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Gulf War and Health, Volume 6: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress
GULF WAR and HEALTH
VOLUME 6
PHYSIOLOGIC, PSYCHOLOGIC, AND PSYCHOSOCIAL EFFECTS OF DEPLOYMENT-RELATED STRESS
Committee on Gulf War and Health: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress
Board on Population Health and Public Health Practice
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
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Gulf War and Health, Volume 6: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress
THE NATIONAL ACADEMIES PRESS
500 Fifth Street, NW Washington, DC 20001
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 competences and with regard for appropriate balance.
This study was supported by Contract V101(93)P-2155B between the National Academy of Sciences and the Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
International Standard Book Number = 13: 978-0-309-10177-6
International Standard Book Number = 10: 0-309-10177-8
Library of Congress Control Number: 2008920197
Additional copies of this report are available from the
National Academies Press,
500 Fifth Street, NW, Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu.
Copyright 2008 by the National Academy of Sciences. All rights reserved.
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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 serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
Suggested citation:
IOM (Institute of Medicine). 2008. Gulf War and Health, Volume 6: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress. Washington, DC: The National Academies Press.
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Gulf War and Health, Volume 6: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
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THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.
www.national-academies.org
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Gulf War and Health, Volume 6: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress
COMMITTEE ON GULF WAR AND HEALTH: PHYSIOLOGIC, PSYCHOLOGIC, AND PSYCHOSOCIAL EFFECTS OF DEPLOYMENT-RELATED STRESS
RICHARD MAYEUX, MD, MSc (Chair), Gertrude H. Sergievsky Professor of Neurology, Psychiatry, and Epidemiology,
Sergievsky Center, and
Codirector,
Taub Institute, Columbia University
KATHRYN KARUSAITIS BASHAM, PhD, MSW, Professor,
Smith College School for Social Work
EVELYN J. BROMET, PhD, Professor of Psychiatry and Preventive Medicine,
State University of New York at Stony Brook
GREGORY L. BURKE, MD, MSc, Professor and Chair,
Public Health Sciences, Wake Forest University School of Medicine
DENNIS S. CHARNEY, MD, Dean, Anne and Joel Ehrenkranz Professor,
Mount Sinai School of Medicine
MICHAEL DAVIS, PhD, Robert W. Woodruff Professor of Psychiatry,
Behavioral Sciences and Psychology, Emory University
DOUGLAS A. DROSSMAN, MD, Professor of Medicine and Psychiatry and Codirector,
UNC Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill
DWIGHT L. EVANS, MD, Ruth Meltzer Professor and Chair,
Psychiatry, and
Professor of Psychiatry, Medicine, and Neuroscience,
University of Pennsylvania School of Medicine
VINCENT J. FELITTI, MD,
Kaiser Permanente Medical Care Program, San Diego, CA
JANICE L. KRUPNICK, PhD, Professor,
Department of Psychiatry, Georgetown University School of Medicine
WILLIAM B. MALARKEY, MD, Professor of Internal Medicine and Molecular Virology, Immunology and Medical Genetics and Director,
Clinical Research Center, Ohio State University
BRUCE S. MCEWEN, PhD, Alfred E. Mirsky Professor and Head,
Harold and Margaret Milliken Hatch Laboratory of Neuroendocrinology, Rockefeller University
THOMAS G. PICKERING, MD, DPhil, Professor of Medicine,
Columbia University
JERROLD F. ROSENBAUM, MD, Psychiatrist-in-Chief,
Massachusetts General Hospital, and
Stanley Cobb Professor of Pyschiatry,
Harvard Medical School
B. TIMOTHY WALSH, MD, William and Joy Ruane Professor of Pediatric Psychopharmacology,
College of Physicians and Surgeons, Columbia University, and
Chief,
Division of Clinical Therapeutics, New York State Psychiatric Institute
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CONSULTANTS
KERRY L. KNOX, PhD, Associate Professor,
Department of Psychiatry and Community and Preventive Medicine, University of Rochester School of Medicine and Department of Veterans Affairs, Director, VISN 2 Center for Excellence at Canandaigua
CAROL NORTH, MD,
VA North Texas Health Care System and Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas
MIRIAM DAVIS, Independent Medical Writer,
Silver Spring, MD
STAFF
CAROLYN FULCO, Scholar
ROBERTA WEDGE, Senior Program Officer
SANDRA GOODBODY, Senior Program Officer
PETER JAMES, Senior Program Associate
DEEPALI M. PATEL, Senior Program Associate
MICHAEL SCHNEIDER, Senior Program Associate
DAVID J. TOLLERUD, Program Assistant
DANIELLE K. STOLL, Program Assistant
DAMIKA WEBB, Research Assistant
RENEE WLODARCZYK, Senior Program Assistant
NORMAN GROSSBLAT, Senior editor
ROSE MARIE MARTINEZ, Director,
Board on Population Health and Public Health Practice
HOPE HARE, Administrative Assistant
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REVIEWERS
This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following for their review of this report:
Elissa S. Epel, Department of Psychiatry, University of California, San Francisco
Manning Feinleib, Department of Epidemiology, The Johns Hopkins University
Edgar Garcia-Rill, Center for Translational Neuroscience, Department of Neurobiology & Developmental Sciences, University of Arkansas for Medical Sciences
Danny O. Jacobs, Department of Surgery, Duke University Medical Center
Karen A. Matthews, Western Psychiatric Institute & Clinic, University of Pittsburgh School of Medicine
Eric J. Nestler, Department of Psychiatry, The University of Texas Southwestern Medical Center at Dallas
William E. Schlenger, Abt Associates, Inc.
