Human and animal studies show that the anticipation or perception of exposure to a severe stressor in the absence of actual exposure can be as powerful as the actual exposure in eliciting the stress response (see Chapter 4). Several of the questionnaires developed after the Gulf War (for example, Sutker et al. 1995; Ikin et al. 2004, 2005) to identify war-zone stressors include anticipated or perceived exposure to chemical weapons in addition to actual combat exposure. Before deployment, most stressors are associated with fear of unknown or expected enemy tactics. In a survey of 1400 U.S. troops just before the January 15, 1991, deadline for the withdrawal of Iraqi troops from Kuwait, researchers found that the fear of Iraqi use of chemical or biologic weapons was the greatest stressor (Norwood et al. 1996). Kang et al. (2003) defined veterans as having been “combat-exposed” if they were “wearing chemical protective gear” or “hearing chemical alarms sounding.” Stretch et al. (1996a), in a survey of over 1500 Gulf War veterans, found that waiting for deployment to the gulf was moderately to extremely stressful for 67% of them.

Predeployment anticipation of an event might be more stressful than its occurrence during deployment. Before the January 1991 gulf air war, Gifford et al. (2006) conducted interviews of Gulf War troops in Saudi Arabia to identify potential stressors and then followed up 6-9 months after the troops returned to the United States. They found that the stressors changed as the soldiers adapted to the new environment in the gulf, the infrastructure was modified with new equipment and facilities, and communication to and from families, the public, and top military and political figures improved (see Table 3-2). However, some stressors persisted throughout the war; for example, soldiers had been told by senior military personnel to expect large numbers of casualties, and this anticipation existed until virtually the end of the war.

Australian Navy Gulf War veterans were surveyed to identify stressors in military units that were not actively engaged in combat or that had little direct combat exposure—those troops served in blockade efforts or provided transport, supplies, or medical support (Ikin et al. 2004, 2005; McKenzie et al. 2004). Of the 1232 respondents, 81% indicated that they had been on a ship or aircraft passing through hostile water or airspace; 71% had been in fear of artillery, missile, Scud rocket, or bomb attack; 71% had been on formal alert or in fear of nuclear, biologic, or chemical attack; 67% felt cut off from family or significant others; and 54% felt that while on board a ship they feared death, injury, or being trapped as a result of a missile attack or hitting a sea mine. For Australian Gulf War-era veterans who had been deployed to areas other than the gulf and for veterans who had not been deployed, the greatest stressor was feeling cut off from family members and significant others. Similarly, a study of the entire cohort of 3000 Gulf War veterans from Canada found that although the vast majority served at sea, they frequently saw Scud missiles overhead, and that resulted in stress because they feared that the missiles contained chemical-warfare agents (Goss Gilroy Inc. 1998).

When United Kingdom (UK) Gulf War-deployed troops were compared with UK troops deployed to Bosnia or not deployed, the Gulf War-deployed troops reported more exposure to all stressors except dead animals and exhaust from heaters or generators (Unwin et al. 1999). Anticipation of attack with chemical or biologic agents was the most common predeployment fear among the UK troops.

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