Bruce P. Dohrenwend

The diagnosis of posttraumatic stress disorder (PTSD) was introduced in 1980 with the publication of the Diagnostic and Statistical Manual of the American Psychiatric Association, Third Edition (DSM-III). DSM-III put forward a novel syndrome consisting of intrusive, avoidance/numbing, and arousal symptoms as distinctive psychopathology following exposure to traumatic events. The traumatic stressors, although expanded in later editions published in 1987 (DSM-III-R) and 1994 (DSM-IV), focus on life-threatening events and situations. However, at least 12 studies, most of them recent, have found associations between the PTSD symptoms and the PTSD symptom syndrome with stressors, such as unemployment and divorce that would not qualify, even in the broadened DSM-IV diagnosis, as traumatic stressors. These findings challenge the basic assumption on which the PTSD diagnosis is based, the assumption that exposure to life-threatening stressors is the primary cause of a unique set of stress response symptoms. The purpose of this paper is to show how to confront this challenge by developing a typology of stressful situations and events that can be tested systematically for their relation to the PTSD symptom syndrome and other relevant variables. The typology includes but is not limited to the types of situations and events defined as “traumatic” in the DSMs.

Elevated prevalence rates of chronic posttraumatic stress disorder (PTSD) have been reported for Black and Hispanic Vietnam veterans. There has been no comprehensive explanation of these group differences. Moreover, previous research has relied on retrospective reports of war‐zone stress and on PTSD assessments that fail to distinguish between prevalence and incidence. These limitations are addressed by use of record‐based exposure measures and clinical diagnoses of a subsample of veterans from the National Vietnam Veterans Readjustment Study (NVVRS). Compared with Majority White, the Black elevation is explained by Blacks' greater exposure; the Hispanic elevation, by Hispanics' greater exposure, younger age, lesser education, and lower Armed Forces Qualification Test scores. The PTSD elevation in Hispanics versus Blacks is accounted for mainly by Hispanics' younger age.

In 1988, the National Vietnam Veterans Readjustment Study (NVVRS) reported 30.9% lifetime and 15.2% current rates of posttraumatic stress disorder (PTSD), and a strong dose/response relationship with retrospective reports of combat exposure. Skeptics argued that recall bias and other flaws inflated the results. Using a new record‐based exposure measure and diagnoses in an NVVRS subsample, the authors addressed this controversy in a recent issue of Science (B. P. Dohrenwend et al., 2006). They found little evidence of falsification, an even stronger dose/response relationship and, when fully adjusted for impairment and evidence of exposure, 18.7% onset and 9.1% current rates of war‐related PTSD. The fact that these rates are lower than the original NVVRS rates has stimulated continuing controversy that has tended to obscure the more important implications of the study's results.

In 1988, the National Vietnam Veterans Readjustment Study (NVVRS) of a representative sample of 1200 veterans estimated that 30.9% had developed posttraumatic stress disorder (PTSD) during their lifetimes and that 15.2% were currently suffering from PTSD. The study 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. We used military records to construct a new exposure measure and to cross-check exposure reports in diagnoses of 260 NVVRS veterans. We found little evidence of falsification, an even stronger dose-response relationship, and psychological costs that were lower than previously estimated but still substantial. According to our fully adjusted PTSD rates, 18.7% of the veterans had developed war-related PTSD during their lifetimes and 9.1% were currently suffering from PTSD 11 to 12 years after the war; current PTSD was typically associated with moderate impairment.

An explosion of research on life events has occurred since the publication of the Holmes and Rahe checklist in 1967. Despite criticism, especially of their use in research on psychopathology, such economical inventories have remained dominant. Most of the problems of reliability and validity with traditional inventories can be traced to the intracategory variability of actual events reported in their broad checklist categories. The purposes of this review are, first, to examine how this problem has been addressed within the tradition of economical checklist approaches; second, to determine how it has been dealt with by far less widely used and far less economical labor-intensive interview and narrative-rating approaches; and, third, to assess the prospects for relatively economical, as well as reliable and valid, solutions.

A 70.9% majority of the U.S. male veterans in a nationwide sample appraised the impact of their service in Vietnam on their present lives as mainly positive. A substantial minority, 41.7%, judged the effects to be highly salient. With controls on level of exposure to war-zone stressors measured with data from military records, the valence and salience of these appraisals are investigated in relation to posttraumatic stress disorder (PTSD) and other indicators of wartime and postwar functioning. The results are consistent with the hypothesis that mainly positive tertiary appraisals are affirmations of successful wartime and postwar adaptation rather than defensive denials related to maladaptive outcomes. The possibility that mainly positive tertiary appraisals also contribute to successful postwar adaptation is discussed.

Three lines of research-studies of extreme situations, epidemiological investigations of relations between socioeconomic status (SES) and psychiatric disorders,...