B

PERCENTAGES OF VETERANS REPORTING SYMPTOMS IN STUDIES OF GULF WAR VETERANS AND MILITARY PERSONNEL

The following graph depicts the percentages of veterans who endorse symptoms as reported in studies cited in Chapter 3. The minimum, median, and maximum are indicated for each category of symptoms. Data are further characterized by whether the reports came from deployed Gulf War personnel and veterans (GWVs), nondeployed Gulf War–era personnel and veterans (NGVs), and Gulf War–era personnel and veterans deployed to other regions (Else). The percentages do not represent prevalence inasmuch as the results of all study types (including military-based and registry studies) cited are not representative of the population. Groups of symptoms are listed along the vertical axis, and the horizontal axis displays the percentage of veterans endorsing the symptoms.

Figure B.1 is followed by additional detail, including the number of times (N) that a symptom was reported in GWVs, and a description of the symptoms in each category as reported by studies. It should be noted that some studies report multiple symptoms in a group; for example, both vomiting and diarrhea are included in gastrointestinal (GI) symptoms and are reported separately by some studies and together in others. Also, the number of studies that reported symptoms in each group varies; for example, many studies reported on cognitive symptoms, fewer on chemical sensitivity. The numbers of symptoms reported by individual studies also vary. Each bar represents a different number of studies, and each bar represents a collection of symptoms.

For NGVs and Else, fewer studies reported percentages for a given symptom. For example, nine studies reported symptoms of allergies in GWVs, eight in NGVs, and one in Else.

Figure B.1 does not differentiate by type of study, number of participants, year, onset, duration, severity, exposure, or other aspects.

Studies that did not report percentages or reported on a study population previously described are not included. And symptoms or symptom groups with five or fewer percentages reported for GWVs are not included in Figure B.1; instead, those symptoms or symptom groups are listed in Table B.1.



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B PERCENTAGES OF VETERANS REPORTING SYMPTOMS IN STUDIES OF GULF WAR VETERANS AND MILITARY PERSONNEL The following graph depicts the percentages of veterans who endorse symptoms as reported in studies cited in Chapter 3. The minimum, median, and maximum are indicated for each category of symptoms. Data are further characterized by whether the reports came from deployed Gulf War personnel and veterans (GWVs), nondeployed Gulf War–era personnel and veterans (NGVs), and Gulf War–era personnel and veterans deployed to other regions (Else). The percentages do not represent prevalence inasmuch as the results of all study types (including military-based and registry studies) cited are not representative of the population. Groups of symptoms are listed along the vertical axis, and the horizontal axis displays the percentage of veterans endorsing the symptoms. Figure B.1 is followed by additional detail, including the number of times (N) that a symptom was reported in GWVs, and a description of the symptoms in each category as reported by studies. It should be noted that some studies report multiple symptoms in a group; for example, both vomiting and diarrhea are included in gastrointestinal (GI) symptoms and are reported separately by some studies and together in others. Also, the number of studies that reported symptoms in each group varies; for example, many studies reported on cognitive symptoms, fewer on chemical sensitivity. The numbers of symptoms reported by individual studies also vary. Each bar represents a different number of studies, and each bar represents a collection of symptoms. For NGVs and Else, fewer studies reported percentages for a given symptom. For example, nine studies reported symptoms of allergies in GWVs, eight in NGVs, and one in Else. Figure B.1 does not differentiate by type of study, number of participants, year, onset, duration, severity, exposure, or other aspects. Studies that did not report percentages or reported on a study population previously described are not included. And symptoms or symptom groups with five or fewer percentages reported for GWVs are not included in Figure B.1; instead, those symptoms or symptom groups are listed in Table B.1. 113

