457

Follow-Up Studies of Veterans

Chapter 18

FOLLOW-UP STUDIES OF VETERANS

ROBERT H. STRETCH, Ph.D.*

INTRODUCTION

WORLD WAR I STUDIES

The 1919–1920 Study

The 1924–1925 Study

WORLD WAR II STUDIES

Mortality

Symptom Prevalence

Occupational Adjustment

Economic Adjustment

Marital Adjustment

Family Adjustment

Community and General Social Adjustment

Psychiatric Disability

Treatment Issues

KOREAN CONFLICT STUDIES

VIETNAM CONFLICT STUDIES

SUMMARY AND CONCLUSION

*Major, Medical Service Corps, U.S. Army Reserve; Grants Associate, Office of Extramural Research, National Institutes of Health, Bethesda,

Maryland; Research Assistant Professor of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
War Psychiatry

458

Marion Greenwood The Dental Front 1945

Marion Greenwood created a series of watercolors depicting the work of the U.S. Army Medical Department at the England General Hospital in Atlantic City, New Jersey during World War II. This watercolor

portrays wounded soldiers waiting for their next medical procedure, in this case a visit with the dentist.

Many of these seriously-wounded soldiers will be separated from the service for medical reasons and will

receive their follow-up care through Veterans Administration hospitals.

Art: Courtesy of US Army Center of Military History, Washington, DC.
459

Follow-Up Studies of Veterans

INTRODUCTION

The role of “soldier” has been glorified throughout the ages as a noble and honorable calling. The

age of modern warfare, beginning with World War

I, has been no exception. Soldiers such as Alvin

York and Audie Murphy have been immortalized

for their heroic deeds on the battlefield. The late

actor, John Wayne, became the idol of millions for

his combat soldier portrayals in countless movies.

These romanticized depictions of wars and the men

who fought in them tend to make one forget that

war is a brutal and dehumanizing experience for

many men.

Soldiers are often simply common men driven by

geopolitical forces beyond their control into the role

of combatant and, as such, typify the strengths and

weaknesses inherent in all men. The vast majority

of soldiers are not career military men. After wars’

end, soldiers once again become civilians and return to their families to try to pick up where they left

off. It is this process of readjustment that has more

often than not been ignored by society. It is the

soldier who is prized and valued, not the ex-soldier.

The purpose of this chapter is to document the

scientific attempts to follow up on veterans since

the end of World War I to gain insight into the

readjustment process and the successes and failures

of veterans who were affected to different degrees

by their war experiences.

WORLD WAR I STUDIES

Follow-up studies of veterans in the modern age

of warfare began with the work of Salmon and

Fenton1 on the psychological adjustment of veterans of World War 1. In 1919, and again in 1924,

Salmon and Fenton studied the postwar adjustment

of a sample of veterans who had been hospitalized

for war neuroses at Base Hospital No. 117 in France.

Base Hospital No. 117 was the third-echelon facility

which received those stress casualties who had not

been returned to duty immediately by the division

psychiatrist or after 3 to 5 days at the field hospital

in the division rear. They had either failed to

recover in 3 weeks at one of the three neurological

hospitals or had been evacuated to the nonpsychiatric hospitals in the rear and therefore had been

transferred to Base Hospital No. 117. They were the

most severe cases.

The 1919–1920 Study

Preparation for the study was begun shortly after

the armistice was signed. The purpose of the study

was to determine the condition of a typical group of

diagnosed war neurosis cases after their return to

the civilian community in the United States. Questionnaire data were used to determine how well or

poorly these men were getting along in terms of

ability to work and contribute to society. The data

do not provide for adequate clinical conclusions for

a medical diagnosis of neurosis during follow-up,

but do provide insight into problems and difficulties in attempts at readaptation. Data were collected from 758 veterans out of the 2,590 veterans

who had been hospitalized at Base Hospital No. 117

in France.

Subjects were classified according to social status

and ability to work and be self-supporting. These

classifications were normal, neurotic, fatigued, disabled, and psychotic. The “normal” group consisted of men who went back to work to support

themselves and their families and readjusted easily

to civilian life. Many of these men noted tendencies

to become angry or easily excited, nervous, restless,

forgetful, and suffered from slight headaches or

dizziness. For the most part these men were in good

health, self-supporting, and happy.

The “neurotic” group consisted of those men

who had only partially adjusted to their way of life

prior to entering the military. They continued to

suffer from one or more nervous difficulties and

were either under a physician’s care or had consulted one about their problems. They were able to

return to work but were often unhappy because of

their neurotic problems. These men tended to exhibit some of the same symptoms shown in France:

tremors and tics, speech defects, weakness, insomnia, jumpiness, inability to concentrate, and memory

disorders. These men also reported a great many

minor injuries and serious accidents resulting from

their nervous condition. Many men in this group

were no longer able to function in their former jobs

in machine shops or factories, but found working

outdoors as salesmen, farmers, laborers, etc. less

difficult.
War Psychiatry

460

The “fatigued” group consisted of men who could

not work regularly without suffering and being

bedridden. These men experienced fatigue, severe

headaches, lack of ambition, depression, and were

only able to work about one half of the time. The

“disabled” group consisted of those men who were

rehospitalized for psychoneurosis or reported a

“nervous breakdown” or some incapacitating disease such as tuberculosis. The last group, the

“psychotics,” consisted of men who suffered from

conditions such as dementia praecox, psychopathic

personality, and epilepsy.

The current adjustment of these men according

to the preceding classifications was then compared

to the military classifications used by the U.S. Army

in France to estimate the man’s future military usefulness at the time of his discharge from Base Hospital No. 117. These men had been classified in one

of four categories, as follows:

• Class A: Officers and enlisted men fit for

combat service.

• Class B: Officers and enlisted men temporarily unfit for combat service but physically

fit for other duty and restorable to Class A

status within 6 months.

• Class C: Officers and enlisted men permanently unfit for combat service but capable

of other supply-oriented service.

• Class D: Officers and enlisted men unfit for

any duty within the American Expeditionary Forces.

This classification system took into account factors such as health, strength, and endurance which

would be of significance in both U.S. Army and

civilian life. The authors reasoned that if the classifications were adequately made, then some positive

correlation should exist between these classifications and the men’s later (1919–1920) conditions.

The percentages of veterans in each group in the

follow-up sample were very similar to the percentages of all cases at the hospital assigned to each

group. These percentages for follow-up vs all cases

were as follows:

• Category Follow-up Cases All Cases

• Class A 24.8% 19.6%

• Class B 36.6% 39.2%

• Class C 29.3% 31.8%

• Class D 7.5% 6.6%

An additional 1.8% of the follow-up group and

2.9% of the total group had been transferred to

another hospital unclassified.

