Conceptualization of PTSD from the Vietnam War to Current Conflicts and Beyond.

IJEMHHR • Vol. 17, No. 3 • 2015 661 The definition of post-traumatic stress disorder (PTSD) underwent substantial changes in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), including the inclusion of negative affective experiences that were underrepresented in prior conceptualizations, among other changes (American Psychiatric Association, 2013). How these changes will impact prevalence and whether the clinical usefulness of this disorder has been improved are still unknown. Recently, Hoge and his associates undertook such a comparison study among US combat veterans (Hoge et al., 2014). Their study showed that the new PTSD symptom criteria did not seem to have greater clinical utility and a high percentage of those who met criteria by one definition did not meet criteria by the other definition. Hoge and his colleagues noted that clinicians might need to consider how to manage discordant PTSD outcomes, particularly for those with PTSD who no longer meet criteria under DSM-5 (Hoge et al., 2014). Another recent study included a 40 year follow-up of veterans of the Vietnam War (Marmar et al., 2015). Originally assessed in the late 1980s (Kulka et al., 1990), this veteran cohort was found to have lower rates of current PTSD than reported previously, typically 10% or less. This prevalence rate was also recently reported for communitybased veterans seen in non-Veterans Affairs (VA) hospitals, based on the DSM-IV criteria (Boscarino, Hoffman, Pitcavage, & Urosevich, 2015a). The latter study is noteworthy because the majority of US veterans today have private health insurance and/or Medicare coverage and receive some or all their care from non-VA institutions (Elbogen et al., 2013; US Department of Veterans Affairs, 2010). Veterans who receive their care at VA hospitals appear to be more impaired (Boscarino et al., 2015a). Thus, studying veterans in VA hospitals alone will tend to distort the true clinical picture. Broader, population-based studies are needed.