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114 CHRONIC MULTISYMPTOM ILLNESS IN GULF WAR VETERANS FIGURE B.1 Range and median of percentages of veterans reporting symptoms in studies of Gulf War veterans and military personnel. 0 10 20 30 40 50 60 70 80 90 NOTE: Else = veteran deployed elsewhere; GI = GWVs gastrointestinal; GWV = Gulf War veteran; NGV = Allergies NDVs nondeployed veteran. Else Cough/cold/ GWVs flu/sinus/ NGVs SOURCES: Doebbeling et al., 2000; Fukuda et al., sore throat Else 1998; Gray et al., 1999, 2002; Iowa Persian Gulf GWVs Skin NDVs Study Group, 1997; Ishøy et al., 1999; Joseph et al., Else 1997; Kang et al., 2000; Kelsall et al., 2004; GWVs Anxiety NDVs Kroenke et al., 1998; Nisenbaum et al., 2004; Else Proctor et al., 1998; Roy et al., 1998; Salamon et al., GWVs Mood NDVs 2006; Simmons et al., 2004; Steele et al., 2012; Else Stretch et al., 1995; Unwin et al., 1999; Wolfe et al., GWVs CogniƟve NDVs 1998. Else GWVs Neurological NDVs Else GWVs Pain NDVs Else GWVs FaƟgue NDVs Else GWVs Sleep NDVs Disturbances Else GWVs Weakness/ NDVs Energy Else GWVs Chest NDVs Pain Else GWVs Cardiac NGVs Else GWVs Genito- NDVs urinary Else GWVs GI NDVs Else GWVs Headache NDVs Else GWVs Hearing NDVs Else GWVs Hot/cold NDVs Else GWVs Joints NDVs Else Mouth, GWVs Teeth, NDVs Gums Else GWVs Respiratory NDVs Else GWVs Weight NDVs change Else GWVs Hair loss NGVs Else ReproducƟve GWVs and Sexual NDVs DysfuncƟon Else

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APPENDIX B 115 The terminology used by study authors to describe symptoms is listed below for each group of symptoms with the number of percentages in GWVs reported (N). There were several symptoms that fit easily into the symptom groups or symptom groups with five or fewer percentages reported in GWVs (see Table B.1). Allergies (N = 9): hay fever or allergies (>6 months); hay fever or allergies; allergic edemas of face, eyes, or lips; allergic eye symptoms; itchy painful eyes; allergies (other than skin); allergies. Cough/cold/flu/sinus/sore throat (N = 36): bothered by cough; cough; cough (>6 months); persistent cough; persistent cough when don’t have cold; continual cough; common cold or flu; flu; head colds; congested/mucous or phlegm; sinus troubles; sinus congestion (>6 months); sinus congestion; runny nose; sore throat; symptoms of bronchitis. Skin (N = 20): rash; rashes; rash or sores (>6 months); skin rashes; skin rash; rash or skin ulcer; skin irritation; rash or skin irritation; dryness or scaling of skin; skin rashes, eczema, skin allergies; skin allergies; eczema; sensations of itching on skin; other forms of skin problems; moderate or multiple skin symptoms. Anxiety (N = 20): nervous or tense; feeling anxious (>6 months); frequent periods of anxiety or nervousness; anxious; chronic anxiety; chronic worry/anxiety; panic or anxiety; feeling of nervousness, irritability, or agitation; feeling jumpy/easily startled; symptoms of anxiety disorder; symptoms of posttraumatic stress disorder (PTSD); PTSD and associated symptoms; anxiety/stress/sleep disturbance; taking medication to sleep or calm down; nightmares/flashbacks; nightmares; distressing dreams. Mood (N = 40): depression; depressed; depressed mood; depression or sadness; feeling depressed (>6 months); feeling down or depressed; frequent periods feeling depressed; symptoms of major depression; symptoms of minor depression; any symptoms of depression; symptoms of chronic dysphoria; crying easily; feeling distant or cut off; avoiding doing things or situations; feeling life is pointless, meaningless; loss of interest; loss of interest in TV, movies, news, friends; mood swings, aggression, irritability; irritability; unusual irritability; unusual anger; irritability or outbursts of anger; feeling irritable/angry outbursts; moody, irritable (>6 months); frequent rage. Cognitive (N = 43): loss of concentration; difficulty concentrating; difficulty remembering or concentrating (>6 months); concentration or memory difficulties; memory difficulties; memory loss; memory loss/lack of concentration; memory problems; problems with memory; short-term memory problems; problems remembering recent information; difficulties leaning new information; problems with forgetfulness; forgetfulness; difficulty finding the right word; difficulty to find words; difficulty with speech; disturbances of speech, trouble finding and pronouncing words correctly; trouble finding words (>6 months); trouble finding words when speaking; confusion; episodes of disorientation (>6 months); feeling disoriented; symptoms of cognitive dysfunction. Neurological (N = 42): dizziness or trouble maintaining balance (>6 months); dizziness; dizziness or feeling lightheaded; feeling dizzy, lightheaded, or faint; balance disturbances or fits of dizziness; blurred or double vision; blurred vision; blurred vision not improved by the use of glasses; double vision; eyes very sensitive to light; increased sensitivity to light; increased sensitivity to noise; numbness; numbness in arms or legs; numbness or tingling; numbness or

