subsample of 260 veterans. It finds little evidence of falsification, an even stronger dose–response relationship, and psychological costs that were lower than previously estimated but still substantial: 18.7% of the veterans had developed war-related PTSD during their lifetimes, and 9.1% were currently suffering from PTSD 11–12 years after the war.

Veterans’ Appraisals of the Impact of the War on Their Lives 10-Plus Years After the War Ended

This chapter presents findings that the large majority (between 61.8% and 70.9%) of U.S. male veterans in the NVVRS sample appraised the impact of Vietnam service on their personal lives as mainly positive, and that negative appraisals, especially those with high salience (i.e., importance), are strongly associated with PTSD onset and current PTSD. A substantial minority (41.7%) judged the effects to be highly salient in their present lives. It investigates the valence and salience of these appraisals in relation to PTSD and other indicators of wartime and post-war functioning. The results are consistent with the hypothesis that mainly positive appraisals are affirmations of successful wartime and post-war adaptation rather than defensive denials related to maladaptive outcomes. It discusses the possibility that mainly positive appraisals, especially those with low salience, also contribute to successful post-war adaptation.

Some Psychological Effects of Changing Public Attitudes on U.S. Vietnam Veterans

This chapter discusses the substantial effect that changing public attitudes toward the Vietnam war had both on veterans’ own attitudes toward the war and on demoralization in the U.S. armed forces toward the end of the war. In addition, as hypothesized, veterans’ negative attitudes at the time of their own entrances and exits from Vietnam, and negative changes in veterans’ initially favorable attitudes, were related to the period of the war in which they served and positively associated with demoralization. Because measurement of veterans’ attitudes toward the war at their entrance and exit occurred long after their service in Vietnam, it is possible that memory distortions played a role in these findings. However, the data indicate that retrospective bias cannot account for the differences in declining favorable and increasing negative attitudes toward the war related to veterans’ time of war entry.

Families of Veterans

This chapter focuses on wives or partners and offspring of a subsample of 115 clinically diagnosed male Vietnam veterans who had one or more children aged 6–16 at the time of the NVVRS. It defines veteran traumatization as meeting criteria for lifetime war-related PTSD. Secondary traumatization is operationalized by elevated scores on children’s internalizing or externalizing behavior problems and on wives’ demoralization. This chapter reports evidence of secondary traumatization in the veterans’ sons. Current PTSD in the veterans is associated with demoralization in their wives or partners, which in turn is associated with behavior problems in their daughters. Demoralization of the wife or partner is also associated with current alcoholism in the veterans. Even with the degree of secondary traumatization present, the veterans’ children appear at least as healthy as their counterparts in the general population.

War-Related PTSD in Black, Hispanic, and Majority White Vietnam Veterans

This chapter investigates elevated prevalence of chronic PTSD for black and Hispanic Vietnam veterans. Previous research relied on retrospective reports of war-zone stress and on PTSD assessments that failed to distinguish between prevalence and incidence. This chapter addresses these limitations using record-based exposure measures and clinical diagnoses on a subsample of NVVRS veterans. Compared with majority white, it explains the black elevation by blacks’ greater exposure to combat and the Hispanic elevation by Hispanics’ greater exposure, younger age, lesser education, and lower Armed Forces Qualification Test (AFQT) scores. Hispanics’ younger age mainly accounts for the PTSD elevation in Hispanics versus blacks. The main reason for the group differences in severity of exposure appears to be racial-ethnic contrasts in the military branches in which the veterans served.

Prelude, War, and Aftermath

This chapter presents a broad summary of this conflict, beginning with its roots in nineteenth-century colonial French Indochina. It details the buildup of U.S. military and economic aid to the South Vietnamese regime after French withdrawal, early U.S. intervention in the ongoing civil war between North and South Vietnam, and the gradual escalation of America’s presence in Southeast Asia under presidents Kennedy, Johnson and Nixon. It describes how and where the war was fought, who served and why, and on-going political and social movements in the U.S. throughout the war and after U.S. withdrawal. It summarizes the human costs in Vietnam and the United States. It describes attempts by psychiatrists to create frameworks for understanding and addressing the trauma, anguish, alienation, and rage experienced and expressed by the U.S. veterans who fought this controversial war, including official recognition in the new diagnosis of post-traumatic stress disorder.

Harming Civilians or Prisoners

This chapter uses responses to direct, closed questions about personal involvement to identify 12.8% of veterans as harmers. It examines qualitative information to compare self-identified harmers of civilians or prisoners with other veterans. It investigates the qualitative data to discover the specific circumstances in which this type of harm took place. It suggests that harm to prisoners may usually have occurred following attacks on clearly identifiable enemy forces. In contrast, many incidents of harm to civilians appear to have occurred in attempts by U.S. forces to implement the policy of clearing the population from areas considered to be under enemy control. Other than their much more severe combat exposure, this analysis reveals very few characteristics of the harmers that differentiated them from those not directly involved in inflicting such harm. The harmers themselves tend to suffer from persistent guilt and anger.

The Roles of Combat Exposure, Personal Vulnerability, and Involvement in Harm to Civilians or Prisoners in War-Related Post-Traumatic Stress Disorder

This chapter examines the central assumption in the DSM-III, DSM-III-R, and DSM-IV that potentially traumatic stressors are more important than personal vulnerability in causing PTSD. This chapter tests this assumption with data from a rigorously diagnosed male subsample (n = 260) from the NVVRS. It concludes that, of the three risk factors, only combat exposure proved necessary for disorder onset. Although none of the three risk factors proved sufficient, estimated onset reached 97% for veterans high on all three, with harm to civilians or prisoners showing the largest independent contribution. Severity of combat exposure proved more important than pre-war vulnerability in onset; pre-war vulnerability was as least as important in long-term persistence. Implications for the primacy of the stressor assumption are discussed.

Measurement of Severity of Combat, Involvement in Harming Civilians and Prisoners, and Personal Vulnerability Load

This chapter presents detailed measures of each of the three factors that most strongly affect the psychological impact of the Vietnam war on U.S. male veterans. These descriptions build on the detailed accounts in Chapter 2 of the use of military records to develop more comprehensive measures of war-zone experiences. The measures of harm to civilians and prisoners are based on veteran self-reports. The measures of pre-Vietnam vulnerability load include data from military records, such as the Armed Forces Qualification Test (AFQT), pre-war education levels, and NVVRS interview data that enable diagnoses of important types of psychiatric disorder other than PTSD. Less central, but perhaps no less important, other risk factor variables and their measurement are set forth in later chapters at the point they are first introduced.