Symptoms in Gulf War Veterans

Persian Gulf Veterans Coordinating Board. Unexplained Illnesses Among Desert Storm Veterans. Arch Int Med 1995; 155: 262-268. Summarizes the frequency of unexplained illnesses (about 3000) and lists the most commonly reported symptoms among veterans evaluated by the DVA (17248 to that point). Describes the components of the uniform case assessment protocol being used by DVA and DOD for GW veterans. Discusses the possible health risks unique to the GW, including living conditions, threat of chemical and biological warfare, nerve agent prophylaxis and immunizations, infectious diseases, and environmental hazards (oil well fires, pesticides, petrochemicals, depleted uranium, microwaves, paints, decontamination solution 2, and airborne allergens and irritants.) Summarizes the DVA and DOD evaluation programs, research initiatives, and previous governmental review activities.

Stretch, R.H. et al. Physical Health Symptomatology of Gulf War-Era Service Personnel from the States of Pennsylvania and Hawaii. Military Medicine 1995; 160: 131-136. Congressionally-mandated questionnaire survey of veterans (active, reserve, Guard) in Pennsylvania and Hawaii to assess the health and adjustment of GW veterans. Questionnaires were mailed to, and distributed through, units. Response rate was 31%. Of the 4,334 respondents, 1524 deployed to the PG, 215 elsewhere, and 2,512 did not deploy. Symptoms within the previous month were recorded. Deployed veterans reported significantly more physical health symptoms than non-deployed veterans. The difference cannot be explained by reasons other than deployment alone. Deployers reported more physician visits during the previous two weeks than non-deployers. Limitations of the study are the low response rate, the unit-based method of distributing the questionnaires, and the absence of objective measures of health status.

Unwin, C. et al. Health of UK Servicemen Who Served in Persian Gulf War. Lancet (1999) 353: 169-178. This British study surveyed servicemen and compared those who served in the Gulf War (GWV) to contemporaries who did not deploy to the Gulf and to others who deployed to the Bosnia conflict. There were about 4248 servicemen randomly selected from each of the groups. Response rates were 70%, 62%, and 63% respectively. GWV reported all symptoms and conditions more frequently than the comparison groups. The five most commonly reported symptoms in all three groups were unrefreshing sleep, irritability, headaches, fatigue, and sleeping difficulties. The five most commonly reported conditions in all three groups were back disorders, hay fever, dermatitis, sinus disorders, and migraines. Of all conditions, the one which was most strongly associated with Gulf War service was self-reported chronic fatigue syndrome, although it was uncommon in all three groups. Among servicemen in all three groups, perceptions of poorer health were associated with virtually all potential risk factors or exposures, regardless of deployment status. Belief in exposure to a chemical warfare agent was associated with the lowest health perception. There was also an association of poorer health and receipt of multiple vaccinations, especially among veterans who recalled experiencing side effects from the vaccines. Patterns of symptoms were the same in all three groups, suggesting that there is no specific "Gulf War Syndrome." Limitations: results are based on self-reports in response to a written questionnaire; disorders which require a clinical interview or examination for diagnosis could not be captured; the lack of physical examinations prevents drawing conclusions about physical disorders which might explain the increased frequency of reported symptoms. The authors do plan further studies which will include detailed physical, neurophysiological, and neuropsychological examinations of symptomatic veterans and controls.

Ismail, K. et al. Is There a Gulf War Syndrome ? Lancet (1999) 353: 179-182. With the results of the questionnaire survey described in the above paper (Unwin et. al.), the authors used factor analysis to investigate whether he symptoms reported by British Gulf War veterans were sufficiently different from recognized disorders to be considered a new disorder. The first three identified factors and the symptoms which loaded onto them were: 1) mood-cognition (headaches, irritability, sleep difficulties, feeling jumpy, unrefreshing sleep, fatigue, feeling distant or cut off from others, forgetfulness, loss of concentration, avoiding doing things or situations, and distressing dreams; 2) respiratory system (inability to breathe deeply, fast breathing, shortness of breath at rest, and wheezing); and, 3) peripheral nervous system (tingling in fingers or arms, tingling in legs or arms, and numbness or tingling in fingers or toes). Applying the factors identified in the Gulf War veterans, the authors found little difference from the patterns of symptoms reported by veterans who did not deploy to the Gulf and veterans of the Bosnia deployment. Although Gulf War veterans reported a higher frequency of symptoms, the similarity in the patterns of symptoms among all three study groups did not support the existence of a syndrome unique to Gulf War veterans. The discussion portion of the paper compares the methods and results of the study with the two previously published studies of Gulf War veterans which used factor analysis (Haley, R. et al. and Fukuda, K. et al.).

