Wa Syndrome an Thei Evaluation Fro th US Civi Wa tth Persia Gul WaKen - PDF document

Wa Syndrome an Thei Evaluation Fro th U.S Civi Wa tth Persia Gul WaKennet C Hyams MD MPH F Stephe Wignall MD an Rober Roswell MPurpose T bette understan th healt problem oveteran o th Persia Gul Wa b analyzin previouwar-relate illnesse an identifyin possibl unifyinDat Source English-languag article an book owar-relate illnesse publishe sinc 186 tha wer locate primaril throug a manua searc o bibliographiesDat Extraction Publication wer Downloaded from https://annals.org by University of Pittsburgh user on 09/05/2019 Tabl 1 Somati Symptom Commonl Associate wit War-Relate Medica an Psychologica IllnessesSymptoWa an IllnesU.S Civi WarWorl Wa IWorl Wa IIVietnamVietna an Othe ConflictsPersia GulfD CostEfforComba StresAgen OrangPost-Traumati StresUnexplaineSyndromSyndromReactioExposurDisordeIllnesseFatigu o exhaustio+ + + + + + Shortnes o breat+ + + + + Palpitation an tachycardi+ + + + Precordia pai+ + + + Headach+ + + + + + Muscl o join pai+ + + Diarrhe+ + + + + Excessiv sweatin+ + + Dizzines+ + + + + Faintin+ + Disturbe slee+ + + + + + Forgetfulnes+ + + + + Difficult concentratin+ + + + + * A plu sig indicate a commonl reporte symptomo patient recovere fro th disorde an thaadministratio o severa drugs includin digitalismay hav ha a beneficia effectO th basi o D Costa' clinica descriptions ii difficul t confidentl determin specifi diagnoses however variou illnesse coul hav causeth symptom i thes patient (6 7) Fe patientha conclusiv evidenc o hear disease Man patient wer debilitate fro malnutrition lac oexercise infectiou disease (includin malari antyphoid) an othe advers medica conditionsSom patient ha symptom o a psychologica illnes o stres reactio (8) I additio t th irritabl hear syndrome a war-relate illnes attributeprimaril t psychologica factor wa reporte durin th U.S Civi War Youn soldier wit obsessiv thought o hom receive a diagnosi o a sever for o homesicknes calle "nostalgia,whic wa characteristicall accompanie b extrem apathy los o appetite diarrhea an sometime feve (9 10)Worl Wa I A syndrom simila t th on describe b DCost becam a majo proble durin Worl WaI Soldier ha t b evacuate t Englan becauso shortnes o breath palpitations an ches pai(11) Affecte soldier als commonl reporte fatigue headache dizziness confusion concentratioproblems forgetfulness an nightmare (Tabl 1(12-14) Thi comple o symptom becam knowa soldier' hear o th effor syndrom becaussymptom wer exacerbate b effort I wa alscalle th D Cost syndrome disordere actio oth heart and i th Unite States neurocirculator astheni (15)A th beginnin o Worl Wa I th efforsyndrom wa frequentl attribute t cardia hypertroph cause b heav marchin pack compressin th ches (16 17) However a th waprogressed th effor syndrom wa believe t encompas a mixe grou o illnesse an causes includin constitutiona nervou weaknes an physica weakness a infectiou diseas o debilit fropreviou infections exhaustio fro lac o sleean exertio i th trenches th effect o poisogas malingering and rarely hear diseas (12-1418-23) I som cases onse o symptom wa alsassociate wit acut stres resultin fro comba oburia dutie (12 22) Digitali an othe drug di nobenefi patient wit th effor syndrome bu a structure rehabilitatio progra wit a graduate exercisregime an encouragemen fro a supervisin medica staf wer effectiv (12 22) I wa als foun thai symptom o th effor syndrom wer attribute thear disease recover an retur t dut wer hindere (12 13) A a result physician wer adviseno t tel soldier tha they ha a hear conditio stha th soldier woul no thin o themselve apatient wh require evacuatio fro th fron (1221 22 24)A concerte clinica an researc progra wadevelope durin Worl Wa I t determin thcause an mos effectiv treatmen o th efforsyndrom (11) Thi progra involve clinica caran empirica observation i tw