In the 1919 to 1920 time frame, the veterans’

groups were adjusting as follows:

• Class A: 68.1% were adjusting adequately

(45.2% were normal, 22.9% were

neurotic).

• Class B: 64.8% were adjusting adequately

(41.8% were normal, 23% were

neurotic).

• Class C: 55.4% were adjusting adequately

(33.3% were normal, 22.1% were

neurotic).

• Class D: 40.3% were adjusting adequately

(21% were normal, 19.3% were

neurotic).

The next stage in the study consisted of an

inquiry into the question of mental disease diagnosis at discharge and its relation to functioning

levels for the 1919 to 1920 period. For this comparison subjects were divided into two groups.

Working veterans were those in the normal

and neurotic categories. Disabled veterans were

those in the fatigued, disabled, and psychotic categories. An examination of the percentages of

various mental diagnoses associated with the

working veterans revealed that the typical war

neuroses at that time, primarily concussion, gas,

and anxiety types, ranked very high in terms

of successful readaptation (75% of veterans diagnosed as having anxiety neurosis, 73.4% of veterans

with gas neurosis, and 67.8% of veterans with concussion neurosis at discharge were among the

working veterans in 1919–1920). The less successfully readapted veterans were those whose diagnoses were of the more pronounced constitutional

types such as hypochondriasis, neurasthenia,

psychasthenia, and hysteria. Thus, veterans

whose diagnosis reflected a recent onset of symptoms in response to war-related trauma exhibited a

greater degree of readjustment than those veterans

whose diagnoses reflected a certain constitutional

susceptibility.

Additional observations revealed a slight tendency for younger men to do better in their readjustment than the older men, as well as a tendency

for those of “good stock” and make-up to readapt

themselves better to civilian life than those from

“poor stock” and make-up. It was also found that

men whose occupations required somewhat more

intelligence for performance were better able to

readapt than men whose occupations demanded

less intelligence.
461

Follow-Up Studies of Veterans

The 1924–1925 Study

A second follow-up of veterans from Base Hospital No. 117 was conducted in the period 1924 to

1925. Data were obtained from 763 subjects. Hospital estimates of potential military value at time of

discharge were again compared to current functioning. As before, the veterans’ current functioning was determined relative to their original classification grade as follows:

• Class A: 83% were functioning adequately

(40.7% normal, 42.3% neurotic)

• Class B: 85.9% were functioning adequately

(39.1% normal, 46.8% neurotic)

• Class C: 73.9% were functioning adequately

(30% normal, 43.9% neurotic)

• Class D: 72.7% were functioning adequately

(40.9% normal, 31.8% neurotic)

Thus, these hospital estimates of future U.S. Army

potential again were predictive of future civilian

readjustment.

A follow-up comparison of the relationship of

specific mental diagnoses to current functioning again revealed that veterans with typical

war neuroses of that time (gas syndrome, exhaustion, concussion, anxiety) showed greater evidence

of recovery than those with more pronounced

constitutional types (neurasthenia, psychasthenia, hypochondriasis). More important is the

observation that practically every diagnostic

group showed an increase in the percentage of

veterans who had readapted adequately from the

first period (1919–1920) to the second period (1924–

1925).

Whereas in the 1919 to 1920 follow-up younger

veterans seemed to be readapting better than older

veterans, the 1924 to 1925 follow-up found a tendency for the extreme age groups, both younger

and older, to make poorer readaptations than men

in the middle age range. The finding in the 1919 to

1920 study of a positive relationship between family history and current functioning was not found in

the 1924 to 1925 study. Personal and family histories were not in themselves predictive of future

civilian readjustment.

Occupational data from the 1924 to 1925 study

revealed that former war neurotics who had difficulty working at manufacturing trades in urban

areas were able to readapt fairly successfully in

agricultural work. Overall, the 5 years between

follow-up studies showed evidence of a great deal

of improvement among veterans of Base Hospital

No. 117. The percentage of veterans who were able

to function adequately increased from 60.9% to

80.8%. The fatigued veterans, who were able to

work only about one half the time, decreased from

17.3% to 9.8% while the disabled and psychotic

groups, who were not able to work, decreased from

21.7% to 9.4%. Salmon and Fenton1 speculated that

the most important factor underlying this marked

improvement was the focus of various governmental and social agencies on the problems of soldiers

that led to their becoming an asset rather than a

burden upon society.

WORLD WAR II STUDIES

The conclusion of World War II saw a continued

interest in the postwar psychological adjustment of

servicemen. The most comprehensive follow-up

study to emerge from the World War II literature is

that of Brill and Beebe.2

 This study was generated

as a result of the establishment by the National

Research Council of a Committee on Veterans Medical Problems whose task was to develop a program

of medical follow-up studies based on the medical

experience of the Armed Forces and the Veterans

Administration.

The study was conducted using subjects drawn

from representative samples of 8,000 U.S. Army

(including U.S. Air Force) and 2,216 U.S. Navy and

Marine Corps veterans who had been diagnosed as

suffering from a psychoneurosis during service

(both combat and noncombat) in World War II.

Psychoneurosis included the following types of disorders: hysteria; anxiety state; hypochondriasis;

neurasthenia; neurocirculatory asthenia; obsessive–

compulsive; psychasthenia; phobias; reactive depression; psychoneurosis; and others, unqualified,

unspecified, including combat exhaustion.

From these U.S. Army and U.S. Navy rosters a

“clinical” sample of 955 veterans with psychoneurosis was selected to receive a 4-hour examination

by one of 225 psychiatrists nationwide who had

agreed to participate in the project. A second

“record” sample of 520 U.S. Army and U.S. Navy

cases of psychoneurosis was selected to be studied

on the basis of military records.

A control group of 397 U.S. Army enlisted men

was chosen at random such that the number among

them who saw service during each month in 1944
War Psychiatry

462

was proportional to the number of psychiatric admissions during each month of that year. Data for

controls consisted of information on their military

and medical histories during service. A second

control group was added in 1951 in response to the

Korean mobilization. This group consisted of 502

new recruits who were given psychiatric examinations as they were received in large training divisions immediately after induction.

The first objective of the study was to determine

the characteristics of the clinical and record samples

and the ways they differed from the general military population both before and during military

service in relation to the chance of breakdown in

service. The second objective was to determine the

etiology of combat breakdown, its progression during service, and its effects on subsequent military

performance. The third major goal was to learn

what happened to these men after they left the

service and to describe their follow-up psychiatric

status approximately 5 years after breakdown. Of

particular importance to this review are the results

of this third goal. For data regarding the first two

objectives the reader is referred to Brill and Beebe.2

Mortality

A mortality check on the 1,475 U.S. Army and

U.S. Navy veterans in the clinical and record samples

was made in 1953. A total of 36 deaths were discovered in comparison to an expected 31 deaths among

same age males in the general population. An

examination of cause of death revealed a relatively

high suicide rate for subjects in the study (six suicides compared to only two expected).