Robert D. Sparks, TASER Foundation
Ezra S. Susser, Department of Epidemiology, Columbia University
Daniel S. Weiss, Department of Psychiatry, University of California, San Francisco
Nancy Fugate Woods, School of Nursing, University of Washington
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Dr. Charles E. Phelps, University of Rochester, and Dr. Harold C. Sox, American College of Physicians/Annals of Internal Medicine. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the author committee and the institution.
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Gulf War and Health, Volume 6: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress
CONTENTS
ACRONYMS
xiii
PREFACE
xvii
SUMMARY
1
Committee’s Interpretation of Its Charge
2
Committee’s Approach to Its Charge
2
Evaluation Criteria
3
Categories of Association
4
Limitations of Veteran Studies
5
Deployment-Related Stressors
5
The Stress Response
6
Posttraumatic Stress Disorder
6
Health Effects
7
Summary of Conclusions
7
Recommendations
9
1
INTRODUCTION
11
Demographics
12
Committee’s Interpretation of Its Charge
13
Committee’s Approach to Its Charge
14
Organization of the Report
15
References
16
2
CONSIDERATIONS IN IDENTIFYING AND EVALUATING THE LITERATURE
17
Identification of the Literature
17
Types of Evidence
18
Inclusion Criteria
23
Additional Considerations
24
Considerations in Assessing the Strength of Evidence
25
Categories of Association
26
Limitations of Veteran Studies
28
Summary
28
References
29
3
DEPLOYMENT-RELATED STRESSORS
31
Stressors During Combat
32
Noncombat Stressors
35
Anticipation of Deployment to a War Zone
36
Military Sexual Assault and Harassment
37
Living Conditions
38
Environmental and Chemical Stressors
39
Reserve and National Guard Troops
39
Peacekeepers
40
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Women
41
Conclusions
43
References
43
4
THE STRESS RESPONSE
49
Central Role of the Brain
50
Modifiers of the Stress Response
56
Chronic Stress and Health
59
Conclusions
66
References
66
5
POSTTRAUMATIC STRESS DISORDER
75
Diagnosis and Clinical Features
76
Prevalence
78
Course
81
Comorbidity and Disability
84
Risk and Protective Factors
86
Neurobiology
94
Conclusions
100
References
100
6
HEALTH EFFECTS
115
Organization of This Chapter
115
Cancer
117
Endocrine Diseases
133
Psychiatric Disorders
142
Substance-Use Disorders
158
Neurobehavioral and Neurocognitive Effects
167
Chronic Fatigue Syndrome
174
Sleep Disturbances
179
Cardiovascular Diseases
183
Respiratory System Diseases
197
Digestive System Disorders
204
Skin Disorders
214
Fibromyalgia and Chronic Widespread Pain
222
Reproductive Effects
229
Suicide and Accidental Death
237
Symptom Reporting
248
References
261
7
PSYCHOSOCIAL EFFECTS
283
Marital and Family Conflict
283
Homelessness
299
Incarceration
304
Employment
308
References
312
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8
CONCLUSIONS AND RECOMMENDATIONS
317
Quality of the Studies
317
Overview of Health Effects
318
Recommendations
321
References
321
INDEX
323
Tables
TABLE S-1
Summary of Findings Regarding the Association Between Deployment to a War Zone and Specific Health and Psychosocial Effects
8
TABLE 3-1
Combat Experiences Reported by Members of the U.S. Army and Marine Corps After Deployment to Iraq or Afghanistan
34
TABLE 3-2
Stressors Experienced by U.S. Forces in the Gulf War
37
TABLE 3-3
Percentage of Active-Duty vs Reserve and National Guard Troops, by War
40
TABLE 5-1
Prevalence of Traumatic Events and PTSD in Men and Women
78
TABLE 5-2
Estimated Prevalence of PTSD in U.S. Military Populations
82
TABLE 6-1
Cancer
128
TABLE 6-2
Endocrine Diseases
141
TABLE 6-3
Psychiatric Disorders
153
TABLE 6-4
Substance-Use Disorders
164
TABLE 6-5
Neurobehavioral and Neurocognitive Effects
171
TABLE 6-6
Chronic Fatigue Syndrome
178
TABLE 6-7
Cardiovascular Diseases
195
TABLE 6-8
Respiratory System Diseases
202
TABLE 6-9
Digestive System Disorders
211
TABLE 6-10
Skin Disorders
220
TABLE 6-11
Fibromyalgia and Chronic Widespread Pain
228
TABLE 6-12
Reproductive Effects
234
TABLE 6-13
Suicide and Accidental Death
245
TABLE 6-14
Symptom Reporting
259
TABLE 7-1
Marital and Family Conflict
295
TABLE 7-2
Homelessness
303
TABLE 7-3
Incarceration
307