specialize hospital i Englan (12 an a specialize referra cente i th Unite State (7 17) Afte th war thMedica Researc Counci continue t overseclinica evaluatio an additiona studie fo thBritis governmen (11) Furthe investigation wergive hig priorit becaus th effor syndrom wath thir mos commo reaso fo disabilit ancompensatio assessmen i England 4 00 veteran eventuall receive pension fo thi conditio(11 14 25)Althoug clinica studie publishe a th en oth wa (26-28 indicate tha th effor syndrom1 Septembe 199 • Annals of Internal Medicine • Volum 12 • Numbe 5 39 Downloaded from https://annals.org by University of Pittsburgh user on 09/05/2019 wa cause b psychologica factors ther wa littlagreemen o wha specifi symptom constituteth effor syndrome whethe i wa primaril a physiologi o psychologica illness an eve whath officia nam o th condi

tio shoul b (29)However ther wa a consensu tha th effor syndrom wa no cause exclusivel b uniqu wartim becaus man soldier reporte havin ha symptom befor th wa (12 19 22)Eac yea fo 5 year afte Worl Wa I a survewa maile t 60 Britis veteran wh ha receivea diagnosi o th effor syndrom an wh hareceive pension (30) Dat fro thi surve anavailabl medica record identifie 5 veteran whha develope variou define illnesses includin2 case o pulmonar tuberculosi an 6 confirme o cardia disease Th healt o mos otheveteran ha remaine stable an mortalit di noincrease I additio t th effor syndrome aacut illnes attribute t comba stres (whic wacalle shel shoc o trenc neurosis wa investigate durin Worl Wa I Thi acut comba stres wa first attribute t a strang ne disease possibl cause b concussio fro moderweapons however a psychologica caus wa soodetermine (31 32) Typica manifestation o acut stres reactio include breakdow i battle daze o detache manner exaggerate startlresponse an sever anxiet (32 33)Durin Worl Wa I i wa determine thasoldier wit shel shoc coul b rapidl rehabilitate i the wer care fo nea th front expect a quic recover (32) Afte soldier wit shel wer take awa fro thei comrade antreate a patient i a hospital the wer mucles likel t retur t combat Also th Britis th nonspecifi ter "no ye diagnosed nervou (NYD) fo th initia designatio o possibl o shel shock thi designatio preventesoldier fro concludin tha the ha a medica tha require hospitalizatio (32 33)Worl Wa IA th beginnin o Worl Wa II th efforsyndrom agai becam a importan medica con fo th Britis militar (14) Whethe theffor syndrom wa predominantl a physiologi opsychologica illnes ha no bee resolve (14 34)However afte Wood' influentia clinica studie o patient (35-37) th effor syndrom wa generall considere t b a psychoneurosi an no a medica diseas (7)Acut comba stres reactio (whic wa knowa battl fatigue comba exhaustion o operationafatigu amon aviatio personne durin Worl WaII als becam bette understoo a thi tim (3338) Studie o comba personne determine thaacut comba stres reactio frequentl manifestea somati symptoms includin fatigue palpitationsdiarrhea headache impaire concentration forgetfulness an disturbe slee (Tabl 1 (39)A i Worl Wa I soldier wit acut combastres reactio wer mor likel t retur t dut i wer treate quickl an nea thei comba an receive a diagnosi o a norma respons extrem stres rathe tha a abnorma condi Consequently us o suc diagnosti label a"wa neurosis wa discourage becaus the connote tha soldier wer sic an shoul b treatea patient (33 39 40)Korea ConflicPossibl becaus th effor syndrom ha bee attribute t psychologica cause durin Worl WaII i wa no reporte a a majo medica probledurin th Korea Conflic (7) Sinc th 1940s th syndrom ha bee identifie les frequentla a uniqu diseas entit (41-43) bu th lineageo man illnesse no relate t wa hav bee bac throug th effor syndrom t th DCost syndrome Suc illnesse includ anxiet neurosi an manic-depressiv condition (44) panidisorder (45) th mitra valu prolaps syndrom(17 46) th hyperventilatio