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116 CHRONIC MULTISYMPTOM ILLNESS IN GULF WAR VETERANS tingling (>6 months); numbness or tingling in extremities; numbness or tingling in fingers or toes; numbness or tingling in hands or feet; numbness or tingling in parts of body; numbness/tingling/dizziness; tingling in fingers and arms; tingling in legs and arms; tingling or shivering of arms, legs, or other parts of the body; shaking; tremors or shaking; tremors/shaking; muscle twitches or trembling; moderate or multiple neurologic symptoms; other neurological or neuromuscular not otherwise specified (NOS). Pain (N = 45): body pain/hurt all over; general aches and pains; general muscle aches and pains; muscle aches/cramps; muscle pain; muscle pain (>6 months); muscle tension, aches, soreness, or stiffness; muscular pain/weakness; pain in muscles; unusual muscle pain; joint pain; joint pain (>6 months); joint pains; pain in joints; roving joint pain; pain without swelling or redness in several joints; aching joints/bones; pain or ache in more than one joint; back ache, low back pain, neckaches or stiffness; back problems; moderate or multiple pain symptoms; symptoms of fibromyalgia. Fatigue (N = 33): fatigue; all fatigue; fatigue (>6 months); unusual fatigue; unusual feeling of fatigue during the day; fatigue lasting 24 hours after exertion (>6 months); fatigue lasting 24 hours; problems with fatigue lasting more than 24 hours after having made a physical effort; abnormal feeling of fatigue (not caused by physical activity); extreme fatigue every day, or almost every day; moderate or multiple fatigue symptoms; excessive sleepiness; sleepiness; sleepy all the time; needed more rest; feeling unrefreshed after sleep; feeling unusually sleepy/drowsy; feeling unwell after exercise/exertion; awakening with a feeling of fatigue and exhaustion after a hole night’s sleep; problems with feeling tired; symptoms of chronic fatigue. Sleep disturbances (N = 19): sleep disturbance; sleeping difficulties; difficulty sleeping (>6 months); difficulty sleeping; trouble sleeping; inability to fall asleep; problems falling asleep; problems falling or staying asleep; trouble falling or staying asleep; problems sleeping all night; not feeling rested after sleep; unrefreshing sleep. Weakness/energy (N = 8): feeling weak in parts of your body; generalized muscle weakness; general muscle weakness; loss of strength; suddenly diminished muscular power; lacking energy; overly tired/lack of energy. Chest pain (N = 11): chest pain (>6 months); chest pain; chest pain/tightness; tightness in chest. Cardiac (N = 12): rapid heartbeat; rapid heart rate; rapid heart rate (not exercising); racing heart; irregular heartbeats or “hear flutters”; irregular heartbeat; blood pressure; heart problems. Genitourinary (N = 10): passing urine more often; frequent urination; frequent or painful urination; frequent, painful urination; pain on passing urine; urinary infections; kidney disease/symptoms; genital system and bladder problems. GI (gastrointestinal) (N = 54): diarrhea; diarrhea (>6 months); frequent diarrhea; recurrent diarrhea; loose or aquaeous stools; diarrhea or constipation; constipation; alternating loose and hard stools; flatulence or burping; gas, bloating, cramps, abdominal pain (>6 months); rumbling in the stomach more than a couple of times a week; nausea; nauseous; nausea or vomiting (>6 months); nausea, vomiting; vomiting, nausea, or upset stomach; nausea, upset stomach; stomach upset; upset stomach; stomach ache; stomach cramp; abdominal pain; abdominal pain or cramping; stomach cramps or excessive gas; stomach pain/ulcer; dyspepsia or esophageal disease; heartburn; gastralgia; irritated bowel syndrome; moderate or multiple GI symptoms; digestive symptoms.