TABLE 7-4
Adverse Employment Outcomes
311
TABLE 8-1
Summary of Findings Regarding the Association Between Deployment to a War Zone and Specific Health and Psychosocial Effects
319
Boxes and Figures
BOX 4-1
Physiologic Changes During the Stress Response
50
BOX 5-1
DSM-IV Diagnostic Criteria for Posttraumatic Stress Disorder
77
BOX 6-1
Case Definition of Chronic Fatigue Syndrome
174
FIGURE 1-1
Schematic depiction of the relationship between deployment to a war zone and adverse health and psychosocial effects
15
FIGURE 4-1
Stress-response pathways
52
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Gulf War and Health, Volume 6: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress
FIGURE 4-2
How chronic stress can affect behavior and health
55
FIGURE 4-3
Chronicity of stressors
57
FIGURE 4-4
The brain-gut axis and IBS
65
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ACRONYMS
ACTH Adrenocorticotrophic hormone, corticotropin
APA American Psychiatric Association
ASI Anxiety sensitivity index
AUDIT Alcohol use disorder identification test
BIRLS Beneficiary identification record locator subsystem
BNST Bed nucleus of the stria terminalis
BSS Body-system symptom
CAPS Clinician-Administered PTSD Scale
CCEP Comprehensive Clinical Evaluation Program
CDC Centers for Disease Control and Prevention
CES Combat Exposure Scale
CFS Chronic fatigue syndrome
CHD Coronary heart disease
CI Confidence interval
CIDI Composite International Diagnostic Interview
CNS Central nervous system
COPD Chronic obstructive pulmonary disease
CRH Corticotropin-releasing hormone
CSF Cerebrospinal fluid
CSMs Cerebrospinal malformations
CTS Conflict Tactics Scale
CVLT California Verbal Learning Test
DIS Diagnostic Interview Schedule
DMDC Defense Manpower Data Center
DoD Department of Defense
DSM Diagnostic and Statistical Manual of Mental Disorders III or IV
GAD Generalized anxiety disorder
GI Gastrointestinal
HDL High-density lipoprotein
HPA Hypothalamus-pituitary-adrenal
HU13 Health Utilities Index Mark 3
HVVP Hawaiian Vietnam Veterans Project
IBS Irritable bowel syndrome
ICD International Statistical Classification of Diseases and Related Health Problems
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IEDs Improvised explosive devices
IOM Institute of Medicine
km Kilometer
MDD Major depression disorder
MHAT Mental Health Advisory Team
MHM Military History Measure
MMPI Minnesota Multiphasic Personality Inventory
MPI Martial Problem Index
MRI Magnetic resonance imaging
MSAs Metropolitan statistical areas
NART National Adult Reading Test
NAS National Academy of Sciences
NCHS National Center for Health Statistics
NCO Noncommissioned officer
NCS National Comorbidity Survey
NHANES National Health and Nutrition Examination Survey
NHL Non-Hodgkin’s lymphoma
NSVG National Survey of the Vietnam Generation
NVVRS National Vietnam Veterans Readjustment Study
OEF Operation Enduring Freedom
OIF Operation Iraqi Freedom
OR Odds ratio
PASAT Paced Auditory Serial Addition Test
PB Pyridostigmine bromide
PIR Proportional incidence rate
PMR Proportional morbidity ratio
PPI Parental Problem Index
PTSD Posttraumatic stress disorder
RR Relative risk
SCID Structured Clinical Interview for DSM-III or IV
SE Standard error
SF-36 36-Item Medical Outcomes Study Short-Form
T3 Triiodothyronine
T4 Thyroxine
TSH Thyroid-stimulating hormone
UK United Kingdom
UN United Nations
VA Department of Veterans Affairs
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VES Vietnam Experience Study
VET Registry Vietnam-Era Twin Registry
vs Versus
WAIS-R Wechsler Adult Intelligence Scale-revised
WCST Wisconsin Card Sorting Test
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PREFACE
Deployment to a war zone has a profound impact on the lives of many of the troops who are deployed to foreign soil and on their family members. Needless to say, numerous stressors are associated with deployment, from terrifying concerns about surviving, being taken prisoner, and being tortured to the horrific possibility of seeing friends die, being maimed, and handling dead bodies. Less traumatic but more pervasive stressors include anxiety about home life, such as loss of a job and income, impacts on relationships, and absence from family.