syndrom (47) anth chroni fatigu syndrom (48)A i Worl Wa I an Worl Wa II acutcomba stres reactio wa a importan clinica durin th Korea Conflic (33 38)Vietna WaTh mos prominen illnes relate t th Vietna Wa wa post-traumati stres disorde (49)whic wa initiall calle post-Vietna syndrom(50 51) Wherea acut comba stres reactio ith immediat consequenc o psychologica traumapost-traumati stres disorde mor ofte refer tth long-ter consequence o extrem psychologica stres (52) Post-traumati stres disorde haals bee recognize a a proble i veteran obot th Korea Conflic an Worl Wa I (53)especiall forme prisoner o wa (54 55) an habee foun i civilian expose t extrem traumno relate t wa (51)N othe prominent poorl understoo wa syndrom wa associate wit th Vietna Wa (5658) althoug controvers abou th rol o AgenOrang (dioxin exposur i th developmen ovariou medica problem an birt defect continue (59) Chroni somati symptom hav generallno bee linke t th effect o herbicid exposuri Vietnam However i i noteworth tha th somati symptom frequentl describe b Vietna veteran wh ma hav bee expose t Agen Orang(56 58 60 ar simila t th symptom commonl40 1 Septembe 199 • Annals of Internal Medicine • Volum 12 • Numbe 5 Downloaded from https://annals.org by University of Pittsburgh user on 09/05/2019 associate wit othe war-relate illnesse (61) includin acut comba stres reactio (39 an posttraumati stres disorde (62-68 (Tabl 1)Persia Gul WaAfte Ira invade Kuwai i Augus 199069 000 soldier fro th Unite States 4 00 soldier fro Grea Britain an 450 soldier froCanad wer deploye t th Persia Gul durin a 5-mont

buildu period thi perio wa followe ba 39-da ai wa an a 4-da groun wa i February 1991 Fa fewe casualtie tha anticipate occurre amon coalitio forces an morbidit ratewer lo compare wit thos i previou war (6970)Afte th wa ended troop returne home anveteran fro divers militar unit o th UniteStates Grea Britain an Canad bega reportinvariou chroni symptoms ofte referre t a thGul Wa syndrom (71-77) Fatigue headachemuscl an join pain diarrhea ski rashes shortnes o breath an ches pai hav bee commosymptom (Tabl 1 (2 78-80) Variou neuropsychologica symptom als hav bee common—particularl slee disturbances impaire concentrationforgetfulness irritability an depression Currentlyn characteristi physica sig o laborator abnor ha bee identifie (2 80 81)N medica report o simila unexplaine illnesse amon othe coalitio troop o amonperson indigenou t th Persia Gul hav bee Durin Worl Wa II n simila unexplaine illnesse wer see amon th Britisan U.S force statione i th Persia Gul (82)Persona account o famil member developinsymptom simila t thos o relative wh serve i Persia Gul Wa an increase birt defectamon childre bor afte th wa hav bee reporte (2 83) Othe recen war-relate conditionhav bee associate wit medica an psychologica amon famil member (59 84) bu ac o healt problem amon famil member veteran wh receive a diagnosi o a war-relateillnes di no increas durin Worl Wa I o WorlWa IITh healt problem experience b veteran afte servic i th Persia Gul Wa hav bee considere a seriou b th involve governments a respons simila t tha see fo th efforsyndrom i Worl Wa I A tri-agenc coordinat boar ha bee establishe i th Unite Statet supervis a comprehensiv clinica an researcprogra (85-87) an compensatio i bein provide t disable wa veteran wh hav unexplaine illnesse (U.S Publi La 103-446 2 Novembe 1994) I addition th U.S Departmen oVeteran Affairs th U.S Departmen o Defensean th government o Grea Britai an Canadhav establishe self-referre healt registrie anspecialize center tha provid comprehensiv clin­ica examination an medica car (2-4)Clinica evaluatio o mor tha 8 00 veteranan initia epidemiologi survey hav identifie a broa rang o healt problem (2 80 88 89)includin symptom o post-traumati stres disor i 5 t 15 o som vetera population(90-94) however a ne o uniqu syndrom hano ye bee