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APPENDIX B 117 Headache (N = 21): any headaches; headache; headache (>6 months); headaches; recurrent headaches; repeated fits of headache; severe headache. Hearing (N = 7): loss of hearing or ringing in ears; ringing in ears; tinnitus; audition disorders; hearing loss. Hot/cold (N = 17): chills; chills/fever; feeling feverish; fever; fever (>6 months); fever or chills; hot or cold spells, fever, sweats, chills; low tolerance for heat or cold; night sweats; night sweats that soak bed sheets (>6 months); night sweats that soak the bed sheets; night sweats/excessive; sweating/fevers; sweating. Joints (N = 11): joint stiffness; joint stiffness (>6 months); joint swelling; swelling in joint; joint swelling/redness. Mouth, teeth, gums (N = 8): problems with mouth gums or teeth; mouth/gum problems; problems with teeth or gums; bleeding gums; teeth loss; mouth sores. Respiratory (N = 25): difficulty breathing or catching breath; difficulty breathing or shortness of breath; unable to breathe deeply enough; shortness of breath; shortness of breath (>6 months); shortness of breath (not exercising); feeling short of breath at rest; dyspnea; dyspnea or cough; wheezing; wheezing (>6 months); wheezing in chest; rapid breathing; faster breathing than normal; moderate or multiple respiratory symptoms; symptoms of asthma. Weight change (N = 13): weight gain/loss; sudden weight gain; unintended weight gain ≥10 lbs; appetite loss/weight loss; sudden weight loss; weight loss; unintended weight loss ≥10 lbs; unintended weight loss ≥10 lbs (>6 months). Hair loss (N = 7): hair loss; unusual hair loss; sudden hair loss; any hair loss or hair disease. Reproductive and sexual dysfunction (N = 13): painful intercourse; pain during intercourse; problems during sexual intercourse; decreased interest in sex (>6 months); sexual dysfunction/lack of sex drive; impotence; burning semen; burning in sex organs; veteran or partner feels a burning sensation after sex; menstrual difficulties.