Symptom Prevalence

During the examination, only 8.7% of examined

cases and an estimated 10.1% of the entire clinical

sample reported experiencing no psychiatric symptoms. The most common symptoms reported by the

subjects were anxiety (45.3%); depression (29.6%);

nightmares (22.1%); insomnia (31.9%); headache

(42.8%); irritability (48.6%); difficulty in concentration (20.1%); restlessness (45.4%); and psychogenic

somatic complaints of the gastrointestinal (41.7%),

cardiovascular (21.9%), and musculoskeletal systems (34.8%). In addition, 9.5% of subjects reported

alcoholism, 10.1% reported hysteria, and 9.8% reported phobias.

The examiners traced these psychiatric symptoms and psychogenic somatic complaints back to

their origin to determine which were evident before

service, which first appeared during service, and

which appeared after discharge. Rather than examining the origin of each symptom, a summary was

made for each subject and a significant number

(19%) presented different complaints originating

both before and during service. All symptoms

originated before service for 24% of subjects and

during service for 43% of subjects. Only 4% of

subjects had all symptoms develop after discharge.

When asked to assess their own health, the subjects indicated that, when compared to entry into

the service, they were currently in better health

than they had been at time of separation. At time of

separation, 81% regarded their health as poorer

than at entry into service, 45% described their health

as “much worse,” and only 19% felt their health was

the same or better. During the follow-up 5 years

later, 71% described their health as poorer than at

entry, 31% felt “much worse,” and 29% reported

their health as the same or better. Although their

health had tended to improve, the vast majority of

the subjects still did not regard themselves as being

well at follow-up.

Occupational Adjustment

Examiners assessed occupational adjustment by

focusing on the veteran’s ability to handle his job,

avoidance of interpersonal difficulties, attitudes

toward his work (including security, pay, working

conditions), and employer satisfaction with the veteran. Satisfactory occupational adjustment was

exhibited by 67% of the subjects, while 7% had a

questionable adjustment, and 26% had an impaired

adjustment. At the time of examination, 76% of the

subjects were employed full-time, 9% part-time,

and 15% were unemployed. Illness was a factor in

preventing full-time employment for 14% of the

sample.

Economic Adjustment

A veteran was considered to have a satisfactory

economic adjustment if he could support his family,

and if any dissatisfaction with his income was within

normal limits or neurotic in origin. Using these

criteria, 74% of the subjects had made a satisfactory

adjustment, 5% were questionable, and 21% were

impaired.

Marital Adjustment

Only 15% of the subjects were still single at follow-up in comparison to 46% at separation and 62%
463

Follow-Up Studies of Veterans

at entry into the service. Examiners reported finding less satisfactory adjustment in this area than in

most others. Only 60% of married subjects were

regarded as having satisfactory adjustment, 22%

were questionable, and 18% were impaired.

Family Adjustment

Assessment of family adjustment was made on

the basis of the subject’s attitudes and behavior

toward either his own wife and children, if any, or

with his parental family. A veteran was considered

to be impaired if he ran away from home before the

end of adolescence, quarreled often with parents or

siblings, refused to cooperate within the family in a

normal fashion (contributing to its support), or was

too dependent upon his family, unable to make

independent decisions or to engage in normal activities outside the family. On this basis, 67% of

veterans were adjusting satisfactorily, 21% were

questionable, and 12% were impaired.

Community and General Social Adjustment

This area of adjustment refers to the boundaries

of socially acceptable behavior and mores. Only

56% of the subjects were deemed to have adjusted

satisfactorily, 25% were questionable, and 19% were

impaired.

Psychiatric Disability

A veteran was considered psychiatrically disabled if his psychiatric symptomatology caused

him to either lose time from work or prevented him

from carrying out his role as a student or father. The

degree of impairment or disability also involved how

the veteran’s adjustment in other areas such as family

and community adjustment was affected. Disability

in one or more minor areas of activity without work

disruption was usually labeled as mild disability,

while a moderate degree of disability usually affected work time or efficiency appreciably.

The results revealed that less than 30% of the

veterans in the follow-up study were more than

slightly disabled due to psychiatric symptoms, and

only 8.1% were more than moderately disabled.

Thus, while there was a great deal of psychiatric

symptomatology present in these veterans, this

symptomatology did not translate into disability.

In looking at changes in psychiatric conditions

since discharge from the service, it was found that

most veterans who were not psychiatrically disabled at discharge either remained the same or

improved. Of those veterans who were disabled at

discharge, 60% appeared to have improved, 24%

remained the same, and 14% became worse.

Treatment Issues

At follow-up it was determined that 36% of the

veterans in the study had sought some type of

psychiatric or other treatment for relief of symptoms. When asked whether they felt the need for

further psychiatric treatment, 56% of the veterans

reported that they did not. Of the 40% who did

express a need for further treatment (4% expressed

no opinion), less than a third felt their need was

great.

The basic conclusions of this large-scale followup study of World War II veterans are similar to

those reported by Salmon and Fenton1 on World

War I veterans. Both studies revealed a marked

tendency for significant improvement among psychiatrically troubled veterans 5 years since discharge from the service. Not only have their conditions improved, but their ability to function as

contributing members rather than as burdens to

society has also improved. This is not to imply that

they have not been significantly affected by their

war-related service. It merely means that for the

majority of impaired veterans, their negative experiences have not served to prevent them from coping in a satisfactory fashion.

Ripley and Wolf3 conducted a follow-up of 100

veterans who had been hospitalized with schizophrenia or schizophrenic-like reactions while participating in combat campaigns in New Guinea and

the Philippines from 1943 to 1945. Follow-up data

over a period of 5 to 8 years after hospitalization

were gathered from records, questionnaires, and

personal interviews. Many of these veterans had

functioned in the military for long periods prior to

their breakdown despite the presence of a high

degree of psychopathologic symptomatology.

Upon evacuation to the United States, marked

symptomatic improvement was noticed in one fifth

of the patients. More than one third of the patients

had been discharged after 2 months of hospitalization, and only four had not been released after

more than a year. In comparing the prewar and

postwar adjustment of these veterans, it was found

that their general health, ability to function at work,

family relationships, and social adaptation were all

poorer.

