A similar study by Cherry et al. (2001a,b) 6-8 years after the Gulf War also used a pain manikin to identify whether and where veterans had experienced pain for at least 24 hours in the preceding month. Among the 9588 male and female UK Gulf War veterans in all service branches, 12.2% reported widespread pain on a manikin compared with 6.5% of 4790 nondeployed veterans; widespread pain was considered to be present if the manikin showed axial skeletal and contralateral body pain. CWP was not associated with exposure to combat although it was associated with other deployment exposures, specifically to insect repellent, medical attention, and side effects of nerve-agent prophylaxis. The study had response rates of 93% of the active-duty military and 80% of those who had left the military.

Posttraumatic Stress Disorder, Fibromyalgia, and Chronic Widespread Pain

As noted earlier, PTSD is highly comorbid with other health problems, particularly chronic pain and psychiatric disorders. Some studies have assessed whether PTSD is comorbid with fibromyalgia and CWP. Two studies that looked at the comorbidity of PTSD and fibromyalgia were identified.

Amital et al. (2006) found that 49% of 55 male Israeli veterans suffering from combat-related current PTSD met the ACR criteria for fibromyalgia, whereas only 5% of 20 veterans with MDD had fibromyalgia; none of 49 healthy control veterans had fibromyalgia. The PTSD veterans also had more tenderness points (assessed by a rheumatologist) than the MDD veterans (mean, 8.85 vs 2.85). Patients who had both PTSD and fibromyalgia also had more severe PTSD symptoms, primarily re-experiencing symptoms, and scored significantly higher on the CAPS than did veterans without fibromyalgia (97.6 ± 13.2 vs 88.2 ± 14.0). The traumatic event that preceded PTSD had occurred during military service 22-36 years before the study.

Fibromyalgia and PTSD are more prevalent in women than in men. Dobie et al. (2004) sent a mail survey to 1206 female Gulf War veterans who received care at VA medical centers in 1996-1998. The presence of PTSD was determined with the PTSD Checklist-Civilian Version, and fibromyalgia was self-reported. Of the 1206 women, 266 (22%) screened positive for current PTSD; these 266 were more likely to screen positive for fibromyalgia (19.2% of the 266) than were the 940 women without PTSD (8.0%) for an age-adjusted OR of 3.00 (95% CI 1.98-4.45). This cross-sectional survey has several limitations, including lack of identification of the trauma associated with the PTSD, use of a treatment-seeking population, lack of diagnostic examinations for either PTSD or fibromyalgia, and reporting bias.

The committee identified only one study that looked at CWP in veterans with PTSD. Ang et al. (2006) found that CWP was associated with symptoms of PTSD in Gulf War veterans (OR 4.5, 95% CI 0.6-32.3, p = 0.1383) more than in nondeployed veterans. Because the veterans were screened for current PTSD with the PTSD Checklist-Military Version, this is a secondary study.

Summary and Conclusions

The diagnosis of fibromyalgia is based on meeting the ACR criteria in a physical examination for tender points and the presence of CWP. The committee identified only two primary studies that diagnosed fibromyalgia on the basis of the ACR criteria and included both Gulf War-deployed and nondeployed veterans: Eisen et al. (2005) and Smith et al. (2000). The committee was unable to locate any studies of fibromyalgia in Vietnam veterans or veterans of other U.S. conflicts. The Eisen et al. (2005) study found that Gulf War-deployed veterans’ risk of fibromyalgia was more than twice that of nondeployed veterans. Smith et al. (2000) found no



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