identifie (80) Preliminar result o studie o veteran o th PersiaGul Wa sho n overal increas i hospitalizatio rate (95) birt defect (96) o mortalit du medica cause (97)Availabl informatio o th natur an caus oillnesse amon veteran o th Persia Gul Wa bee evaluate b five independen panel i Unite State (70 98-101) Thes panel di identif a ne illnes (70 98 100 o establis a definitio o a uniqu syndrom (70 98 99101) the conclude tha veteran o th PersiaGul Wa ha numerou illnesse tha resulte frovariou cause (70 98) However on advisor committe conclude tha a rar o mil illnes coul bmisse b larg cas series suc a th Persia Gul registries whic hav examine approximatel 10 o al U.S veteran o th Persia GulWa (100)Compariso o Wa SyndromeSinc th U.S Civi War tw genera categorieo war-relate illnesse hav bee recognized onpoorl understoo grou though t b associatewit physiologi diseas an anothe grou o psychologica illnesse attribute t wartim stres (Tabl 2) Althoug ther hav bee tw genera typeo war-relate illnesses wa syndrome hav nobee consistentl define o identifie b a pathognomoni physica sig o laborator abnormality Aa result th diagnosi o a physiologi o psychologica illnes i individua patient ha bee impre an ha depende o self-reporte symptoman th impressio o th examinin physicia (813 34 61 98)Th wa syndrome though t b associate witorgani patholog hav bee characterize b twsimilaritie tha coul indicat a relate diseaseFro th D Cost syndrom t th mor recenGul Wa syndrome th first commo featur habee th similarit o reporte symptoms Sharesymptom includ fatigue shortnes o breathheadache slee disturbances impaire concentration an forgetfulnes (Tabl 1) Commo symp alone however d no sho tha veteran o1 Septembe 199 • Annals of Internal Medicine • Volum 12 • Numbe 5 40 Downloaded from https://annals.org by University of Pittsburgh user on 09/05/2019 Tabl 2 Compariso betwee Categorie o War-Relate IllnesseWaCategor o IllnesPhysiologicall Attribute Psychologicall AttributeU.S Civi WaWorl Wa 1 Worl Wa IKorea ConflicVietna WaPersia Gul WaD Cost syndrom (irritabl heart NostalgiEffor syndrom (soldier' heart neurocirculator asthenia Shel shoc (trenc neurosisEffor syndrom Battl fatigue comba exhaustion operationa fatiguBattl fatigue comba exhaustioAgen Orang exposur Post-traumati stres disorde (Post-Vietna syndromeGul Wa synd

rom Post-traumati stres disordevariou war ha a relate diseas process becaussuc symptom ar an ar frequentlfoun i al adul population (102-106) particularl amon person wit psychologica stres (3956 107 an post-traumati stres disorde (62 63108)A secon possibl unifyin facto ha bee thhig frequenc o reporte diarrhe an othe infectiou disease precedin th onse o thes syndrome (5 13 19 109) Th significanc o thifacto i unclea becaus crowde population omilitar personnel particularl troop sen t tropica an developin regions hav a inevitabl higrat o infectiou diseas (58 82) However n deployment-relate syndrom ha bee reporte afte larg peacetim militar exercises Iaddition infectiou disease hav no bee provet caus chroni somati symptom i th absenco measurabl sign o diseas (110) excep possiblamon person pron t depressio (111 112) Nevertheless convalescenc ca b prolonge afteman infection (113) an th chroni fatigu syndrome althoug no associate wit characteristi o disease i suspecte o havin a infectiouorigi (114)Othe tha thes tw similarities ther i littladditiona evidenc o a single uniqu wa syn tha i unrelate t psychologica stressHowever 19th-centur an earl 20th-centur clini characterization ar difficul t compar wit data an th psychologica aspect o ill wer no a wel appreciate an reporte i past Furthermore becaus o th genera improvemen i healt an nutritio durin thi century i i difficul t compar th illnesse o militar population o differen erasAlthoug historica dat ar difficul t compareampl evidenc show tha numerou comple factor wer responsibl