A year after combat soldiers leave Iraq, those with symptoms of post-traumatic stress disorder say they're in worse physical health, suffer more pain and are more likely to miss work than veterans without PTSD symptoms, according to a military study out Monday.

The anonymous survey of nearly 3,000 Iraq veterans is the first to look at a link between PTSD and physical symptoms. It was released at the American Psychiatric Association meeting in Toronto.

"Their mental health problems may be taking a toll," says psychiatrist Charles Hoge, chief of psychiatry and neuroscience at the Walter Reed Army Institute of Research in Washington, D.C. Physical complaints may send a disproportionate number of these stressed soldiers to primary-care doctors, he says.

In the survey, about 17% of the soldiers had PTSD symptoms, Hoge says. Compared with those without stress symptoms, they were much more likely to report all kinds of pain — from headaches to backaches — and gastrointestinal complaints such as nausea and indigestion.

Anxiety can contribute to these health problems, Hoge says. Also, nightmares and flashbacks — symptoms of PTSD — can interfere with sleep, leading to worse health, he adds. About one out of five soldiers without PTSD symptoms said they were in fair to poor health, compared with nearly half of those with PTSD symptoms.

Soldiers are screened for mental and physical problems when they leave Iraq, then three and six months later, Hoge says.

New "practice guidelines" are alerting military and Veterans Affairs doctors to possible ties between physical and mental symptoms in soldiers, says Charles Engel, director of the Deployment Health Clinical Center at Walter Reed Army Medical Center.

Soldiers sometimes downplay their stress reactions, so the number of soldiers with PTSD who also have physical health problems is, "if anything, conservative," says psychologist Charles Figley, a traumatic-stress expert at Florida State University. "When they come in with back pain, doctors are going to have to keep asking what happened to them in the war, not just now but five years from now."

There's strong evidence in civilian studies that trauma survivors use more health care at a higher cost, says University of Tulsa psychologist Elana Newman, who has studied health and traumatic stress.

Military spokesmen have repeatedly said that Iraq veterans' needs for physical and mental health care will be met.

But bureaucratic paperwork and trouble getting a human being on the line at the VA make access difficult, says Shad Meshad, president of the National Veterans Foundation, an education group that runs an information hotline for veterans.

"We're hearing about waiting lists to get VA mental health services, particularly in large cities," he says. "We hear from the ones who are afraid they're going to hit their wives or are close to committing suicide. PTSD is just disabling overall."