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OCR for page R1
Evaluation of the U.S. Department of Defense
Persian Gulf Comprehensive Clinical
Evaluation Program
Committee on Me DoD Persian Gulf Syndrome
Comprehensive Clinical Evaluation Program
Division of Heath Promotion and
Disease Prevention
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Washington, D.C. 1996
OCR for page R2
NATIONAL ACADEMY PRESS · 2101 Constitution Avenue, N.W. · Washington, DC 20418
NOTICE: The project that is the subject of this report was approved by the Governing
Board of the National Research Council, whose members are drawn from the councils of
the National Academy of Sciences, the National Academy of Engineering, and the
Institute of Medicine. The members of the committee responsible for the report were
chosen for their special competencies and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to procedures
approved by the Report Review Committee consisting of members of the National
Academy of Sciences, the National Academy of Engineering, and the Institute of
Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences
to enlist distinguished members of appropriate professions in the examination of policy
matters pertaining to the health of the public. In this, the Institute acts under both the
Academy's 1863 congressional charter responsibility to be an adviser to the federal
government and its own initiative in identifying issues of medical care, research, and
education. Dr. Kenneth I. Shine is the president of the Institute of Medicine.
This study was supported by the U.S. Department of Defense under Contract Number
DADA 15-94-C-0126. The views presented are those of the Institute of Medicine
Committee on the DoD Persian Gulf Syndrome Comprehensive Clinical Evaluation
Program and are not necessarily those of the funding organization.
Additional copies of this report are available in limited quantities from:
Division of Health Promotion and Disease Prevention
2101 Constitution Avenue, N.W.
Washington, DC 20418
Call (202) 334-2383 for more information.
Copyright 1996 by the National Academy of Sciences. All rights reserved.
Printed in the United States.
The serpent has been a symbol of long life, healing, and knowledge among almost
all cultures and religions since the beginning of recorded history. The image adopted as
a logo-type by the Institute of Medicine is based on a relief carving from ancient Greece,
now held by the Staatlichemusseen in Berlin.
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COMMITTEE ON THE DOD PERSIAN GULF SYNDROME
COMPREHENSIVE CLINICAL EVALUATION PROGRAM
Gerard Burrow,* Chair, Dean, Yale University School of Medicine, New
Haven, Connecticut
Dan Blazer,* Dean of Medical Education and Professor of Psychiatry, Duke
University Medical Center, Durham, North Carolina
Margit Bleecker, Director, Center for Occupational and Environmental
Nuerology, Baltimore, Maryland
Ralph Horwitz, Chairman, Department of Internal Medicine, Yale University
School of Medicine, New Haven, Connecticut
Howard Kipen, Associate Professor and Director, Occupational Health
Division, Robert Wood Johnson Medical School, Piscataway, New Jersey
Adel Mah~noud,* Chairman, Department of Medicine, Case Western Reserve
University and University Hospitals of Cleveland, Cleveland, Ohio
Michael Osterholm, State Epidemiologist, Minnesota Department of Health,
Minneapolis, Minnesota
Robert Pynoos, Professor of Psychiatry, University of California at
Los Angeles, Los Angeles, California
Anthony Scialli, Associate Professor, Department of Obstetrics and
Gynecology, Georgetown University Medical Center, Washington, D.C.
Rosemary Sokas, Associate Professor of Medicine, Division of Occupational
and Environmental Medicine, George Washington University School of
Medicine, Washington, D.C.
Guthrie Turner, Chief Medical Consultant, Division of Disability
Determination Services, State of Washington, Tummwater, Washington
Michael Weisman, Professor, Division of Rheumatology, University of
California at San Diego Medical Center, San Diego, California
Staff
Michael A. Stoto, Director, Division of Health Promotion and Disease
Prevention
Kelley A. Brix, Study Director
Deborah Katz, Research Assistant
Amy Noel O'Hara, Project Assistant
Donna D. Thompson, Division Assistant
Mona Brinegar, Financial Associate
~Member, Insititute of Medicine
. . .
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Contents
EXECUTIVE SUMMARY
INTRODUCTION .
GOALS AND PROCEDURES OF THE CCEP
Overview, 5
Committee Assessment of the Overall Goals and Procedures
of the CCEP, 6
IMPLEMENTATION OF THE CCEP ................
Referrals of Patients from Phase I to Phase II of the CCEP, 7
Systematic Guidelines for Psychiatric Referrals
and Adequacy of Psychiatric Resources, 8
ANALYSIS AND INTERPRETATION OF THE RESULTS OF THE
CCEP
Symptoms and Diagnoses in the CCEP Population, 9
Clinical Evidence of a New, Unique Persian Gulf Syndrome, 11
Potential Relationship of Illnesses in CCEP Patients to
Service in the Persian Gulf, 12
Comparison of the CCEP Population with Other Populations, 13
SPECIFIC MEDICAL DIAGNOSES
Psychiatric Conditions, 15
7
... 9
v
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V1
CONTENTS
Prevalence and Impact of Psychiatric Conditions Among CCEP
Patients, 15
Standardization of Psychiatric Evaluations in the CCEP, 17
Recognition of Psychosocial Stressors in the CCEP
Population, 18
Musculoskeletal Conditions, 20
Signs, Symptoms, and Ill-Defined Conditions, 21
Infectious Diseases, 21
Chronic Fatigue Syndrome, Fibromyalgia, and Multiple Chemica
Sensitivity, 23
USE OF THE CCEP RESULTS FOR EDUCATION, IMPROVEMENTS
IN THE MEDICAL PROTOCOL, AND OUTCOME
EVALUATIONS ....................................
Use of the CCEP Results for Education, 24
Use of the CCEP Results to Improve the Medical Protocol, 25
Use of the CCEP Results for Patient Outcome Evaluations, 26
Specialized Care Center, 27
Overview of the Goals, Structure, and Early Progress of the
SCC, 27
Committee Comments on the Goals, Structure, and
Early Progress of the SSC, 28
EPIDEMIOLOGIC RESEARCH RELEVANT TO THE CCEP
Exposure Assessment Research Relevant to the CCEP, 30
Health Outcome Research Relevant to the CCEP, 31
REFERENCES ..............................
APPENDIXES
A Agendas for the Four Meetings of the IOM Committee on the
DoD Persian Gulf Syndrome Comprehensive Clinical Evaluation
Program ...... .......... ... . .. ... . . .
B Outline of the Standardized Medical Protocol: Selected
Pages from the Comprehensive Clinical Evaluation (CCEP) Guide,
January 5, 1995, U.S. Department of Defense
24
. 29
. 33
.. 37
. 47