Evidence was found for a gradual trend toward

decreased disability, although several common

symptoms persisted: vague somatic complaints, ir-
War Psychiatry

464

ritability, headaches, seclusiveness, insomnia, difficulty in concentration, dejection, excessive fantasy, suspiciousness, anxiety, restlessness, hallucinations, and resentment toward authority. Eleven

patients had had further hospitalizations. Over one

fifth of the veterans were severely disabled by these

symptoms after 5 or more years. The most important factors in promoting a good readjustment were

a warm, tolerant, helpful attitude on the part of a

wife or other family member, satisfactory work

situation, and success in school and social contacts.

Additional evidence concerning the long-term

effects of war neuroses can be found in the report of

a 5-year follow-up study by Futterman and

Pumpian-Mindlin.4 This study of 200 combat veterans seeking treatment at the Veterans Administration Mental Hygiene Clinic in Los Angeles provided evidence of fresh cases of traumatic war

neuroses that had not previously sought treatment

since the war. Common symptomatology among

these veterans included: intense anxiety, recurrent

combat-related dreams, startle reactions, depression, guilt, and a tendency to sudden, violent behavior. Secondary symptoms included a tendency

to avoid people, fear of criticism, difficulty in making decisions, and various sleep disturbances.

Similar findings were reported by Archibald,

Long, Miller, and Tuddenham5 in their 15-year follow-up report on gross stress reactions resulting

from combat during World War II. Questionnaire

data were obtained from 57 combat veterans and 48

noncombat control subjects. The data indicated

that the combat veterans were bothered by problems of tension, irritability, depression, diffuse anxiety symptoms, headaches, startle reactions, dizziness, blackouts, avoidance of activities similar to

combat experience, internalization of feelings, insomnia, and nightmares. Eighty-two percent of the

combat veterans reported that their psychological

symptoms had interfered with their abilities to provide for their families.

Ponteva6 conducted a follow-up study of Finnish

soldiers who had been treated for psychiatric reasons during the war with Russia (1941–1944). Approximately 15,700 soldiers had been hospitalized

for psychiatric causes. Subjects for the follow-up

study were selected at random from these hospitalized veterans using records maintained at the War

Casualties Archives. A control group was also

picked at random from pneumonia patients because of the lack of correlation between pneumonia

and psychiatric disorders.

Data were obtained from 373 patients and 372

controls. It was found that at the time of follow-up

(1971) approximately 43% of the psychiatric patients and 23% of the controls were either partially

or entirely unable to work. The two most important

causes of disability for the patients were cardiovascular diseases and mental diseases. Ponteva concluded that the adaptation of wartime psychiatric

patients to civil life after the war was very good in

the subgroups of veterans suffering from neurotic

and reactive disorders. The more severely disturbed veterans, however, were not as successful in

their readjustment.

Long-term reactions to modern warfare are by no

means limited to American or European veterans.

Meguro7 conducted a 20-year follow-up study of

war neurosis cases discharged from the former

Konodai Army Hospital in Japan between 1941 and

1945. Questionnaires and interviews were used to

collect data from 104 Japanese veterans selected at

random from the total population of 2,205 war neurosis patients. Results revealed that, of those who

had developed war neuroses and were unable to

adapt to military life, more than 56% were now

considered medically healthy and socially adapted.

Approximately 68% of the veterans reported that

their war neurosis symptoms had, in the medical

sense, been cured. Meguro noted, however, that

about one sixth of this group was still jobless and

single in their middle age and could not be considered socially adapted. Among those veterans who

were found “cured” of their former principal symptoms, the data indicated that the whole group still

tended to be more neurotic than a normal group.

KOREAN CONFLICT STUDIES

Little research has been conducted on the followup status of Korean conflict veterans. Archibald

and Tuddenham8 investigated the long-term effects

of combat stress on veterans of the Korean conflict

as part of a further follow-up on an earlier study of

World War II veterans.5 All subjects were seen as

outpatients at the Oakland, California Veterans

Administration (VA) mental hygiene clinic. Included

in the study were 15 Korean conflict veterans showing

evidence of combat fatigue and 17 Korean conflict

noncombatants with various psychiatric diagnoses

representative of the clinic population.
465

Follow-Up Studies of Veterans

Archibald and Tuddenham were interested in

assessing the existence of a poststress syndrome of

restlessness, irritability, tension, headaches, sleep

disturbance, overreactive startle reflex, feelings of

isolation and distrust, sense of inadequacy, and

restriction of social contacts and activities. Questionnaire data revealed that the combat-fatigued

veterans showed a significantly higher incidence

than the noncombat veterans of sweaty hands, dizziness, depression, irritability, combat dreams, restlessness, and difficulty in concentration and in

memory. At time of sampling the combat-fatigued

veterans had a higher incidence of every one of the

symptoms than they did during combat.

On a rating of changes in health status, fewer

combat-fatigued veterans reported improvement

and more reported deterioration than did the noncombat veterans. Significant differences were also

found between the combat fatigued veterans and

noncombat veterans in response to noises of airplanes, sudden loud noises such as firecrackers,

combat portrayals on television or in movies, and

going through a highway tunnel. These results

among Korean conflict veterans confirm the findings for similar groups of World War II veterans.

Thienes-Hontos, Watson, and Kucala9 assessed

the prevalence of stress symptomatology among a

sample of 29 Korean veterans and 29 Vietnam veterans who had been hospitalized for psychiatric reasons at the St. Cloud, Minnesota VA medical center

between 9 and 36 months after their military separation dates. Hospital files for these veterans were

examined to determine the incidence of the following stress-related symptoms: recurrent dreams and

recollections of a traumatic event, intrusive

thoughts, constricted affect, feelings of estrangement from others, diminished interest in one or

more significant activities, hyperalertness, sleep

disturbance, survivor guilt, memory impairment,

and trouble concentrating. Results indicated that

constricted affect, memory impairment/trouble

concentrating, and diminished interests were more

commonly reported by Korean rather than Vietnam

veterans. Recurrent dreams were more often reported by Vietnam rather than Korean veterans.

Overall, nearly identical percentages of Korean

(42.2%) and Vietnam (42.3%) veterans reported

symptoms that were found to be stress-related.

The period since the end of U.S. involvement in

Vietnam has witnessed an unparalleled amount of

research interest in the readjustment of its veterans.

The impetus for this interest stems largely from the

myriad of controversies and mystiques that surround both the conduct of the war and the men who

fought in it. Never before in the history of the

United States has there been such an unpopular and

divisive conflict as expressed by the antiwar demonstrations of the late 1960s. Perhaps more important was the way in which the public outcry against

the war carried over to the men who fought in it.

