appropriate by their primary care physician. Evaluation at this phase includes a survey for nonspecific patient symptoms, including fatigue, joint pain, diarrhea, difficulty concentrating, memory and sleep disturbances, and rashes.

The primary care physician may refer patients to Phase II for further specialty consultations if he or she determines it is clinically indicated. These Phase II evaluations are conducted at a regional medical center and consist of targeted, symptom-specific examinations, lab tests, and consultations. During this phase potential causes of unexplained illnesses are assessed, including infectious agents, environmental exposures, social and psychological factors, and vaccines and other protective agents. Both Phase I and Phase II are intended to be thorough for each individual patient and to be consistent among patients.

Every medical treatment facility has a designated CCEP physician coordinator who is a board-certified family practitioner or internal medicine specialist. The coordinator is responsible for overseeing both the comprehensiveness and quality of Phase I exams. At regional medical centers CCEP activities are coordinated by board-certified internal medicine specialists who also oversee the program operations of the medical treatment facilities in their region.

In March 1995, the DoD established the Specialized Care Center at Walter Reed Army Medical Center to provide additional evaluation, treatment, and rehabilitation for patients who are suffering from chronic debilitating symptoms. A small select group of patients have been referred from regional medical centers to the Specialized Care Center for an intensive 3-week evaluation and treatment program designed to improve their health status.

Implementation

The DoD has summarized the information obtained through the CCEP in reports released to the public. In the most recent published report, which covered 18,598 participants seen through December 6, 1995, the most frequent primary diagnoses were psychological conditions (18.4%); musculoskeletal conditions and connective tissue diseases (18.3%); symptoms, signs, and ill-defined conditions (17.9%); respiratory diseases (6.8%); and digestive system diseases (6.3%). An additional 9.7% were found to be healthy.

When both primary and secondary diagnoses were considered, the most common diagnostic categories were musculoskeletal diseases (47.2%); symptoms, signs, and ill-defined conditions (43.1%); psychological conditions (36.0%); digestive diseases (17.5%); and nervous system diseases (17.8%) (CCEP report on 18,598 participants, April 2, 1996).

The most frequently recorded psychological diagnoses were tension headache, depression, anxiety disorders, adjustment reactions, and somatoform disorders. For participants with a primary diagnosis of symptoms, signs, and ill-



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