War and anxiety disorders.

Psychologic reactions are common after trauma. Much attention has been devoted to posttraumatic stress disorder after harrowing events, including natural disasters such as earthquakes and floods, assault of individuals, episodes of mass violence such as riots and terrorist attacks, and combat. The prevalence of stress disorders varies among these studies, in part as a result of differences in sampling schemes, type and timing of measurements, and types of exposures (eg, natural or manmade, extent of damage). In this issue of EPIDEMIOLOGY, Donald Black and his colleagues report on anxiety among Gulf War veterans. Their article provides insights into the psychologic impact of trauma—both in general and as it relates to combat in particular. Importantly, this report assesses not only veterans who experienced combat, but also those who were deployed and not in combat, as well as personnel who were not deployed. It is notable that an increase in psychologic symptoms was seen in both deployed groups, whether or not they directly experienced combat. Previous studies have focused mostly on direct victims of violence, and, in the case of mass disasters, the victims’ families, first-responders, and their families. There are fewer data on responses among the general population or among persons considered “indirectly exposed.” In recent work on New York City residents after the September 11 attacks, posttraumatic stress disorder was most common among those directly exposed to the collapse of the World Trade Centers, but rates were elevated also among most of people not directly exposed. In fact, the latter group produced nearly half of the cases of probable posttraumatic stress disorder among city residents. Similarly, the present study of Gulf War veterans suggests that psychologic trauma can extend to less-exposed populations. Although much of the literature on trauma has dealt with posttraumatic stress disorder, Black and his colleagues found that panic attacks and generalized anxiety disorders were also related to wartime exposure. Other documented consequences of traumatic events include depression and substance abuse, both of which have been closely tied to posttraumatic stress disorder. These findings emphasize the need to cast a wide net when searching for psychologic outcomes after traumatic events. The increased prevalence of posttraumatic stress disorder, anxiety, and panic attacks in this military population even 4 years after the Gulf War is a reminder that a substantial psychologic burden could linger years after the event. In prospective studies of trauma (patients hospitalized as a result of a traumatic event, female rape victims, and persons affected by motor vehicle accidents), more than half of cases of posttraumatic stress disorder have been found to remit in the first 3 to 6 months after onset. Similarly, the National Comorbidity Survey showed a steep decline in posttraumatic stress symptoms in