fo th healt problem o waveterans a i an population an tha man illnesse wer describe afte successiv wars A sub proportio o veteran wit chroni somati wer foun t hav variou physiologian psychologica illnesse (13 30 80 89) I addition veteran o eac wa ha hig rate o acut stres reactio an post-traumati stres disorde (33) Stil othe veteran ha illnesse thamee th recentl suggeste criteri fo a diagnosi th chroni fatigu syndrom (48 70 89 115)Althoug n single recurrin war-relate diseasha bee identified man aspect o th procesuse durin th pas 13 year t evaluat thhealt problem o veteran hav bee repeatewit eac war Th mos importan an consistenfacto i tha thi proces ha involve medica eval afte th critica event thereb precludin a definitiv demonstratio o causality Consequently illnesse tha occu afte a wa ma b t wartim exposure an epidemiologi regardles o thei siz o design canno resolv medical legal an politicaquestion abou th cause o post-wa healt problem (116) I additio t th problem o interpretin th result o retrospectiv studies i ha beedifficul t identif simila contro population becaus o th exceptiona natur o wartim experi an th uniqu characteristic o militar popBecaus studie o war-relate illnesse havbee don afte exposur an withou simila contro groups researc effort hav frequentl beelimite t th evaluatio o a serie o clinica casesResearc effort hav bee furthe hampere becaus wa syndrome hav no bee associate wit an measurabl sign o diseas thawoul allo fo th developmen o specifi casdefinition (8 98) I additio t thes researclimitations th proble o diagnosti labelin haplaye a critica rol i th evaluatio o wa syndromes Th namin o a syndrom ha repeatedlexerte a powerfu effec o th medica approactoward officia recognitio of an patien perceptio o thes poorl understoo condition (11 33)A medicall recognize diagnosi fundamentall alter th live o active-dut militar personne anveterans influencin everythin fro typ an locatio o dut assignmen t medica treatment expectation o recovery an eligibilit fo compensatio (13 37) Th influenc o a medica classificatioha als bee foun t b substantia amon nonmilitar population (117-119)40 1 Septembe 199 • Annals of Internal Medicine • Volum 12 • Numbe 5 Downloaded from https://annals.org by University of Pittsburgh user on 09/05/2019 ConclusionDespit enormou progres i medica sciencepoorl understoo wa syndrome hav recurre aleas sinc th U.S Civi War N single previousluncharacterize illnes o underlyin caus tha i t psychologica stres i apparen froth availabl reports However man illnesse havbee foun amon wa veteran evaluate fo thessyndromes A expecte i an larg adul populatio expose t comple environmenta an psycho conditions variou healt problem hav developedAlthoug n uniqu war-relate diseas i evident on unifyin facto ha bee prominen i th o thes syndromes A uniqu populatiowa intensel scrutinize afte experiencin a exceptional life-threatenin se o exposures Th pro b whic thes syndrome wer evaluate andefine i th mos eviden similarityDesignin studie t evaluat th healt o waveteran inevitabl present severa seriou methodol

ogi problem (116) Fo example i i difficul t accurat healt an ris facto dat afte a potentiall harmfu experience particularl i therha bee extensiv o sensationa medi coveragebecaus o reportin bia (120-122) Durin wartim conditions i i no feasibl fo th militar t comprehensiv exposur dat amon comba becaus th primar focu mus b t fight an wi th warA apparen solutio t thes methodologiproblem i t gathe mor extensiv baselin medica an exposur dat an t desig larg prospectiv studie befor an futur conflict A a resul onumerou recen oversea deployments th U.S o Defens i developin a greatl en surveillanc system Fo militar operation Bosnia whic bega i 1995 environmenta an diseas surveillanc team hav bee deployed U.S troop ar bein provide extensivhealt guidanc before during an afte th operation medica