The Rest of the Story

The April 2006 edition of the American Journal of Psychiatry has an article about the longitudinal course of Posttraumatic Stress Disorder.  The abstract is here; the full version is here, but requires a subscription.  Additionally, there is a Medscape article based upon the original paper, here (free registration required).  From the Medscape synopsis:

The study was done with Israeli soldiers who served in the 1982 war with Lebanon.  The results are at least vaguely consistent with my own observations of soldiers in the US who served in Viet Nam, but one would need to be cautious about generalizing the results.
The Israeli investigators compared PTSD symptoms exhibited at 1, 2, 3 and 20 years after the war among 131 veterans diagnosed with combat stress reaction and 83 soldiers in the same units who did not develop an acute stress reaction. The researchers note that the two groups did not differ significantly in their premilitary screening of physical and psychiatric symptoms. [...]

At year 1, subjects in the combat stress reaction group had a 10.57-fold higher odds of meeting PTSD criteria than the comparison subjects. At years 2, 3 and 20, the odds were reduced to 5.15, 5.41, and 3.09, respectively.

Those with a combat stress reaction also had significantly more PTSD symptoms at all four time points.

The authors observed that 19.8% of the combat stress reaction group and 61.4% of the comparison group did not meet PTSD criteria at any of the four tests. However, members of the comparison group were more vulnerable to delayed onset.

What they did was to divide the soldiers into two groups: those who had shown "combat stress reaction" immediately during or shortly after combat, and those who did not have obvious symptoms in the immediate aftermath of combat.  Note that they used DSM-III criteria, since the DSM-IV did not exist in the early '80s.  If they had used the DSM-IV, they probably would have used the term Acute Stress Disorder.  (Acute Stress Disorder was not defined in DSM-III.)

There are a few key points here.  One is that, in this study, they did not find premorbid psychological factors that were associated with the subsequent development of combat stress reaction.  Another is the unsurprising observation, that the persons who had the most symptoms early on, also had more symptoms over time.  

Perhaps the more interesting finding is that the soldiers who did not have combat stress reaction were more susceptible to delayed onset of PTSD.  That is, some soldiers deal with the stress well on an acute basis, but then are more vulnerable to have problems later on.  

"Our findings suggest that (war veterans) need long-term monitoring and professional attention," the investigators conclude.

I hope that the people in charge of disability determinations for the VA system are paying attention.  Often, veterans who turn up years after war, claiming disability for PTSD, are greeted with skepticism.  That merely adds insult to injury.  The situation is already difficult enough for veterans who have delayed-onset PTSD.  For them, one of the most vexing things about the condition is that it seems inexplicable to them, to have done well acutely, but to develop problems later on.  When they take note of that apparent paradox, they tend to ascribe meaning to it.  These faulty attributions usually are self-deprecating.

Delayed-onset PTSD can occur also in civilians, although a quick Medline search did not turn up very much information of this.  There might be articles out there that I did not find, but if not, I would think this would be an important question to look into more thoroughly.

(update here.)