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118 CHRONIC MULTISYMPTOM ILLNESS IN GULF WAR VETERANS TABLE B.1 Symptoms Not Included in Figure B.1 (≤5 Reported Percentages per Symptom or Symptom Group) Symptom Study % GWVs % NGVs % Reporting Reporting Deployed Symptom Symptom Elsewhere Reporting Symptom Alcohol: symptoms of alcohol abuse; Nisenbaum et al., 2004; 19.4–11.9 4–16.8 5.0 intolerance to alcohol Schwartz et al., 1997 Appetite: appetite loss; loss or decrease in Gray et al., 2002; 9.4–13.3 3.0–5.2 3.4–8.5 appetite Nisenbaum et al., 2004 Chemical sensitivity: chemical sensitivity; Fukuda et al., 1998; Gray 4.3–17.0 0.7–8.0 0.7 chemical sensitivity (>6 months); multiple et al., 2002; Kang et al., chemical sensitivity; sensitive to chemicals; 2000; Salamon et al., 2006; symptomatic response to chemicals, odors Steele et al., 2000 Chronic/frequent infection Simmons et al., 2004 5.8 1.6 Deterioration of general health Simmons et al., 2004 3.7 2.9 Difficulty in swallowing: problems Kang et al., 2000; Salamon 12.1–16.2 5.0–7.2 swallowing; trouble with swallowing; et al., 2006; Stretch et al., difficulty swallowing 1995 Eyes, ears, nose: eyes trouble; eyes, ears, Salamon et al., 2006; 17.0–26.0 5.5–5.6 nose trouble; nasal sores (>6 months) Stretch et al., 1995 Hoarseness Stretch et al., 1995 9.7–12.0 4.1–3.7 Injuries and healing: retarded wound Ishoy et al., 1999; Kang et 3.5–13.0 1.7–7.0 healing; bruise easily; tendency to bruise or al., 2000; Salamon et al., bleed easily; slowness of healing; slow healing 2006 Lump in throat Nisenbaum et al., 2004 8.0 3.0 3.80 Milk intolerance (>6 months) Fukuda et al., 1998 7.0 4.0 Nuisances after vaccination Ishoy et al., 1999 2.8 0.0 Other: other; other symptoms; other Joseph et al., 1997; Roy et 5.1–21.4 1.9–6.5 symptoms not otherwise specified al., 1998; Simmons et al., 2004; Stretch et al., 1995 Reporting ≥1 symptom Simmons et al., 2004 60.7 36.7 Single episodes of acute infections Simmons et al., 2004 2.7 2.0 Skeletal and other muscular symptoms Simmons et al., 2004 15.1 13.2 Suicidal thoughts Gray et al., 2002 6.4 2.7 2.6 Sweaty clammy or damp hands Ishoy et al., 1999; Wolfe et 7.0–7.9 3.9 al., 1998 Swelling of feet Kang et al., 2000 11.0 6.0 Swollen glands: sore or swollen glands in Fukuda et al., 1998; Kang 8.0–17.7 2.0–8.0 neck; swollen glands; swollen lymph nodes et al., 2000; Salamon et al., (>6 months) 2006; Steele et al., 2000 Tendency to bruise or bleed easily Salamon et al., 2006 3.5