Fukuda, K. et al. Chronic Multisymptom Illness Affecting Air Force Veterans of the Gulf War. JAMA 1998; 280: 981-988. This article reports on the 2^nd and 3^rd third phases of a survey of Gulf War veterans (GWV) from a Pennsylvania Air National Guard unit and three comparison air force populations. Phase two surveyed the units for prevalence of symptoms among currently active members of the units and phase three characterized the clinical and laboratory findings among GWV who met a case definition derived from phase two. After comparing preliminary definitions from clinical and statistical approaches, a case was defined as having 1 or more chronic symptoms (more than 6 months) from 2 of the following categories: fatigue; mood and cognition; and musculoskeletal. GW veterans reported almost all symptoms more often than the non-deployed. GW veterans who met the case definition were regarded as severe in 6% and mild-to-moderate (MTM) in 39%, compared to 0.7% and 14% among nondeployed veterans. Cases were associated with GW service, enlisted rank, female sex, and smoking. Clinical evaluations were done on only one unit. Severe cases reported histories of pre-GW depression and sinusitis more often than non-cases. On physical examinations, the only difference was slightly higher body mass index among severe cases. Cases were associated with significant decreases in functioning and well-being as measured by the Medical Outcomes Study Short Form-36. There was no association found between cases and abnormalities on any of the blood, urine, or stool tests, to include examinations for evidence of infectious agents. Current depression was more common among cases. Seven severe and one MTM cases met the CDC criteria for chronic fatigue syndrome. There was no association between cases and risk factors specific to the GW. Limitations of the study: findings can not be generalized to non-Air Force services or to GWV who have left the service. The self-reporting of symptoms raises the possibility of reporting or recall bias.

Southwick, S.M. et al. Trauma Related Symptoms in Veterans of Operation Desert Storm: A 2-year Follow-Up. AmJ Psychiatry 1995; 152: 1150-1155. This paper reports on the continuation of a study of 84 soldiers from two National Guard units (one medical, one military police) who had served in the GW. Sixty two of the original 84 who were evaluated at one and six months completed evaluations at 2 years. Depending upon the diagnostic criterion used, six or eight veterans met the criteria for PTSD at 2 years. Mean PTSD scores were higher after two years, particularly in the medical unit. Most PTSD-specific symptoms had developed by six months. Scores for symptoms related to hyperarousal (especially startle responses, sleep disturbance, and irritability) were significantly higher than scores for symptoms associated with reexperiencing or avoidance. Limitations of the study were the incompleteness of the study group, dropouts at two years, reliance on self-reports, and a tendency for subjects to underreport symptoms.

The Iowa Persian Gulf Study Group. Self-reported illness and Health Status Among Gulf War Veterans. A Population – Based Study. JAMA 1997; 277: 238-245. This study studied a sample of the 28,968 Iowans from the National Guard, Reserve, or active component who were on active duty during the Gulf War. A stratified random sample selected 4,886 subjects of whom 3,695 (76%) completed a structured telephone interview. Participants were asked about symptoms, health status, and exposures during the GW. Compared to those who did not deploy, personnel deployed to the Gulf reported significantly higher prevalence rates of symptoms of depression, PTSD, chronic fatigue, cognitive dysfunction, bronchitis, asthma, fibromyalgia, alcohol abuse, anxiety, and sexual discomfort. Most of the self-reported GW exposures were significantly related to many of the medical and psychiatric conditions. Personnel who served in Iraq, Saudi Arabia, or Kuwait were significantly associated with depression, cognitive dysfunction, and fibromyalgia, compared with those who were stationed elsewhere in the theater. The authors discuss the several possible interpretations of the associations found. They note that their study included a wide range of diagnoses more likely to be evaluated in outpatient settings, an advantage over other studies which used hospitalization data. Limitations of the study are: the possibility that a study of Iowans may not be generalizable; internal validation of responses was not done; medical conditions are based on self-reports of the participants and they have not been validated by objective physical or laboratory findings; and, the multiple comparisons in the analysis could have revealed statistically significant relationships by chance alone.

Roy, M.J. et al. Signs, Symptoms, and Ill-Defined Conditions in Persian Gulf War Veterans: Findings from the Comprehensive Clinical Evaluation Program. Psychosomatic Medicine 60: 663-668, 1998. The authors analyzed the CCEP database of 21,579 participants in the evaluation program for findings pertaining to diagnoses that fell into the ICD-9 category of "Signs, Symptoms, and Ill-Defined Conditions (SSID)." This category includes "symptoms, signs, abnormal results of laboratory or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded." SSID diagnoses were categorized as 1) those with objective findings (such as sleep apnea, sleep disorder due to periodic limb movements, seizure disorders, rash, weight loss, positive TB skin test, and test abnormalities) and 2) those that are symptoms only (patient complaints for which there is neither objective confirmation nor an explanatory diagnosis). 17.2 % of all CCEP participants had their primary (main) diagnosis within the SSID category and 41.8 % had an SSID diagnosis as either their primary or secondary diagnosis. 28.6% of primary SSID were objective abnormalities but most SSID were symptoms. Patients with SSID diagnoses were comparable to other CCEP participants with regard to age, race, gender, self-reported wartime exposures, length of stay in the combat theater, and days of work missed in the previous 3 months. Patients with an SSID primary diagnosis after Phase I of the CCEP were twice as likely to be referred to a Phase II evaluation at a medical center. Two thirds (464) of the referred 703 Phase I SSID patients had a non-SSID primary diagnosis after Phase II. The final diagnoses for 45% of these 464 were psychological, chiefly mood disorders, somatoform disorders, tension headache, and posttraumatic stress disorder. As the depth of evaluation increased, the proportion of diagnoses that were SSID decreased but the proportion of psychological diagnoses increased. The three most common symptom diagnoses were fatigue, headache, and memory loss. For patients with these primary diagnoses in Phase I who completed a Phase II evaluation, most did not retain the same primary diagnoses. Limitations of the study: CCEP participants are self-selected and are not necessarily representative of all Gulf War veterans. Self-reported information, such as wartime exposures, may be subject to recall bias. There is likely variation in practice and interpretation of clinical data from one medical facility to another. The study does not prove that there is not a new illness or syndrome.