The veterans of Vietnam did not return to the victory parades of an adoring nation. Far too often

they returned alone and afraid of the very society

they had fought to protect. As with the diversity of

opinions about the war itself, a dichotomy of opinions existed among researchers interested in the

prevalence and severity of apparent stress reactions

experienced by returning Vietnam veterans. Figley10

delineated two diverse perspectives that emerged

from the literature in the 1970s: stress evaporation

and residual stress.

The stress evaporation perspective holds that the

Vietnam veteran probably did suffer some psychological readjustment problems during and immediately after military service, but any problems disappeared since returning home. Representative

studies of this perspective include those by

Worthington,11,12 and Borus.13–16 These studies found

no significant differences between veterans who

served in Vietnam and those who did not on a wide

range of psychosocial behaviors. These studies did

not, however, always include control groups or

assess for combat experience.

The residual stress perspective holds that the

nature of the Vietnam combat experience is such

that it has a significant impact on the veteran, making the transition back to civilian life difficult. Studies representative of this perspective include those

by Wilson,17 Strayer and Ellenhorn,18 Haley,19 and

Figley and Southerly20 which have documented significantly more problems of adjustment among Vietnam combat veterans than among noncombat Vietnam-era veterans.

There are two basic conclusions that can be drawn

from these studies of the readjustment of Vietnam

veterans in the 1970s. If one looks at Vietnam-era

veterans as a group, there do not appear to be any

significant differences in comparison to nonveterans

VIETNAM CONFLICT STUDIES
War Psychiatry

466

in most areas of interpersonal and intrapersonal adjustment.11–16 However, if one controls for either service in Vietnam in general, or combat experience in

particular, then there is considerable evidence that

suggests that Vietnam combat veterans, when compared to Vietnam-era veterans or nonveterans, exhibit

significantly more (a) negative general and specific

orientations toward violence,21 (b) psychological symptoms,17,20,22 (c) indices of depression,23 (d) political alienation,4,24,25 and (e) adjustment problems.10,17,18,20

Research on Vietnam veterans in the 1980s witnessed a shift in emphasis brought about by the

inclusion of the category of Post-Traumatic Stress

Disorder (PTSD), both Acute and Chronic/Delayed,

in the third edition of the American Psychiatric

Association’s Diagnostic and Statistical Manual of

Mental Disorders (DSM-III) in 1980.26

Briefly, PTSD is characterized by the development of common symptomatology following a psychologically traumatic event that is outside the range

of normal human experience. The characteristic

symptoms involve reexperiencing the traumatic

event through intrusive memories, recurrent

dreams, or “flashbacks” caused by environmental

or ideational stimuli; numbing of responsiveness to

or reduced involvement with the external world as

evidenced by diminished interest in activities, feelings of detachment or estrangement, constricted

affect; and a variety of autonomic, dysphoric, or

cognitive symptoms such as exaggerated startle

response, sleep disturbances, survivor guilt, difficulty concentrating, memory impairment, or avoidance of activities that arouse recollection of the

traumatic event.

The inclusion of the category of PTSD in DSM-III

has resulted in fewer studies whose purpose is to

either document or refute the existence of readjustment problems among Vietnam veterans. More

studies are attempting to determine how prevalent

these problems are in the veteran population as

well as their etiologies and appropriate treatment

modalities.

One of the most comprehensive studies of the

readjustment of Vietnam veterans is the five-volume report by the Center for Policy Research,27

which examined educational and occupational adjustment, social and psychological problems, longterm stress reactions, and how veterans have dealt

with their war experiences. The data for this project

consist of in-depth interviews with over 1,400 Vietnam and Vietnam-era veterans from various parts

of the country, both urban and rural.

The results of this study reveal that Vietnam

veterans have not attained as high a degree of education as their peers and tend to hold jobs that are of

lower levels than both Vietnam-era veterans (those

who did not serve in Vietnam) and nonveterans.

Unemployment is a particularly acute problem

among black Vietnam veterans, while a greater

proportion of whites have not fully utilized the

educational opportunities available to them under

the “GI Bill” (the Veterans Readjustment Benefits

Act of 1966).

Combat was found to have a significant impact

on the social and psychological adjustment of Vietnam veterans. Evidence was found documenting a

direct, significant relationship between combat and

current drug and alcohol use, arrests, medical problems, and stress-related symptoms. This latter relationship to stress-related symptoms seemed to be

concentrated primarily among veterans who served

in combat during and after 1968 when public opinion and support for the war became highly negative. Reactions to combat among Vietnam veterans

also differed along racial lines. Increased combat

exposure among white veterans was characterized

by excessive alcohol use while among black veterans drug abuse was found more frequently.

An examination of long-term stress reactions

among these Vietnam veterans revealed that differences in family stability and the amount and intensity of combat experiences interacted to affect veterans to different degrees. Supportive relationships

with others were found to have a significant effect

in reducing the incidence and severity of stress

reactions for all veterans, regardless of amount of

combat experience. For veterans residing in large

cities, interaction with other Vietnam veterans was

found to alleviate stress reactions, while veterans in

smaller cities and rural areas tended to be helped by

the presence of a highly supportive network of close

friends.

Additional data reveal that Vietnam veterans

have attempted to deal with their war experiences

in different ways. Some veterans have tried to

simply forget or block out the past; others cling to it

tenaciously; while still others have attempted to

work through their past experiences by reflection

and dialogue with others. It appears, however,

that the majority of Vietnam veterans interviewed

in this study have not made substantial progress

in resolving the conflicts and problems resulting

from their war experiences. Many men still tend to

avoid emotional conflicts, blame others for their

problems, or have fallen victim to self-pity or selfflagellation.

Among the recommendations generated by this

study to improve the readjustment of Vietnam vet-
467

Follow-Up Studies of Veterans

erans are to extend the period of eligibility for “GI

Bill” education and training benefits, develop training programs for chronically unemployed veterans,

promote the use of fellow veterans as mental health

counselors and therapists, and develop more expertise in understanding and treating psychosocial aftereffects of traumatic war experiences.

Recent estimates of the prevalence of stress reactions such as PTSD among the 2.8 million veterans

who served in Vietnam range from 500,00028 to

700,00029 to as many as 1.5 million.30,31 These figures

indicate that anywhere from 18% to 54% of Vietnam

veterans are currently experiencing symptoms of

PTSD.