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APPENDIX B 119 REFERENCES Doebbeling, B. N., W. R. Clarke, D. Watson, J. C. Torner, R. F. Woolson, M. D. Voelker, D. H. Barrett, and D. A. Schwartz. 2000. Is there a Persian Gulf War syndrome? Evidence from a large population- based survey of veterans and nondeployed controls. American Journal of Medicine 108(9):695-704. Fukuda, K., R. Nisenbaum, G. Stewart, W. W. Thompson, L. Robin, R. M. Washko, D. L. Noah, D. H. Barrett, B. Randall, B. L. Herwaldt, A. C. Mawle, and W. C. Reeves. 1998. Chronic multisymptom illness affecting Air Force veterans of the Gulf War. Journal of the American Medical Association 280(11):981-988. Gray, G. C., K. S. Kaiser, A. W. Hawksworth, F. W. Hall, and E. Barrett-Connor. 1999. Increased postwar symptoms and psychological morbidity among U.S. Navy Gulf War veterans. American Journal of Tropical Medicine and Hygiene 60(5):758-766. Gray, G. C., R. J. Reed, K. S. Kaiser, T. C. Smith, and V. M. Gastanaga. 2002. Self-reported symptoms and medical conditions among 11,868 Gulf War-era veterans. American Journal of Epidemiology 155(11):1033-1044. Iowa Persian Gulf Study Group. 1997. Self-reported illness and health status among Gulf War veterans: A population-based study. Journal of the American Medical Association 277(3):238-245. Ishøy, T., P. Suadicani, B. Guldager, M. Appleyard, H. O. Hein, and F. Gyntelberg. 1999. State of health after deployment in the Persian Gulf. The Danish Gulf War study. Danish Medical Bulletin 46(5):416-419. Joseph, S. C., R. R. Blanck, G. Gackstetter, R. Glaser, K. C. Hyams, S. Kinty, C. Magruder, J. Mazzuchi, F. L. O’Donnell, M. D. Parkinson, R. E. Patterson, and D. H. Trump. 1997. A comprehensive clinical evaluation of 20,000 Persian Gulf War veterans. Military Medicine 162(3):149-155. Kang, H. K., C. M. Mahan, L. Y. Lee, C. A. Magee, and F. M. Murphy. 2000. Illnesses among United States veterans of the Gulf War: A population-based survey of 30,000 veterans. Journal of Occupational and Environmental Medicine 42(5):491-501. Kelsall, H. L., M. R. Sim, A. B. Forbes, D. C. Glass, D. P. McKenzie, J. F. Ikin, M. J. Abramson, L. Blizzard, and P. Ittak. 2004. Symptoms and medical conditions in Australian veterans of the 1991 Gulf War: Relation to immunisations and other Gulf War exposures. Journal of Occupational and Environmental Medicine 61(12):1006-1013. Kroenke, K., P. Koslowe, and M. Roy. 1998. Symptoms in 18,495 Persian Gulf War veterans: Latency of onset and lack of association with self-reported exposures. Journal of Occupational and Environmental Medicine 40(6):520-528. Nisenbaum, R., K. Ismail, S. Wessely, C. Unwin, L. Hull, and W. C. Reeves. 2004. Dichotomous factor analysis of symptoms reported by UK and US veterans of the 1991 Gulf War. Population Health Metrics 2. Proctor, S. P., T. Heeren, R. F. White, J. Wolfe, M. S. Borgos, J. D. Davis, L. Pepper, R. Clapp, P. B. Sutker, J. J. Vasterling, and D. Ozonoff. 1998. Health status of Persian Gulf War veterans: Self- reported symptoms, environmental exposures and the effect of stress. International Journal of Epidemiology 27(6):1000-1010. Roy, M. J., P. A. Koslowe, K. Kroenke, and C. Magruder. 1998. Signs, symptoms, and ill-defined conditions in Persian Gulf War veterans: Findings from the comprehensive clinical evaluation program. Psychosomatic Medicine 60(6):663-668. Salamon, R., C. Verret, M. A. Jutand, M. Begassat, F. Laoudj, F. Conso, and P. Brochard. 2006. Health consequences of the first Persian Gulf War on French troops. International Journal of Epidemiology 35(2):479-487. Simmons, R., N. Maconochie, and P. Doyle. 2004. Self-reported ill health in male UK Gulf War veterans: A retrospective cohort study. BMC Public Health 4:1-10.

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120 CHRONIC MULTISYMPTOM ILLNESS IN GULF WAR VETERANS Steele, L., A. Sastre, M. M. Gerkovich, and M. R. Cook. 2012. Complex factors in the etiology of Gulf War illness: Wartime exposures and risk factors in veteran subgroups. Environmental Health Perspectives 120(1):112-118. Stretch, R. H., P. D. Bliese, D. H. Marlowe, K. M. Wright, K. H. Knudson, and C. H. Hoover. 1995. Physical health symptomatology of Gulf War-era service personnel from the states of Pennsylvania and Hawaii. Military Medicine 160(3):131-136. Unwin, C., N. Blatchley, W. Coker, S. Ferry, M. Hotopf, L. Hull, K. Ismail, I. Palmer, A. David, and S. Wessely. 1999. Health of UK servicemen who served in Persian Gulf War. Lancet 353(9148):169- 178. Wolfe, J., S. P. Proctor, J. D. Davis, M. S. Borgos, and M. J. Friedman. 1998. Health symptoms reported by Persian Gulf War veterans two years after return. American Journal of Industrial Medicine 33(2):104-113.