majority of the other disorders began in the same year as PTSD. Although the high rate of psychiatric and substance-use comorbidity can be partly explained by symptom overlap in DSM-IV, it does not diminish the diagnostic integrity of PTSD; rather, it suggests the importance of complete clinical evaluations to elucidate the full clinical picture of each patient.
PTSD can result in profound and long-term impairment of functioning and quality of life. This section considers the functional outcomes and disability that may occur in veterans with PTSD. Psychosocial effects and the impact of PTSD on family, friends, and others are discussed in Chapter 7. DSM-IV requires that a diagnosis of PTSD include “clinically significant distress and/or impairment in social, occupational, and/or other important areas of functioning” (APA 2000). Therefore, it is important to understand the distress and disability that may be associated with it.
Zatzick et al. evaluated 1190 male and 432 female Vietnam veterans by using data from the NVVRS (1997a,b). Of the men, 242 (15.3%) were diagnosed with PTSD and more than 90% of those men reported having one or more of 30 chronic nonpsychiatric medical conditions within the preceding 12 months. Of the veterans with no nonpsychiatric medical disorders, less than 10% had PTSD, whereas of the 141 veterans reporting four or more medical disorders, 31.9% had PTSD. Among the women, 8.9% had PTSD diagnosed, of whom 70% reported having one or more of 37 chronic medical conditions within the preceding 12 months. PTSD was present in only 4.2% of the female veterans with no chronic medical conditions but in 19.1% of those reporting four or more medical conditions. Veterans with PTSD reported significantly (p < 0.05) more functional impairment than veterans without PTSD, including inability to work, fair or poor health, diminished well-being, current limitation in physical functioning, and more days in bed in the preceding 3 months.
Dohrenwend et al. (2006) also reanalyzed the NVVRS data, including the Global Assessment of Functioning (GAF) scale that is traditionally used by VA to assess a veteran’s functional impairment. Of the sample of 260 veterans who had no diagnosis of PTSD or a diagnosis of past PTSD, 47% and 44%, respectively, were rated as having good functioning, although none of the veterans who had a diagnosis of current PTSD had good functioning in all GAF areas. Of those with current PTSD, 15% had only slight impairment, 41% had some difficulty, and 37% had moderate or serious impairment. The GAF scores were related to the severity of the PTSD.
A study of 70 UK active-duty military personnel referred to a PTSD clinic found that a diagnosis of PTSD, major depression, or alcohol dependence did not predict disability in work, relationships, or social activities, although symptoms of depression accounted for much of any total functional impairment, particularly in family life (Neal et al. 2004). Bleich and Solomon (2004) found that in Israeli veterans, PTSD symptoms resulted in more impairment in occupational functioning than in interpersonal functioning or activities of daily living.
World War II veterans 70-74 years old, who had PTSD as a result of their participation in secret military tests of mustard gas during the war were assessed for health-related disability (Schnurr et al. 2000b). As of 1996, compared with similarly exposed veterans without PTSD, veterans with PTSD had decreased functioning and increased impairment on all measures: physical function, social function, physical role impairment, emotional role impairment, lifetime disability, and current unemployment.