Schnurr et al. (2000) screened 605 of the veterans (98% white and 85% World War II veterans) for PTSD symptoms with the Mississippi Scale for Combat-Related PTSD. They found that 1% of the study participants had a score on the scale that indicated symptoms of PTSD. More combat exposure was correlated with more PTSD symptoms, and both combat and PTSD symptoms were correlated with increased self-reports of poor physical and mental health (Schnurr and Spiro 1999). When PTSD symptoms were associated with various physician-diagnosed health outcomes, a 10-point increase in PTSD symptom scores was found to increase the risk of having an arterial disorder by 27%, a lower GI disorder by 23%, a dermatologic disorder by 18%, and a musculoskeletal disorder by 9%. Increases in arterial, pulmonary, and upper GI disorders, but decreases in onset of other heart disorders, were associated with increased combat exposure. No association was found between PTSD and cancer, genitourinary disorders, or endocrine disorders (Boscarino 1997; Schnurr et al. 2000). The ambulatory care veterans from the VA Veterans Health Study who screened positive for PTSD were found to have significantly more chronic lower back pain than veterans without PTSD (OR 2.85, 95% CI 2.25-3.63, p ≤ 0.05) adjusted for age and for depression (Spiro et al. 2005).

Women with PTSD have a greater risk of poor health status than do women without PTSD. Using NVVRS data, Zatzick et al. (1997b) found that female veterans with PTSD reported poorer health status and well-being, had more days in bed, were more likely not to be working currently, and had more limitations in physical functioning than female veterans without PTSD. In a mailed survey of female veterans who attended a VA medical facility, those who screened positive for PTSD (n = 266) using the PTSD Checklist-Civilian Version were significantly more likely than those without PTSD (n = 940) to also screen positively for a drinking problem (OR 1.68, 95% CI 1.22-2.30), a drug problem (OR 3.56, 95% CI 2.36-5.37), being a victim of domestic violence (OR 2.58, 95% CI 1.92-3.46), and various psychiatric disorders, including panic disorder and major depression. Female veterans who screened positive for PTSD were also more likely to have several self-reported medical problems, including fibromyalgia, stroke, irritable bowel syndrome, chronic pelvic pain, premenstrual syndrome, and polycystic ovary disease (all ORs > 2.0, 95% CIs > 1.0) (Dobie et al. 2004).

Unexplained Illness

Unexplained illnesses have been described primarily in the Gulf War veteran literature. As discussed above, veterans who were deployed to the Persian Gulf region report more symptoms than their nondeployed counterparts. The numerous symptoms or clusters of symptoms have been referred to by a variety of terms, such as Gulf War syndrome, chronic multisymptom illness, and “unexplained” illness. They are “unexplained” not in the sense that they are of unknown etiology (which is true of many medical conditions) but rather in the sense that they do not fit into established medical diagnostic categories (IOM 2006). The ICD includes a category “unknown and unspecified causes of morbidity,” R69, that might be appropriate for this health effect. Several studies for unexplained illness that met the committee’s criteria for primary studies because they did not rely on self-reports are included in Table 6-14.

The committee identified eight studies of unexplained illness in Gulf War veterans beginning with a study by Fukuda et al. (1998) that established the CDC case definition for chronic multisymptom illness. In response to a request from DoD, VA, and the Commonwealth of Pennsylvania, Fukuda et al. (1998) assessed the health status of Air Force veterans who had been deployed to the Gulf War. Their focus was to assess the prevalence and causes of an unexplained illness in members of one Air National Guard unit. They administered a 35-item



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