Additional information on the prevalence of PTSD

in Vietnam veterans is contained in the summary of

preliminary findings from the National Vietnam

Veterans Readjustment Study (NVVRS).32 This study

was conducted under contract with the Veterans

Administration (now the Department of Veterans

Affairs) and mandated by Congressional legislation (Public Law 98-160). The study was designed

to be the most rigorous and comprehensive examination to date of the prevalence of PTSD and other

psychological problems in the readjustment to civilian life of Vietnam veterans. In-depth interviews

averaging 3 to 5 hours were conducted with over

3,000 men and women representing three major

groups of interest: Vietnam-theater veterans, Vietnam-era veterans, and nonveterans or civilian counterparts.

Among the many findings of this study are that

the majority of Vietnam-theater veterans have successfully readjusted to civilian life and currently

experience few symptoms of PTSD or other readjustment problems. Male Vietnam-theater veterans

typically do not differ from Vietnam-era veterans

on various indices of current life adjustment. Female Vietnam veterans, however, currently experience more readjustment problems than female Vietnam-era veterans matched for age and military

occupation.

Employing multiple assessment procedures, the

results indicate that 15.2% of all male Vietnamtheater veterans are currently experiencing symptoms of PTSD. Among female Vietnam-theater veterans, the current PTSD prevalence is estimated to

be 8.5%. These rates are considerably higher than

the rates for either Vietnam-era veterans (males =

2.5%, females = 1.1%) or civilian counterparts (males

= 1.2%, females = 0.3%). These figures represent

individuals with symptoms that qualify for a clinical diagnosis of PTSD. If one looks at those individuals who have clinically significant stress reaction symptoms that are insufficient to qualify as full

PTSD, but still may require professional attention,

an additional 11.1% of male and 7.8% of female

Vietnam-theater veterans can be classified as currently experiencing “partial PTSD.”

Additional analyses indicate that 30.6% of male

and 26.9% of female Vietnam-theater veterans have

had PTSD at some point in their lives. This means

that of all the male and female Vietnam-theater

veterans who have ever had PTSD, over one third of

these males and over one fourth of these females

still have PTSD today. Other findings reveal a

strong relationship between PTSD and other postwar readjustment problems. Individuals with PTSD

have a greater tendency to exhibit other specific

psychiatric disorders and other postwar readjustment problems. This is particularly true among

those Vietnam-theater veterans who have high levels of exposure to combat and other war zone stressors.

Significant differences were also found for minority group veterans. The current PTSD prevalence rate for PTSD is estimated to be 27.9% for

Hispanic veterans, 20.6% for blacks, and 13.7% for

whites. It is believed that the differences between

blacks and whites can be explained by differing

levels of exposure to war zone stress, but this does

not explain the differences between Hispanics and

either blacks or whites.

Overall, this study provides evidence that nearly

500,000 of the 3.14 million men and women who

served in the Vietnam theater are currently suffering from PTSD and nearly 1,000,000 have had PTSD

at some point in their lives.

Over the past several years this author has been

conducting an epidemiologic study of the psychosocial adjustment of Vietnam and Vietnam-era veterans.33–38 These studies represent a programmatic

research effort into the assessment of the prevalence and severity of post-traumatic stress disorder

as well as the factors involved in its etiology among

Vietnam veterans.

The major hypothesis of this research is that the

prevalence and severity of PTSD is affected by a

combination of different factors that include combat/war zone experience, and social support system legitimization of experiences both during service in Vietnam and upon reentry (primarily the

first year back). The importance of combat experience has already been demonstrated in the literature and in this review.

The importance of supportive relationships in

reducing the incidence of stress reactions among

Vietnam veterans has already been noted by the
War Psychiatry

468

Center for Policy Research.27 It may be that stress

reactions such as PTSD involve the failure of social

support systems to promote the catharsis or

abreaction of stressful combat experiences. Without validation or legitimization of these experiences, Vietnam veterans may be unable to cope

successfully.

In addition to its epidemiologic orientation, the

studies by Stretch differ from previous reports in

that they examine populations of Vietnam veterans

that have been largely ignored in the past. More

specifically, these studies examine PTSD and factors involved in its development among Vietnam

and Vietnam-era veterans still on active duty in the

U.S. Army (including a subsample of nurses), U.S.

Army Reservists, prior-service civilians, and more

recently, Canadians who joined and served in the

U.S. military in Vietnam.

The results of these ongoing studies indicate that

not all Vietnam veterans are currently experiencing

PTSD to the degree determined among the civilian

veteran population. A questionnaire, the VietnamEra Veterans Adjustment Survey (VEVAS), was sent

to all Vietnam and Vietnam-era veterans assigned

to a moderate-sized U.S. Army post on the East

Coast in the Spring of 1982. Data were gathered on

attitudes and opinions about the war, combat experience, past and current psychosocial health problems, and social support experiences both during

and after service in Vietnam. Using the DSM-III

criteria for assessing PTSD, it was determined that

12 of the 238 Vietnam veterans (5.1%) are currently

experiencing symptoms related to PTSD and 25

veterans (10.5%) report symptoms of PTSD that

occurred during service in Vietnam.

VEVAS data were also collected from 667 Vietnam veterans assigned to U.S. Army Reserve troop

units nationwide in the Spring of 1982. Results

indicate that 73 of these randomly selected veterans

(10.9%) report current symptoms of PTSD and 84

(12.4%) report having been bothered in Vietnam.

Similar data were collected from 361 active duty

Vietnam veteran nurses in the Spring of 1983. Again

using DSM-III criteria, it was determined that 12

out of 361 Vietnam veteran nurses (3.3%) are currently suffering from PTSD and 33 nurses (9.1%)

were bothered by symptoms of PTSD during Vietnam. Additional data were collected from 499 Vietnam veterans with no current military affiliation

who were obtained at random from VA medical

benefits files. Of these latter veterans, 160 (32.1%)

were found to be currently suffering from PTSD

and 127 (25.5%) report symptoms of PTSD during

their service in Vietnam.

Another group of Vietnam veterans that has been

ignored by other researchers until now, consists of

the estimated 10,000 to 40,000 Canadians who enlisted in the U.S. military and served in Vietnam.39

The study of PTSD among these Canadian Vietnam

veterans is important for several reasons. One is the

nature of their homecoming and subsequent readjustment experiences. While many Americans returned home to face rejection and hostility for their

role in the war, Canadians found neither rejection

nor recognition. No one knew they had been in

Vietnam so they were ignored and isolated from

other veterans. Because they served with the U.S.

military, they were denied veteran status in Canada

and are not eligible for any veterans benefits from

the Canadian government. They are also not eligible to join veterans groups such as the Royal

Canadian Legion and have been labeled “mercenaries” and “traitors.” Among 164 Canadian Vietnam

veterans who responded to a modified version of

the VEVAS, 90 Canadians (55%) are currently experiencing symptoms of PTSD. A total of 83 veterans

(51%) report experiencing symptoms of PTSD during their Vietnam service.

