Adequacy of the Comprehensive Clinical Evaluation Program

A Focused Assessment

Committee on the Evaluation of the Department of Defense Comprehensive Clinical Evaluation Program

Division of Health Promotion and Disease Prevention

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.
1997



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--> Adequacy of the Comprehensive Clinical Evaluation Program A Focused Assessment Committee on the Evaluation of the Department of Defense Comprehensive Clinical Evaluation Program Division of Health Promotion and Disease Prevention INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1997

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--> NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 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 report has been reviewed by a group other than the authors according to procedures approved by the Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is the president of the Institute of Medicine. This study was supported by the US Department of Defense under Contract Number DASW01-96-K-007. The views presented are those of the Institute of Medicine Committee on the Evaluation of the Department of Defense Comprehensive Clinical Evaluation Program and are not necessarily those of the funding organization. International Standard Book No. 0-309-05949-6 Additional copies of this report are available for sale from: National Academy Press 2101 Constitution Avenue, N.W. Box 285 Washington, DC 20055 Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP's on-line bookstore at http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at http://www2.nas.edu/iom. Copyright 1997 by the National Academy of Sciences. All rights reserved. Printed in the United States. 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.

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--> COMMITTEE ON THE EVALUATION OF THE DoD COMPREHENSIVE CLINICAL EVALUATION PROGRAM Dan G. Blazer,* Chair, Dean of Medical Education and J.P. Gibbons Professor of Psychiatry, Duke University Medical Center, Durham, North Carolina Rebecca Bascom, Director, Environmental Research Facility, University of Maryland, Baltimore Margit L. Bleecker, Director of the Center for Occupational and Environmental Neurology, Baltimore, Maryland Evelyn J. Bromet, Professor, Department of Psychiatry, State University of New York at Stony Brook, Stony Brook, New York Gerard N. Burrow,* Special Advisor to the President for Health Affairs, Yale University School of Medicine, New Haven, Connecticut Howard Kipen, Associate Professor and Chief, Occupational Health Division, UMDNJ, Robert Wood Johnson Medical School, Piscataway, New Jersey Adel A. Mahmoud,* Chairman, Department of Medicine, Case Western Reserve University and University Hospitals of Cleveland, Cleveland, Ohio Robert S. Pynoos, Professor of Psychiatry and Director of the Trauma Psychiatry Service, University of California, Los Angeles, California Guthrie L. Turner, Jr., Chief Medical Consultant, Office of Disability Determination Services, State of Washington, Tummwater, Washington Mark J. Utell, Professor of Medicine and Environmental Medicine and Director, Pulmonary/Critical Care and Occupational Medicine Divisions, University of Rochester Medical Center, Rochester, New York Michael H. Weisman, Professor, Division of Rheumatology, Department of Medicine, University of California at San Diego Board on Health Promotion and Disease Prevention Liaison Elena O. Nightingale,* Scholar-in-Residence, Institute of Medicine and Board on Children, Youth and Families, Washington, DC Board on Neuroscience and Behavioral Health Liaison William E. Bunney, Jr.,* Distinguished Professor and Della Martin Chair of Psychiatry, University of California, Irvine, California *   Member, Institute of Medicine.

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--> Staff Lyla M. Hernandez, Study Director Sanjay S. Baliga, Research Associate Donna M. Livingston, Project Assistant Kathleen R. Stratton, Director, Division of Health Promotion and Disease Prevention Constance M. Pechura, Director, Division of Neuroscience and Behavioral Health Donna D. Thompson, Division Assistant

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--> Contents     EXECUTIVE SUMMARY   1 1   INTRODUCTION   11 2   OVERVIEW OF THE INSTITUTE OF MEDICINE'S PERSIAN GULF ACTIVITIES   15 3   THE COMPREHENSIVE CLINICAL EVALUATION PROGRAM   17     Overview,   17     Signs, Symptoms, and Ill-Defined Conditions (SSID),   18     Chronic Fatigue Syndrome (CFS) and Fibromyalgia in the CCEP Population,   20     Stress and Psychiatric Disorders,   21 4   IOM REVIEW: DIFFICULT-TO-DIAGNOSE AND ILL-DEFINED CONDITIONS   25     Chronic Fatigue Syndrome,   26     Fibromyalgia,   29     Multiple Chemical Sensitivity,   31     Controversies and Overlap,   34 5   IOM REVIEW: STRESS, PSYCHIATRIC DISORDERS, AND THEIR RELATIONSHIP TO PHYSICAL SIGNS AND SYMPTOMS   37     Stressors and Stress,   37     Consequences of Stress,   39

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--> 6   CONCLUSIONS AND RECOMMENDATIONS   45     Medically Unexplained Symptom Syndromes,   46     Stress,   47     Screening,   48     Program Evaluation,   50     Coordination with the VA,   51     REFERENCES AND SELECTED BIBLIOGRAPHY   53     APPENDIXES     A   Presidential Advisory Committee on Gulf War Veterans' Illnesses: Final Report Recommendations   61 B   Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action   67 C   Health Consequences of Service During the Persian Gulf War: Recommendations for Research and Information Systems   79 D   Evaluation of the U.S. Department of Defense Persian Gulf Comprehensive Clinical Evaluation Program: Overall Assessment and Recommendations   91 E   Workshop on the Adequacy of the CCEP for Evaluating Individuals Potentially Exposed to Nerve Agents: Agenda and Speakers List   109 F   Adequacy of the Comprehensive Clinical Evaluation Program: Nerve Agents   113 G   Workshop Agendas and Speakers Lists   121     Workshop on Difficult-to-Diagnose and Ill-Defined Conditions,   121     Workshop on Stress and Psychiatric Disorders,   123 H   Outline of the CCEP Medical Protocol   127 I   Screening Instruments for Substance Abuse   131

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--> Adequacy of the Comprehensive Clinical Evaluation Program A Focused Assessment

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