an psychologica screenin wil occu befor an afte deployment an a repositorfo seru collecte befor an afte deploymen ibein establishe (123)Intensiv surveillanc wil substantiall ai i thevaluatio o veterans health However i wil b t desig prospectiv studie t answe alpost-wa healt question becaus th locatio an o eac wa varie to greatl t predicever healt risk I addition studie o militarpopulation alon wil no sufficientl explai warrelate syndrome becaus thes syndrome involvfundamental unanswere question abou healtan illness T mor full understan th healt o population militar o civilian researc effortwil hav t b don t answe tw basi questions1 Wha i th relatio betwee chronic non-specifi symptom an physiologi an psychologicaillnes (124-127) 2) Wha factors—medical environmental psychological o social—creat a persona sens o il healt (128-131)Evaluatin fundamenta question o healt ilarg population i alway extraordinaril difficultbu i particularl s afte traumati an complewartim events Nevertheless unles thes difficulquestion ar answered w ris repeate occurrence o unexplaine symptom amon veteranafte eac warDisclaimer: Th opinion an assertion containe herei ar thprivat one o th author an ar no t b construe a officiao reflectin th view o th U.S Navy Departmen o Defense Departmen o Veteran AffairsFinancial Support: B th U.S Nava Medica Researc anDevelopmen Command NMC NCR Bethesda MD wor uninumbe 62787A-001-01EAX1288Requests for Reprints: Kennet C Hyams MD MPH U.S NavaMedica Researc Institute 1230 Washingto Avenue RockviUe M 20852Current Author Addresses: Dr Hyams U.S Nava Medica Re Institute 1230 Washingto Avenue Rockville M 20852 Wignall U.S Nava Medica Researc Uni No 2 (Jakarta Bo 3 Uni 8132 AP A 96520-8132Dr Roswell Departmen o Veteran Affair (VIS 8) P Bo5007 Ba Pines F 22504Reference1 Cotto P Veteran seekin answer t syndrom suspec the wer goat iGul wa [News] JAMA 1994;271:1559-612 Unexplaine illnesse amon Deser Stor veterans A searc fo causestreatment an cooperation Persia Gul Veteran Coordinatin Board ArcInter Med 1996;155:262-83 Bridgin th Gul [Editorial] Lancet 1996;347:3414 Robinso A Veteran worr tha unexplaine medica problem a legac oservic durin Gul War Ca Me Asso J 1995;152:944-75 D Cost JM O irritabl heart a clinica stud o a for o functionacardia disorde an it consequences A J Me Sci 1871;61:17-526 Jarch S Functiona hear diseas i th Civi Wa (D Costa 1871) A J Cardiol 1959;4:809-177 Pau O D Costa' syndrom o neurocirculator asthenia B Hear J 198758:306-158 Ettedgu E Bridge M Posttraumati stres disorder Psychiat Cli NortAm 1985;8:89-1039 Hammon WA A Treatis o Insanit i It Medica Relations Ne YorkAppleton 1883:411-510 Peter DC Remark o th evil o youthfu enlistment an nostalgiaAmerica Medica Times 1863;6:75-611 Howel JD Soldier' heart th redefinitio o hear diseas an specialtformatio i earl twentieth-centur Grea Britain Me His Suppl 1985;534-5212 Lewi T Repor o neurocirculator astheni an it management MilitarSurgeon 1918;42:409-2613 Lewi T Th Soldier' Hear an th Effor Syndrome Ne York P.BHoeber 191914 Lewi T Th Soldier' Hear an th Effor Syndrome 2 ed London Shaw194015 Jarch S Harlo Brook o neurocirculator astheni i Worl Wa I A J Cardiol 1966;18:892-716 MacLea WC Disease o th hear i th Britis army th caus an thremedy B Me J 1867;1:161-417 Woole CF Fro irritabl hear t mitra valv prolapse Britis arm medica reports 186 t 1870 A J Cardiol 1985;55:1107-918 Cotto T Lewi T Thiel FH A not o th "irritabl heart o soldiersB Me J 1915;1:72219 MacKenzi J Th soldier' heart B Me J 1916;1:117-91 Septembe 199 • Annals of Internal Medicine • Volum 12 • Numbe 5 40 Downloaded from https://annals.org by University of Pittsburgh user on 09/05/2019 20 Parkinso J Th cardia disabilitie o soldier o activ service Lancet1916;2:133-821 Abraham A Soldier' heart Lancet 1917;1:442

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