Table 18.1 presents the PTSD prevalence rates for

these five different groups of Vietnam veterans.

“Acute” PTSD refers to those veterans who reported

experiencing PTSD during Vietnam service, but do

not report symptoms at the present time. These

rates range from a low of 6.6% for Reserve veterans

to a high of 10.4% among Canadian Vietnam veterans. “Delayed” PTSD refers to veterans who did not

report PTSD symptoms during Vietnam, but are

currently bothered by PTSD. The delayed PTSD

rates range from 1.4% among U.S. Army nurses to

14.8% among prior-service civilian veterans.

“Chronic” PTSD is represented by those veterans

who were bothered by symptoms of PTSD during

their Vietnam service, and are still bothered by

PTSD at the present time. Chronic PTSD rates vary

from 1.9% for U.S. Army nurses to 40.2% for Canadian veterans. These mutually exclusive categories

may be combined to yield an “Overall” PTSD rate

representing the percentage of veterans who have

experienced symptoms of PTSD at any time during

or after service in Vietnam. As can be seen, the

overall prevalence of PTSD ranges from 10.5%

among U.S. Army Nurse Corps Vietnam veterans to

65.2% among Canadian Vietnam veterans.

The results of these studies suggest that factors

other than combat affect the attenuation of PTSD.

Social support, particularly during the first year

back from Vietnam, was found to be just as predictive of current PTSD symptomatology as combat
469

Follow-Up Studies of Veterans

TABLE 18-1

PREVALENCE OF POST-TRAUMATIC STRESS SYNDROME (PTSD) AMONG VIETNAM VETERANS

Adapted with permission from Stretch R. Effects of service in Vietnam on Canadian Forces military personnel. Armed Forces Society.

1990;16:582.

experience. The data suggest that initially PTSD

does result from traumatic combat/war zone experiences, but the veteran’s ability to either successfully cope with or succumb to this disorder depends

upon social support. Veterans in the studies who

had received positive social support from friends

and relatives reported fewer symptoms of PTSD

than did veterans who reported encountering negative or hostile reactions from others upon return

from Vietnam.

Active duty veterans had high levels of social

support and low levels of PTSD. The significantly

greater percentage of U.S. Army Reserve Vietnam

veterans reporting symptoms of PTSD is likely to be

the result of their having been exposed to more

negative or hostile societal reactions to their service

in Vietnam than their active duty counterparts.

Vietnam veterans who remained on active duty

were able to interact with fellow veterans in an

affirming military culture on a daily basis. Being

full-time members of the civilian community and

only “part-time soldiers” provided reservists with

fewer opportunities to work through their Vietnam

experiences in a supportive nonjudgmental atmosphere. The Vietnam veteran subjects obtained

from the VA severed their ties with the military

early on and likely received less social support for

their service than their active duty or reserve counterparts. They also have much greater rates of PTSD

than these other groups.

The Canadian Vietnam veterans have the most

serious PTSD prevalence rates of any group studied. This is surprising in that they cannot be accused of faking symptoms in order to gain compensation because their lack of legal status as “veterans”

has made them ineligible for compensation. Based

on data from questionnaires and corroborating evidence from veterans’ letters and informal interviews, it is likely that this higher prevalence of

PTSD is due to three reasons: (1) lack of social

support and recognition from Canadian society and

the government of Canada, (2) isolation from other

Vietnam veterans in Canada, and (3) lack of availability of any medical or psychological readjustment counseling services in Canada.

The data also suggest that further research is

needed to clarify what is meant by “combat experience.” Few would disagree that combat is traumatic, but what exactly is it that is traumatic? This

author’s research also focused on nurses who served

in Vietnam. Nurses are not normally considered to

have experienced “combat.” While they certainly

differ from infantry troops in that they do not carry

weapons or actively engage in firefights with enemy soldiers, they do share many common experiences. Nurses stationed in hospitals and field units

in Vietnam were not always in safe, secure locations

and were often subjected to enemy shelling.

More importantly, nurses were often exposed to

the horrors and carnage of war on a daily basis. One

does not have to fire a weapon or kill someone to

become traumatized by war. Constant exposure to

maimed, dying, and dead soldiers is certainly in

itself traumatic. This was confirmed by Futterman

and Pumpian-Mindlin4

 who reported that traumatic

war neuroses were more common among certain

groups of noncombatants such as medical first-aid

men who were exposed to the violent effects and

results of combat, but had not been active participants in combat.

Table18-1 is not shown because the copyright permission granted to the Borden Institute, TMM, does

not allow the Borden Institute to grant permission to other users and/or does not include usage in

electronic media. The current user must apply to the publisher named in the figure legend for

permission to use this illustration in any type of publication media.
War Psychiatry

470

The data demonstrate that duty in Vietnam by

nurses was just as traumatic as combat duty for the

other active duty and reserve Vietnam veterans.

VEVAS data on PTSD symptoms exhibited during

Vietnam duty reveal no significant differences

among the number of nurses (9.1%), other active

duty veterans (10.5%), and Reservists (12%) experiencing PTSD at that time.

SUMMARY AND CONCLUSION

This review of follow-up studies on the readjustment of veterans has demonstrated that while weaponry and tactics may change from war to war, the

impact of war on its participants remains largely

unchanged. Medical and psychiatric nomenclature

of reactions to war experiences also change, but the

reactions themselves are remarkably similar. Veterans of World War I suffered from “shell shock,”

World War II and Korean veterans suffered from

“war neuroses,” and Vietnam veterans suffer from

“post-traumatic stress disorder.”

These past studies demonstrate that the majority

of veterans are able to make a satisfactory adjustment to civilian life. This does not mean that they

emerged from war unscathed. It is unrealistic to

expect someone to not be affected by the inhumanity and brutality of war. It is also unrealistic to

assume that veterans cannot put these experiences

into their proper perspective by acknowledging

their impact and then using that perspective to

continue on with their lives. Supportive relationships with others appears to be the key to successful

readjustment for these veterans.

In many ways veterans of previous war eras may

have had a better opportunity for successful readjustment than Vietnam veterans. Vietnam veterans

did not return from their war en masse on transport

ships which often took weeks to arrive in the States.

They returned on jetliners as individuals denied the

therapeutic opportunity to work through their war

experiences with their fellow veterans. They also

returned to a society that did not greet them as

conquering heroes or even acknowledge the sacrifices they made.

For these reasons and others it appears that Vietnam veterans have been less successful than veterans of previous war eras in readjusting to civilian

life. As society begins to realize that the veterans who

served in Vietnam were not necessarily responsible

for the mistakes made there, then many more Vietnam

veterans will be able to put the past behind them and

look to the future more confidently.

