agencies in the United States and elsewhere have pursued or funded ambitious research programs to study CMI (Mahoney, 2001; Zavestoski et al., 2004). Most research on the cause of CMI has focused on environmental toxicants to which military personnel may have been exposed. Those toxicants include a long list of chemical, biologic, and physical agents (Persian Gulf War Veterans Act of 1998, Public Law 277, 105th Cong., October 8, 1998; Veterans Programs Enhancement Act of 1998, Public Law 368, 105th Cong., October 21, 1998). The focus on toxicants may be attributed, at least in part, to “a general fear of toxins spread as a result of modern industrial life” (Jones and Wessely, 2005). Many agents used in combat operation may be harmful to humans, depending on exposure routes and quantities. Concern about health effects of exposure to toxicants during war became ingrained in our culture with the Vietnam War, when a herbicide, Agent Orange, was implicated as a source of serious health problems in veterans and others who were exposed.

The present committee is not the first Institute of Medicine (IOM) committee to evaluate treatments for CMI in Gulf War veterans. In 2001, IOM released a report, Gulf War Veterans: Treating Symptoms and Syndromes, which examined how to manage medically unexplained physical symptoms (MUPS; termed CMI in this report) (IOM, 2001). The committee that wrote that report found sparse evidence on treatments for MUPS and so was unable to recommend specific treatments. It did, however, recommend a general approach for the management of patients who had MUPS. That approach included

•  Using diagnostic testing and medication only as medically necessary.

•  Using appropriate reassurance strategies to comfort patients.

•  Setting realistic goals in collaboration with patients.

•  Encouraging patients to exercise regularly to improve functioning.

•  Encouraging patients to involve their families and friends, if appropriate, in their care.

•  Coordinating care among clinicians so that patients do not bounce from specialist to specialist, receive many unnecessary diagnostic procedures, and end up on multiple unnecessary medications.

•  Introducing specialty mental health consultation, if needed. (“Most patients with MUPS do not require psychiatric treatment or psychological testing.”) (IOM, 2001).

In 2006 and again in 2010, IOM committees reviewed and evaluated the scientific literature on the health status of 1991 Gulf War veterans. Both committees found that veterans of the 1991 Gulf War who had been deployed reported more symptoms than their nondeployed counterparts (IOM, 2006b, 2010a). The later report concluded that there is “sufficient



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