The effects of deployment-related stressors on a veteran’s health during and after deployment are numerous. When sudden and life-threatening stressors are encountered, the body will typically react with an acute “flight or fight” response that subsides when the stressor goes away. If the stressor or the acute response persists, the body may react with a more prolonged stress response that can lead to harmful long-term effects on health. The focus of this report, by the Institute of Medicine (IOM) Committee on Gulf War and Health: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress, is the long-term effects of deployment-related stress. What happens to military personnel when they are subjected to the many stressors that occur in a war zone?
The U.S. Department of Veterans Affairs and Congress have secured the assistance of IOM in evaluating the scientific literature regarding an association between deployment-related stressors and health effects. Congress’s request regarding the possible association between illness and exposure to stressors in the Gulf War is similar to its approach after the Vietnam War to exposure to Agent Orange and after the 1991 Persian Gulf War to exposure to numerous biologic and chemical agents. Although seemingly straightforward conceptually, this task has proved to be much more difficult than previous studies. The committee discussed how to define deployment-related stress, the types of stressors encountered, and how they might be assessed or measured.
In this report, the committee equated deployment-related stress with being deployed to a war zone, although it recognized that not everyone deployed to a war zone would respond to stressors in the same way and that not everyone would necessarily find a particular event stressful. The reaction to deployment-related stressors would depend on numerous factors that were present before, during, and after deployment. Stressors that people experienced in childhood, their interactions with friends and family, and whether they were wounded during deployment would all play a role in the nature of the response. The committee also understood that some military personnel would have minor reactions and transient health effects, some would have severe reactions and more chronic health effects, and some would go on to develop posttraumatic stress disorder (PTSD), which could be associated with additional health effects. That approach is detailed in the committee’s report.
The committee deliberated for many months and met 14 times. It reviewed all the studies of health effects in veterans deployed to a war zone and found that most studies did not measure the stressors of war (although that was not required for inclusion in the committee’s analysis), and that the ones that did measure deployment-related stress were most often related to PTSD. The committee noted that although experimental data from studies in animals indicated
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Gulf War and Health, Volume 6: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress
numerous health effects associated with various types of stressors, the human literature is much more challenging to interpret.
I am deeply appreciative of the hard work of our committee members: Kathryn Basham, Evelyn Bromet, Gregory Burke, Dennis Charney, Michael Davis, Douglas Drossman, Dwight Evans, Vincent Felitti, Janice Krupnick, William Malarkey, Bruce McEwen, Thomas Pickering, Jerrold Rosenbaum, and Timothy Walsh, and of our expert consultants Carol North, Kerry Knox, and Miriam Davis. The committee would like to thank Jack Gorman for his thoughtful input. Although the committee developed conclusions independently of input from IOM staff, we deeply appreciate their hard work and attention to detail and the extensive research that they conducted to ensure that we had all the information that we needed from the outset. It has been a privilege and a pleasure to work with the IOM staff directed by Roberta Wedge and Carolyn Fulco. Without them, this report would not have been possible. Most of all, our committee appreciates the veterans who have served in this country’s wars. It is for them that we do this work, and we hope that this report will inform those who have given so much to our nation.
Richard Mayeux, MD, MSc (Chair)
Sergievsky Professor of Neurology, Psychiatry, and Epidemiology
Director, Sergievsky Center; Codirector, Taub Institute
College of Physicians and Surgeons
Columbia University