REFERENCES

1. Salmon TW, Fenton N, eds. In the American Expeditionary Forces [Section 2]. Neuropsychiatry. Vol 10. In: The

Medical Department of the United States Army in the World War. Washington, DC: Office of The Surgeon General,

US Army; 1929.

2. Brill NQ, Beebe GW. A Follow-up Study of War Neuroses. Washington, DC: US Government Printing Office; 1955.

3. Ripley HS, Wolf S. Long-term study of combat area schizophrenic reactions. Am J Psychiatry. 1951;108:409–416.

4. Futterman S, Pumpian-Mindlin E. Traumatic war neuroses five years later. Am J Psychiatry. 1951;108:401–408.

5. Archibald HC, Long DM, Miller C, Tuddenham RD. Gross stress reactions in combat: A 15-year follow-up. Am

J Psychiatry. 1962;119:317–322.

6. Ponteva M. After-effects of mental disorders of war. Presented at VI World Congress of Psychiatry; August 28–

September 3, 1977; Honolulu, Hawaii.

7. Meguro K. War neurosis: A 20-year follow-up study. Seishinigaku. 1967;8:999–1007 and 9:39–42.

8. Archibald HC, Tuddenham RD. Persistent stress reaction after combat. A 20-year follow-up. Arch Gen Psychiatry. 1965;12:475–481.

9. Thienes-Hontos P, Watson CG, Kucala T. Stress-disorder symptoms in Vietnam and Korean war veterans. J

Consult Clin Psychol. 1982;50:558–561.
471

Follow-Up Studies of Veterans

10. Figley CR. Symptoms of delayed combat stress among a college sample of Vietnam veterans. Milit Med.

1978;143:107–110.

11. Worthington ER. The Vietnam-era veteran, anomie and adjustment. Milit Med. 1976;141:169–170.

12. Worthington ER. Demographic and pre-service variables as predictors of post-military service adjustment. In:

Figley CR, ed. Stress Disorders Among Vietnam Veterans. New York: Brunner/Mazel; 1978: 173–187.

13. Borus JF. Re-entry I. Arch Gen Psychiatry. 1973;28:501–506.

14. Borus JF. Re-entry II: “Making it” back in the States. Am J Psychiatry. 1973;130:850–854.

15. Borus JF. Re-entry III: Facilitating healthy readjustment in Vietnam veterans. Psychiatry. 1973;36:428–429.

16. Borus JF. Incidence of maladjustment in Vietnam returnees. Arch Gen Psychiatry. 1974;30:554–557.

17. Wilson JP. Identity, Ideology, and Crisis: The Vietnam Veteran in Transition: Part II. (Report to Disabled American

Veterans Association). Cleveland: Cleveland State University, Forgotten Warrior Project; 1978.

18. Strayer R, Ellenhorn L. A study exploring adjustment patterns and attitudes. J Soc Issues. 1975;31:81–94.

19. Haley, S. Treatment implications of post-combat stress response syndromes for mental health professionals. In:

Figley CR, ed. Stress Disorders Among Vietnam Veterans. New York: Brunner/Mazel; 1978: 254–257.

20. Figley CR, Southerly WT. Psychosocial adjustment of recently returned veterans. In: Figley CR, Leventman S,

eds. Strangers at Home: Vietnam Veterans Since the War. New York: Praeger; 1980: 167–180.

21. Brady D, Rappoport L. Violence and Vietnam: A comparison between attitudes of civilians and veterans. Hum

Relat. 1974;26:735–752.

22. DeFazio VJ, Rustin S, Diamond A. Symptom development in Vietnam era veterans. J Orthopsychiatry. 1975;45:158–163.

23. Helzer JE, Robins LN, Wish E, Hesselbrock M. Depression in Vietnam veterans and civilian controls. Am J

Psychiatry. 1979;136:526–529.

24. Pollock, JC, White D, Gold F. When soldiers return: Combat and political alienation among white Vietnam

veterans. In: Schwartz D, Schwartz S, eds. New Directions in Political Socialization. New York: Free Press; 1975:

317–333.

25. Wikler NJ. Vietnam and the veterans consciousness. Paper presented at the annual meeting of the Pacific

Sociological Association, San Jose, California. March 1974.

26. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-III, 3rd ed.

Washington, DC: APA; 1980.

27. Legacies of Vietnam: Comparative Adjustment of Veterans and Their Peers. New York: Center for Policy

Research; 1981.

28. Disabled American Veterans Association. Forgotten warriors: America’s Vietnam era veterans. DAV. 1980;Jan.

29. Walker JI, Cavenar JO. Vietnam veterans: Their problems continue. J Nerv Ment Disease.1980;170:174–180.

30. Harris L, and Associates. Myths and Realities: A Study of Attitudes Toward Vietnam Era Veterans. Submitted by the

Veterans Administration to the Committee on Veterans Affairs, U.S. Senate, Senate Committee Print No. 29.

Washington, DC: US Government Printing Office; 1980.

31. Schindler FE. Treatment by systematic desensitization of a recurring nightmare of a real life trauma. J Behav Ther

Exp Psychiatry. 1980;2:53–54.
War Psychiatry

472

32. Kulka RA, Schlenger WE, Fairbank JA, et al. Executive Summary: Contractual Report of Findings from the National

Vietnam Veterans Readjustment Study. Research Triangle Park, NC: Research Triangle Institute; 1988.

33. Stretch R. Post-traumatic stress disorder among US Army Reserve Vietnam and Vietnam-era veterans. J Consult

Clin Psychol. 1985;53:935–936.

34. Stretch R. Incidence and etiology of post-traumatic stress disorder among active duty Army personnel. J Appl

Soc Psychol. 1986;16:464–481.

35. Stretch R. PTSD among Vietnam and Vietnam-era veterans. In: Figley CR, ed. Trauma and Its Wake: The Study and

Treatment of Post-Traumatic Stress Disorder. New York: Brunner/Mazel; 1986: 156–192.

36. Stretch R. Post-traumatic stress disorder and the Canadian Vietnam veteran. J Traumatic Stress. 1990;3:239–254.

37. Stretch R. Psychosocial readjustment of Canadian Vietnam veterans. J Consult Clin Psychol. 1991;59:188–189.

38. Stretch R, Vail J, Maloney J. Post-traumatic stress disorder among Army Nurse Corps Vietnam veterans. J

Consult Clin Psychol. 1985;53:704–708.

39. McAndrew B. Viet Nam vets in Canada still feel isolated. Toronto Star. 6 July 1986; A9.